Management of fracture frontal bone
Balasubramanian M.S. D.L.O.
involving the frontal bone are very uncommon injury. The
incidence ranging from 5 - 15% of all facial injuries. This
injury is potentially fatal because of its close proximity to the
frontal lobe of brain.
frontal sinus is a pyramidal air filled cavity within the frontal
bone. Its size and shape are highly variable. In fact it
is usually asymmetrical. It has two
walls: the anterior and posterior tables. The anterior
table is very strong when compared to the posterior table. The
posterior table is in close proximity to the frontal lobe of
the brain. The floor of the frontal sinus is
very weak and is formed by membranous bone.
Fractures involving the frontal sinus must be considered as
head injuries and should be managed thus because of the close
proximity of the brain.
Causes of frontal sinus
1. Road traffic accident
4. Recreational accidents
of patient with injury to frontal sinus:
suspected patients should undergo a complete ophthalmic examination
to rule out injury to the eye.
2. All these patients must undergo
CT scan of brain and skull for compete evaluation
patient's consiousness should be monitored carefully to rule out
4. Other associated injuries must be
looked for because the force necessary to cause fracture
of frontal bone is enormous.
Goals of treatment of
fracture frontal sinus are:
1. Removing the factors if any
predisposing to infection
2. Restoration of normal sinus
3. To treat cosmetic
Classification of frontal sinus fracture:
Depressed anterior wall fractures
2. Posterior wall
3. Through and through injury involving both tables of
4. Fractures involving the fronto nasal duct
Anterior Wall fracture of frontal
sinus: Linear fractures that has not displaced the
fractured fragments may be managed conservatively.
Depressed fractures involving the anterior wall must be elevated,
frontal sinus inspected and fixed. Compound
anterior wall fractures should always be explored, foreign bodies if
any must be removed.
In the case of large comminuted
fractures of anterior wall with missing fragments of bone, frontal
sinus obliteration should be resorted to using abdominal fat and
reconstruction under taken with free iliac / rib graft. If the
bone gap is less than 1.5 cms then bone grafting need not be
Posterior wall fracture of frontal
sinus: Linear fractures involving the posterior wall
should always be explored. The frontal sinus should be
obliterated if there is entrapment or displaced of mucosa. All
cases of depressed fractures of posterior table should be
considered for frontal sinus obliteration. If the posterior
wall fracture is extensively comminuted, then cranialization
of the frontal sinus should be resorted to. CSF leaks if
any should be sealed by a meticulous dural repair. Since the
posterior table is thin, even minor deflections of bony
fragments is sufficient to cause ingrowth of sinus mucosa into
the anterior cranial fossa leading onto the formation of
mucopyocele. This is one of the reason why some authors
advocate routine obliteration of frontal sinus in all cases of
fractures involving the posterior table.
injuries: These injuries are very difficult to diagnose
even with a CT scan. The presence of unresolving fluid
inside the frontal sinus for a period of more than 4 weeks should
lead to the suspicion. A diagnostic trephening should be done
in these patients and the fluid if any should be evacuated.
The patency of the duct can be tested by instilling methylene
blue or flourescein dye and looking for it discharge from
the nose. Exploration is indicated if there is no efflux
of the dye introduced. Fractures involving the
anterior table with involvement of naso ethmoidal complex should
always be explored because involvement of naso frontal duct is
common in these patients. It is always easy to treat
unilateral injuries because a simple removal of the intersinus
septum will cause the drainage to occur via the opposite side.
Bilateral involvement is a problem, and in these patients the duct
must be reconstructed either by stenting or mucosal flaps. A
high degree of failure is common in these cases.
Through and through fractures involving the frontal sinus
tables is highly dangerous associated with more than 50%
mortality. Exploration is a must in these patients,
cranialisation of the sinus should be resorted to. CSF leaks
if any should be meticulously closed. In extreme cases frontal
lobotomy need to be performed.
fractures of frontal sinus:
3. Cosmetic defect
4. Injury to naso frontal
5. Injury to the frontal lobe of brain
This 38 year old male patient presented
with h/o injury 15 days duration. He had irregular sutured
wound over the left frontal area. There was a depression seen
over the anterior wall of left frontal sinus.
CT scan taken
showed depressed fracture of anterior table of frontal sinus.
The posterior table was found intact. The frontal sinus was
fould filled with fluid.
photograph showing depressed fracture of anterior table of left
frontal sinus. (Note the irregularly sutured
anterior table fragment is seen being
Procedure: Open reduction and
Under general anesthesia through an
incision below the left eyebrow the fractured area was
exposed. The depressed fragment of bone was elevated.
The frontal sinus was inspected. Suction applied. A
small bone fragment was seen inside the frontal sinus and the
same was removed. A small hole is made over the fractured
segment of bone. Since the bony defect was less than 1 cm
no bone grafting was done. The fractured fragment
was anchored to the surrounding tissue using 2 - 0 proline.
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