Frontal Bone Fractures Research Articles

A novel classification of frontal bone fractures: The prognostic significance of vertical fracture trajectory and skull base extension

The broad spectrum of frontal bone fractures, including those with orbital and skull base extension, is poorly understood. We propose a novel classification scheme for frontal bone fractures. Maxillofacial CT scans of trauma patients were reviewed over a five year period, and frontal bone fractures were classified: Type 1: Frontal sinus fracture without vertical extension. Type 2: Vertical fracture through the orbit without frontal sinus involvement. Type 3: Vertical fracture through the frontal sinus without orbit involvement. Type 4: Vertical fracture through the frontal sinus and ipsilateral orbit. Type 5: Vertical fracture through the frontal sinus and contralateral or bilateral orbits. We also identified the depth of skull base extension, and performed a chart review to identify associated complications. 149 frontal bone fractures, including 51 non-vertical frontal sinus (Type 1, 34.2%) and 98 vertical (Types 2-5, 65.8%) fractures were identified. Vertical fractures penetrated the middle or posterior cranial fossa significantly more often than non-vertical fractures (62.2 v. 15.7%, p=0.0001) and had a significantly higher mortality rate (18.4 v. 0%, p<0.05). Vertical fractures with frontal sinus and orbital extension, and fractures that penetrated the middle or posterior cranial fossa had the strongest association with intracranial injuries, optic neuropathy, disability, and death (p<0.05). Vertical frontal bone fractures carry a worse prognosis than frontal bone fractures without a vertical pattern. In addition, vertical fractures with extension into the frontal sinus and orbit, or with extension into the middle or posterior cranial fossa have the highest complication rate and mortality.

Intracranial repair of posttraumatic cerebrospinal fluid rhinorrhea associated with recurrent meningitis.

The purposes of this study are to assess the efficacy of our intracranial surgery and evaluate the association between failure after first surgical repair and the risk factors that have been applied on a group of 13 patients affected by posttraumatic cerebrospinal fluid rhinorrhea associated with recurrent meningitis. We retrospectively collected data on 13 patients referred to our institution. All patients had history of head trauma and experienced 2 or more episodes of meningitis. Three of the 13 patients had craniectomy defect due to previous trauma and surgery, 9 patients had linear fracture, and 1 patient had no apparent fracture line on preoperative radiologic evaluation. Ten of the 13 patients had identified frontal bone fracture involving the frontal sinus during surgery. Dural tear was identified intradurally and was repaired using a fascia lata graft with or without fibrin glue. Fibrin glue was applied over the suture in 7 patients. Three of the 13 patients had large dural defects. The size of bone and dural defect seems to be an important prognostic factor of episodes of meningitis. The use of fibrin glue to fixate fascia lata graft did not benefit the outcome.

Lacrimal Gland Fistula following Severe Head Trauma.

We aim to present a unique case with discharging lacrimal gland fistula secondary to severe head trauma by an animal. A 9-year-old girl presented with serous fluid discharge from a cutaneous fistula in the left orbital region. The patient had history of surgery for traumatic frontal bone fracture and skin laceration in the superior orbital rim three weeks earlier. She underwent a complete ophthalmological examination and there was no anterior segment or fundus pathology. The orifice of the fistula was detected in mediolateral part of the left superior orbital rim and fluid secretion was increasing with irritation of the left eye. Neurosurgical complications were excluded and radiological assessment was nonremarkable. The patient's legal representatives were informed and lacrimal gland fistulectomy was planned. However, the fistula was self-closed one week after initial ophthalmological examination, and the patient had no symptoms. In conclusion, traumatic injuries of superior orbital region should be carefully evaluated and wounds should be well closed to prevent consecutive lacrimal gland fistula.

Panfacial Trauma - A Flexible Surgical Approach

Panfacial fractures are those involving the mandible, maxilla, and zygomatic complex at the same time and usually accompanying naso-orbito-ethmoid (NOE) and frontal bone fractures. When there are multiple facial fractures, involving upper &amp; lower face, reconstruction should be approached as puzzle. It is difficult to follow an established pattern of sequencing and organizing the repair of panfacial fractures. Successful reconstructions can be achieved through a flexible approach that adheres to several key principles. The goal of treatment as with all facial fracture is to restore both the functions and pre-injury 3-dimensional facial contours. To achieve this goal, various management schemes have been proposed including “bottom to top,” “top to bottom,” “inside-out,” or “outside-in”. Nevertheless, despite aggressive management, severe post-traumatic deformities continue to appear. The correct timing of surgical intervention and use of rigid fixation allows the restoration of morphological and functional nature of face after Panfacial fractures. The aim of presenting the paper is to analyze the principles that determine the choice of method of treatment and that prevent the development of secondary deformity. DOI: http://dx.doi.org/10.3126/jucms.v2i3.11828 Journal of Universal College of Medical Sciences Vol.2(3) 2014: 41-44

Frontal bone fractures.

