Frontal Bone Fracture Management in the ED Treatment & Management

ABCs are the first priority. Hold the airway open by chin lift, jaw thrust, or airway adjuncts, including endotracheal intubation. ^[18]

Because of concerns over intracranial placement of endotracheal tubes, avoid using the nasotracheal route for intubation if the patient has extensive facial damage, or if midface fracture is suspected.

Place the patient on a backboard with a collar if cervical spine injury is a possibility.

Treat patients with hypoventilation with intubation and bag ventilation.

Control actively bleeding wounds by applying a bandage with direct pressure.

ABCs take priority; reassess the airway frequently.

Do not focus solely on the obvious deformity, thereby failing to perform a complete primary survey.

Rapidly diagnose other life threats and undertake appropriate resuscitation. Follow with a complete secondary survey.

Diagnosis of frontal bone fracture in the ED is part of the secondary survey.

After initial stabilization, perform a thorough history and physical exam.

Perform a non-contrast CT scan of the head and facial bones. If a frontal sinus fracture is observed on CT, this indicates significant trauma, and it is imperative to search for corresponding injuries. ^[3]

Thoroughly evaluate the patient to avoid the possibility of missing other potentially devastating injuries. ^[3]

Select an appropriate management approach. Appropriate classification and indications for surgical repair of frontal sinus fractures remain controversial, and a variety of management strategies are available. ^[3]

Identify any life-threatening injuries and stabilize the patient upon presentation. ^[3]

Enlist the support of an interprofessional team for comprehensive management, depending on the extent of the injury. Surgical reconstruction will need to be carried out by appropriate specialists. ^[3]

If a frontal bone fracture is diagnosed, refer the patient to a neurosurgeon, as these injuries often are associated with intracranial injury.

Provide care for a patient with multiple injuries in collaboration with a surgeon who is experienced in trauma care.

The incidence of posttraumatic stress disorder is high in patients with facial injuries; consider consultation with a psychiatrist. ^[10]

Enlist the support of an interprofessional team for comprehensive management, depending on the extent of the injury. Surgical reconstruction will need to be carried out by appropriate specialists. ^[3]

Given that frontal bone fractures require extreme force, admitting all except those few patients with isolated, nondisplaced anterior table fractures is appropriate.

Management of frontal bone fracture takes into consideration the location and displacement of the fracture, as well as the presence or absence of any associated maxillofacial or other head injuries. ^[1]

Patients with depression of the inner table often require neurosurgical intervention to elevate the fragment.

Common surgical fixation options include the use of titanium plates/screws, titanium mesh/screws, or a combination of these methods to obtain an ideal open reduction internal fixation construct. ^[1]

Those with continued CSF leak may require a frontal sinus procedure involving ablation of the sinus and removal of the inner table to allow the frontal sinus to become part of the cranium. 

A CSF leak in patients with facial fracture can result in meningitis and other central nervous system complications. In a retrospective cross-sectional study of 1,287 patients admitted to a medical center with head and face injuries over a 7-year period (2004-2010), 17 had CSF leaks. Among patients with CSF leak, 8 (47%) were treated spontaneously, 2 (11.8%) were treated through lumbar drain placement, and 7 (41.2%) were treated by surgical intervention. ^[19]

Pediatric frontal sinus fractures are rare. A retrospective review of 39 patients aged birth to 18 years shows that fractures of the anterior or posterior table with displacement greater than one table-width were significantly associated with higher hospital costs, higher-velocity mechanisms of injury, lower Glasgow Coma Scale scores, nasofrontal outflow tract (NFOT) involvement, and CSF leak. According to the authors, pediatric patients without NFOT involvement can be managed with observation only, but those with NFOT involvement or persistent CSF leak should be treated with obliteration or cranialization, respectively, to reduce the risk of severe complications. ^[20]

Successful surgical management revolves around the concept of minimizing cosmetic deformity, maintaining normal sinus function, and avoiding short- and long-term complications. ^[2]

Complications of frontal bone fracture vary according to the extent of injury but can include frontal sinusitis, meningitis, mucocele, poor aesthetic outcome, brain abscess, frontal headaches, ophthalmoplegia, and/or local paresthesia. ^[3]

CSF leaks may continue, although most cease by 2-3 weeks after the injury. Observe the patient closely for signs and symptoms of meningitis or abscess formation.

A delay in operative management of frontal sinus fractures in patients requiring operative intervention was shown to be associated with increased risk for serious infection. A retrospective chart review of 242 consecutive patients with surgically managed frontal sinus fracture reported that serious infections included meningitis, encephalitis, brain abscess, frontal sinus abscess, and osteomyelitis. Delayed operative interventions were defined as procedures performed more than 48 hours after admission. Operative delay beyond 48 hours was independently associated with a 4.03-fold increased risk for serious infection; external use of a CSF drainage catheter and local soft tissue infection conferred 4.09-fold and 5.10-fold increased risk, respectively. ^[21]

Common postoperative complications include but are not limited to the following:

• Surgical site infection (SSI)
• Supraorbital nerve paresthesia
• Facial nerve paralysis (transient) ^[1]

In a retrospective review of pediatric facial fractures (285 patients 18 years or younger), the most common fractures were those of the mandible (29.0%), orbit (26.5%), nasal bone (14.4%), zygoma (7.7%), and frontal bone/frontal sinus (7.5%). Intracranial hemorrhage was present in 70 patients (24.6%), skull fracture in 50 (17.5%), cervical spine fracture in 10 (3.5%), and lumbar spine fracture in 11 (3.9%). Midface fractures and a depressed Glasgow Coma Scale score (GCS) showed a strong correlation with intracranial hemorrhage and cervical spine fracture. The mean GCS for patients with and without intracranial hemorrhage was 11.0 and 14.6, respectively (P< 0.05). The mean GCS for patients with and without cervical spine fracture was 11.2 and 13.8, respectively (P< 0.05). Researchers recommended that patients with midface fractures should be evaluated for intracranial hemorrhage and spine fracture if the GCS is abnormal. ^[9]

The primary method of avoiding or mitigating frontal bone fracture consists of consistent wearing of helmets during sporting activities involving rapid movement (cycling, driving, skiing, skateboarding, etc.), rapid projectile travel (baseball, cricket, softball, etc.), and full body contact (American football, ice hockey, lacrosse). Helmets should also be worn during activities involving heavy machinery or work in dangerous environments (construction workers, industrial factory workers, soldiers, etc.). ^[3]

Although trauma typically is incidental, some methods remain to reduce the chance of occurrence and the severity of injuries. These involve evaluating potential risk of child abuse, suicidal tendencies, and risky social behaviors (including injurious sports or recreational activities). ^[4]

Adults and children alike see a decreased rate of injury or death when age- and size-appropriate car seats and restraints are used. Additionally, use of personal protective equipment for participation in recreational and sporting activities should be encouraged. ^[4]