Management of Frontal Bone Fracture in a Tertiary Neurosurgical Care Center-A Retrospective Study

Abstract

Objective We present our experience in the management of frontal bone fractures using the previously described radiologic classification of frontal bone fractures. Methodology A retrospective study was conducted, which reviewed the medical records and computed tomographic (CT) scan images of patients with frontal bone fracture from January 2016 to February 2019. Patients with complete medical records and a follow-up of minimum 1 year were included in the study. Demographic details, mechanism of injury, associated intracranial injuries, maxillofacial fractures, management, and complications were analyzed. CT scan images were used to classify the frontal bone fractures using the novel classification given by Garg et al (2014). The indications for surgical treatment were inner table frontal sinus fracture with cerebrospinal fluid (CSF) leak, intracranial hematoma with significant mass effect requiring surgical evacuation, and outer table comminuted fracture that is either causing nasofrontal duct obstruction or for cosmetic purpose. Results A total of 55 patients were included in the study. Road traffic accidents as the commonest cause of frontal bone fractures. The most common fracture pattern was type 1 followed by type 5 and depth B followed by depth A. Four patients presented with CSF rhinorrhea. CSF rhinorrhea was more frequent with fracture extension to the skull base (depth B, C, D), which was statistically significant ( p < 0.001). Conclusion Frontal bone fracture management has to be tailor-made for each patient based on the extent of the fracture, presence of CSF leak, and associated intracranial and maxillofacial injuries.

Keywords: CSF leak; cranialization; frontal bone fracture; frontal sinus fracture.

Fig. 1

Illustrative figure: Frontal bone fracture types. Type 1 fractures are isolated to the frontal sinus without a vertical trajectory (purple). Type 2 fractures are vertically oriented and extended into the orbit but not the frontal sinus (blue). Type 3 fractures are vertically oriented and extended into the frontal sinus but not the orbit (yellow). Type 4 fractures are vertically oriented and extended into ipsilateral frontal sinus and orbit (green). Type 5 fractures extend into the frontal sinus and the orbit on both sides of the face or the contralateral side of the face (red). Image courtesy: Garg et al.

Fig. 2

Computed tomography of brain bone window: Patients with frontal bone fractures, nonvertical fracture—Type 1 and vertical fractures Type 2–5. Type 2 fracture shown with involvement of the orbit but not the frontal sinus. Type 3 fracture depicted with involvement of the frontal sinus but not the orbit. Type 4 fracture involves the ipsilateral right frontal sinus and orbit. Type 5 fracture involves the right frontal sinus and extends inferiorly into the bilateral orbits.

Fig. 3

Illustrative figure: Skull base penetration: Depth A fractures involve the anterior table of the frontal bone with or without posterior table involvement and do not extend into the anterior cranial fossa (purple). Depth B fractures involve the floor of the anterior cranial fossa (blue). Depth C fractures involve the middle cranial fossa (yellow). Depth D fractures extend into the posterior cranial fossa (red). Image courtesy: Garg et al.

Fig. 4

Computed tomography of brain reconstructive image: Patients with frontal bone fractures and skull base extension. Depth A fracture demonstrated with fracture of anterior and posterior frontal bone tables (pink arrow) but no skull base involvement. Depth B fracture shown with involvement of the fovea ethmoidalis (pink arrows). Depth C fracture shown extending to the fovea ethmoidalis, sphenoid sinus, greater sphenoid wing, and the pituitary fossa (pink arrow). Depth D fracture depicted with extension beyond the clivus (pink arrow) into the foramen magnum.

Fig. 5

Intraoperative images: ( A ) Open reduction and internal fixation of outer table fracture fragments with miniplates, ( B ) harvested pericranial fascia and obliteration of frontal sinus with bone wax, (C) cranialization with pericranial fascia.