The aim of this retrospective study was to evaluate the epidemiology, treatment, and complications of frontal bone fractures associated, or not, with other facial fractures. This evaluation also sought to minimize the influence of the surgeon's skills and the preference for any rigid internal fixation system. The files from 3758 patients who attended the Oral and Maxillofacial Surgery Department of the School of Dentistry of Ribeirao Preto, University of Sao Paulo, from March 2004 to November 2011 and presented with facial trauma were scanned, and 52 files were chosen for the review. Eleven (21.15%) of these patients had pure fractures of the frontal bone, and trauma incidence was more prevalent in men (92.3%), whites (61.53%), and adults (50%). Despite the use of helmets at the moment of the trauma, motorcycle crashes were the most common etiological factor (32.69%). Fracture of the anterior wall of the frontal sinus with displacement was the main injury observed (54.9%), and the most common treatment was internal fixation with a plate and screws (45.09%). Postoperative complications were observed in 35.29% of the cases. The therapy applied was effective in handling this type of fracture, and the success rate was comparable to that reported in other published studies.

Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes.

Head trauma is a common cause of morbidity and mortality in the pediatric population and often results in a skull fracture. Pediatric skull fractures are distinct from adult fractures. Pediatric fractures have a greater capacity to remodel, but the pediatric brain and craniofacial skeleton are still developing. Although pediatric head trauma has been extensively studied, there is sparse literature regarding skull fractures. The authors' aim was to investigate the characteristics, injuries, complications, and outcomes of the patients in whom surgical intervention was needed for skull fractures. The authors performed a retrospective review of patients presenting to the emergency department of a pediatric Level I trauma center between 2000 and 2005 with skull fractures. Patient demographics, mechanism of injury, associated injuries, fracture bone involvement, surgical intervention, complications, and outcomes were analyzed. Groups treated nonoperatively, for skull fracture repair, and for traumatic brain injury were compared. A total of 897 patients with a skull fracture were analyzed. Most patients (n = 772, 86.1%) were treated nonoperatively (Non-Op group). Fifty-eight patients (6.5%) underwent repair of the fracture (Repair group) and 67 (7.5%) required intervention for treatment of traumatic brain injury (TBI group). The Non-Op group was significantly younger, and the TBI group had a lower initial Glasgow Coma Scale (GCS) score. A fall (51.2%) was the most common mechanism of injury in the Non-Op group, whereas a motor vehicle crash (23.9%) and being hit in the head with an object (48.2%) were most prevalent in the TBI and Repair groups, respectively. Associated injuries were seen in all 3 groups, with brain injury (hematoma) being the most common. Frontal bone fracture was seen most in the Repair and TBI groups, and the parietal bone was the most frequent bone fractured in the Non-Op group. Patients in the TBI group were much more likely to have 2 or 3 skull bones fractured. In the Repair group, 36.2% had a complication (38.0% intervention related and 62.0% trauma related), but no patient had a worsening of their neurological status. In the TBI group, 48.7% of the patients suffered a complication, the vast majority (90.6%) of which were related to the trauma. The majority of pediatric skull fractures can be managed conservatively. Of those requiring surgical intervention, fewer than half of the surgeries are performed solely for skull fracture repair only. Patients hit in the head with an object or involved in a motor vehicle crash are more likely to need surgical intervention either to repair the skull fracture or for TBI management, respectively. Frontal bone fractures are more likely to necessitate repair, and those patients treated for TBI have a greater incidence of 2 or 3 bones involved in the fracture. Complications occurred but most were related to underlying trauma, not the surgery. No patients who underwent intervention for repair of their skull fracture only had a worsening of their neurological status.

Reconstruction of orbital floor fracture using porous polyethylene mesh

Objective: Treatment of traumatic orbital injury has long been a formidable challenge to maxillofacial and oculoplastic surgeon. Significant complication can occur as a result of these injuries including enopthalmus, persistent diplopia, vertical dystopia and restriction of gaze. Surgical techniques have been more aggressive with primary surgical repair directed at restoring bony orbital volume and contour while repositioning the herniated tissues. The study was undertaken to assess the treatment results with alloplastic graft for reconstruction of orbital floor. Material and methods: It is a prospective randomized study during the period of January 2010 to December 2012 including the follow up of six months on ten orbital floor fractures. Results: Eyeball movement restriction and infraorbital nerve paresthesia improved in all patients. One patient who also had associated head injury and the fracture of supraorbital rim, frontal and temporal bone had persistent enopthalmus, vertical dystopia and diplopia postoperatively. Conclusion: We conclude that early exploration of orbital floor minimizes the morbity associated with late reconstruction due to the fibrosis of tissues entrapped. Use of prolene mesh reduces the operating time and donor site morbidity.

Fronto-orbital bone fracture: management and outcome

ObjectiveThe aim of this study was to review the effect of early and late surgical intervention and armamentarium used on the functional and esthetic outcome of fronto-orbital fracture repair.BackgroundOrbital roof fractures represent an important group of orbital fractures because of their close relation to the frontal lobe of the brain and also because of their relation to the eye. Management of orbital roof fractures requires good assessment, early reconstruction, if possible, and team management. Functional and esthetic outcomes should be assessed.Patients and methodsTwelve patients with orbital roof and frontal bone fractures were included in this study. Surgical treatment included open bone reduction alone, open reduction with fixation, and/or orbital reconstruction. Postoperative assessment of functional ocular deformities (limited eye movement and diplobia) and esthetic deformities (enophthalmos, dystopia, and proptosis) was carried out. Radiologic assessment for bone reduction and orbital volume was carried out.ResultsAll patients were males. They ranged in age from 16 to 61 years. Road traffic accidents were the cause of trauma in about 67% of patients. Early intervention was performed in 50% of patients, with 100% correction of functional deformities, 90% correction of esthetic deformities and accurate bone reduction in 95% of cases, and good patient satisfaction in 85% of cases. This was much better than late intervention. Titanium mesh was used in 50% of the cases, with accurate orbital volume reduction in 90% of the cases, which was only 50% with bone graft use.ConclusionEarly management of orbital roof and frontal bone fractures yields the best results. The use of titanium mesh leads to good functional and esthetic outcomes, with no donor-site morbidity, and saves time.

Facial trauma: Not a stigma in a newer single stage reconstructive surgery

In trauma surgery, instead of discarding the fractured bone segments as done in earlier days in patients with depressed skull fractures, these fragments can be used to reconstruct the damaged facial architecture.The aim of the study was to test the feasibility of managing comminuted frontal bone depressed fracture by a single stage debridement, reduction and replacement of the bone fragments and soft tissue reconstruction. bone cranioplasty using the native fractured bones was prospectively done in 11 patients over a period of one year from January 2011 to December 2012. We report on our clinical cases and the surgical technique of managing comminuted frontal bone fractures. The posttraumatic frontal bone defect was caused by road traffic accident. There were no deaths due to the minimal complications from the procedure. Two patients (18%) had mild scalp infections, 1 patient (0.9%) had epileptic seizure, which was controlled by medication. It thus concluded that the fractured frontal bone can be reconstructed immediately with debridement in spite of major sinus involvement and underlying brain and dural damage. Factors contributing to success are removal of foreign debris from the fractured bone segments, perfect dural repair with the use of pericranial flaps and bone cover being provided from beneath by the pericranial flap and above the skin. These segments heal excellently with bone remodeling.

Serial CT Findings of a Rapidly Calcified Epidural Hematoma in a Young Adult: A Case Report

We report serial computed tomography (CT) findings in a rare case of a rapidly calcified epidural hematoma. A 21-year-old female patient was admitted to our hospital after being involved in a motor vehicle accident. An initial cranial CT revealed a right frontal bone fracture. She complained of right frontal headache, but showed no neurological deficit or tendency for bleeding. Therefore, she was treated conservatively without surgical intervention. Follow-up CT revealed an ossified epidural hematoma (EDH) 17 days after the head injury, and the ossification later thickened. However, a decrease in the width of the EDH was observed during the 9 months of follow-up during which serial CT images were acquired. The EDH resolved 9 months after the initial trauma, but the calcification layer remained thickened.

The spectrum of facial fractures in motor vehicle accidents: an MDCT study of 374 patients

Road traffic accidents are a major health problem worldwide resulting frequently in maxillofacial injuries. The purpose of the study was to assess the incidence and spectrum of facial fractures in patients involved in a motor vehicle accident (MVA). Using picture archiving and communication system, all requests for suspected facial trauma were retrieved during a 62-month period; 374 met the inclusion criteria. Two researchers interpreted the multidetector computed tomography images by consensus. The motor vehicles involved were divided into two groups: those involving a passenger car or a larger vehicle and those involving a motorized two-wheeler. Furthermore, the motor vehicle accidents were divided into collisions and run-off-road accidents. Of the 374 patients (aged 15-80, mean 34), 271 (72 %) were male and 103 (28 %) female. Of all patients, 262 (70 %) had a facial or skull base fracture; of these, multiple separate fractures were present in 56 %. Nasal fractures were the most common fractures followed by orbital, skull base, and maxillary fractures. Frontal bone, LeFort, and zygomatic arch fractures were always accompanied by other fractures. Fractures were more frequent in the group of collisions compared with run-off-road accidents. In the two-wheeled group, only 15 % did not have facial or skull base fractures. Fractures often occur in multitudes as 39 % of all patients have multiple facial or skull bone fractures, and thus, emergency radiologists should be familiar with the complexity of the injuries. Negative clear sinus sign and low-energy sentinel injuries should be trusted as indications of undetected injuries in MVA victims.

A computed tomography study on two skulls of mistreated dogs from the Roman Age

The study of ancient skeletons is of high interest, as the relationship between men and animals can be reconstructed. In dogs, head injuries frequently result from direct physical traumas. The excavation of a prehistoric well (Genomi, Sardinia) brought to light sixty canine bones of the Age Roman (2nd century AD), although this well was built during the Nuragic Age. (1st millennium BC). Two canine skulls showing three traumatic lesions underwent computed tomography in order to study the endocast of the brain cavity and indirectly locate possible brain lesions. In the first case, a traumatic lesion was found in the left parietal bone with depression of the outer surface. This lesion determined compression of the left frontal cortex and was compatible with life, as can be deduced by the inflammation of the periostenum. In the second case, two different traumatic lesions were found. The former was a wide fracture of the right frontal bone near the orbital cavity. The injured area showed clear signs of bone remodeling which took place many months before death. The latter was a severe comminuted fracture involving both the outer and inner surface of the left frontal bone, which provoked a deep wound in the left frontal cortex. The sharp outline of bone splinters with no signs of bone remodelling indicates that the trauma was not compatible with life. All lesions described were consequent to severe blows from humans and testify mistreatment of dogs in the Roman Age.

Malignant infantile osteopetrosis

Osteopetrosis, a rare congenital genetic disease characterized by increased bone density due to impaired bone resorption by osteoclasts. It is classified into three forms: Infantile malignant autosomal recessive (AR) osteopetrosis, intermediate (AR) osteopetrosis and autosomal dominant (AD) osteopetrosis. Incidence of infantile malignant AR is 1/2,00,000 and if untreated has a fatal outcome. The condition is commonly diagnosed in infancy with symptoms of significant hematologic abnormalities with bone marrow failure, hepatosplenomegaly, macrocephaly with frontal bossing and bone fractures. Because of rarity of this type of malignant infantile form of osteopretrosis, we like to report this case of malignant infantile osteopetrosis who presented with bronchopneumonia, anemia with melaena at 2 months 15 days of age.

Bear Maul Craniocerebral Trauma in Kashmir Valley

Craniocerebral injuries constitute the bulk of the trauma patients in all the tertiary-care hospitals. Bear attacks as a cause of trauma to the brain and its protective covering are rare. This was a hospital-based retrospective (January 1990 to July 2005) and prospective study (August 2005 to December 2010). Craniocerebral trauma was seen in 49 patients of bear maul injuries. Loss of scalp tissue was seen in 17 patients, 13 of whom had exposed pericranium and needed split-thickness skin grafting, while 4 patients with exposed skull bones required scalp transposition flaps as an initial procedure. Skull bone fractures without associated brain injury were observed in 24 cases. Frontal bone was the site of fracture in the majority of cases (95%). Surgical intervention was needed in 18 patients for significantly depressed fractures. Three of these patients had depressed frontal bone fractures with underlying contusions and needed brain debridement and duraplasty. Injury to the brain was observed in 8 patients. Trauma to the brain and its protective coverings as a result of bear attacks is rarely known. Brain injury occurs less commonly as compared to soft tissue and bony injury. Craniocerebral trauma as a result of bear assaults has been a hitherto neglected area of trauma as the past reported incidence has been very low. Of late, the incidence and severity of such attacks has assumed grave proportions in areas adjacent to known bear habitats. An innocuous-looking surface wound might be the only presentation of an underlying severe brain trauma. Public awareness has to be generated to protect the people living in hilly areas.

Treatment of Frontal Sinus Fracture Using Bioabsorbable Mesh Plates

Accurate reduction and stable fixation are important in the treatment of frontal sinus fracture. Usually, metal plates and screws were used because of easy handling and delicate fixation. However, palpability and possibility for secondary operation for plate removal were shortcomings. For improving these problems, we used absorbable mesh plate for fixation of reduced frontal bones.In this study, 14 patients with frontal sinus fracture were treated by open reduction and rigid fixation using absorbable mesh plates. Mean follow-up period was 17.6 months. Considering anterior and posterior table involvement, nasofrontal duct injury, and concomitant neurosurgical problems, additional surgical procedures including degloving sinus mucosa, cranialization, and obliteration of nasofrontal duct were also conducted.There was no remarkable early and late postoperative complication. Aesthetic results were also satisfactory. Absorbable mesh plates were easy to mold and convenient for screw fixation. Moreover, there was no necessity of secondary operation for removal of plates.We believe that absorbable mesh plates might be a useful material for fixation instead of metal plates and screws especially in mild to moderate degree of frontal bone fractures.

Association between plate location and plate removal following facial fracture repair

Titanium-based plates used to repair facial fractures are sometimes removed despite their high biocompatibility. Local discomfort can lead to plate removal surgery. Local discomfort may differ according to patient characteristics, tissue properties and plate thickness; however, little is known about the relationship between these conditions and plate removal. We performed a hospital-based, retrospective cohort study of patients who underwent internal fixation for facial or frontal bone fracture. To identify factors associated with plate removal, we used multivariate logistic regression models. Data from 138 patients were analysed. All plates were made of commercially pure titanium, and all screws were made of titanium, 6% aluminium and 4% vanadium alloy. Plate thickness was 1.2 mm or 0.6 mm. Among plate locations, the frontozygomatic suture showed the highest percentage of complications (84%, 86 of 102 patients). The majority consisted of palpability and visibility. In patients who underwent plate removal (n = 96), all plates and screws were removed successfully. All plate-related complications were resolved after plate removal. No complications were introduced by plate removal. Plates 1.2 mm in thickness on the frontozygomatic suture had a relative risk of complications 2.48 times (95% confidence interval, 1.13-5.43) that of plates 0.6 mm in thickness. By multivariate analysis, the presence of plates on the frontozygomatic suture was a significant and independent risk factor for removal. Patients with plates on the frontozygomatic suture had a risk of plate removal 3.95 times (95% confidence interval, 1.55-10.07; P < 0.01) that of patients without plates on the frontozygomatic suture. Plates on the frontozygomatic suture have a high rate of complications. Thick plates increase these risks. Patients with plates on the frontozygomatic suture are more likely to undergo plate removal surgery than patients without plates on the frontozygomatic suture.

The Tolerance of the Frontal Bone to Blunt Impact

The current understanding of the tolerance of the frontal bone to blunt impact is limited. Previous studies have utilized vastly different methods, which limits the use of statistical analyses to determine the tolerance of the frontal bone. The purpose of this study is to determine the tolerance of the frontal bone to blunt impact. Acoustic emission sensors were used to provide a noncensored measure of the frontal bone tolerance and were essential due to the increase in impactor force after fracture onset. In this study, risk functions for fracture were developed using parametric and nonparametric techniques. The results of the statistical analyses suggest that a 50% risk of frontal bone fracture occurs at a force between 1885 N and 2405 N. Subjects that were found to have a frontal sinus present within the impacted region had a significantly higher risk of sustaining a fracture. There was no association between subject age and fracture force. The results of the current study suggest that utilizing peak force as an estimate of fracture tolerance will overestimate the force necessary to create a frontal bone fracture.

Esthetic correction of depressed frontal bone fracture

Depressed frontal bone fractures are occasionally seen in maxillofacial trauma patient. If untreated, they look un-esthetic. Although there are numerous options available for correction of these defects, use of bone cement (polymethylmethacrylate or PMMA) is simple and reliable. This is the report of one such case.

Orbital Floor Fracture Reconstruction Using Conchal Auricular Cartilage Graft

Orbital Floor Fracture Reconstruction Using Conchal Auricular Cartilage Graft

Orbital Floor Fracture Reconstruction using Conchal Auricular Cartilage Graft

Orbital Floor Fracture Reconstruction using Conchal Auricular Cartilage Graft