What are the treatment options for frontal bone fractures?

Frontal Bone Fracture Treatment

Treatment of frontal bone fractures depends primarily on the anatomical location and extent of injury: isolated anterior table fractures can often be managed conservatively or with open reduction and internal fixation (ORIF), while posterior table fractures with CSF leak or intracranial complications require surgical exploration with sinus cranialization or obliteration. 1, 2

Initial Assessment and Imaging

• CT maxillofacial without contrast is the gold standard initial imaging modality, providing superior delineation of osseous structures and detection of subtle nondisplaced fractures 1, 3
• Complementary CT head without contrast is essential since 56-87% of frontal bone fractures have associated intracranial injuries, with 8-10% requiring surgical intervention for subdural or epidural hematoma 1, 4
• 3D reconstructions are critical for surgical planning and characterizing complex fractures, significantly improving surgeon confidence 1, 3
• Evaluate for cervical spine injury, present in 6-19% of significant maxillofacial trauma cases 1

Treatment Algorithm by Fracture Type

Isolated Anterior Table Fractures (One-Third of Cases)

Non-displaced fractures:

• Conservative management with observation is appropriate 5, 6
• Follow-up imaging to monitor for delayed complications 5

Displaced fractures:

• ORIF via existing laceration or trans-eyebrow zig-zag approach to minimize scarring while maintaining adequate surgical access 2, 5, 7
• Titanium mini-plates for fixation in most cases 6
• Titanium mesh for comminuted fractures requiring larger reconstruction 6

Combined Anterior and Posterior Table Fractures (Two-Thirds of Cases)

Without CSF leak or nasofrontal duct involvement:

• Conservative ORIF approach via existing scar can achieve satisfactory results without requiring intracranial exploration 2
• Multidisciplinary discussion with neurosurgery is essential 2, 8

With CSF leak or nasofrontal duct obstruction:

• Surgical exploration via bifrontal craniotomy with sinus cranialization or obliteration is the standard approach 1, 2, 6
• Fat obliteration may be performed to prevent mucocele formation 6

Fractures with Specific Complications

Nasofrontal duct involvement:

• Requires surgical intervention to prevent mucocele formation and osteomyelitis 1, 4
• Injuries along the inferomedial aspect of the frontal sinus and anterior ethmoids are particularly high-risk 1

Cribriform plate involvement:

• Mandates surgical exploration due to risk of CSF leak and chronic sinusitis 1, 4
• CSF rhinorrhea is statistically more frequent with fracture extension to skull base (p < 0.001) 8

Orbital roof involvement:

• Requires evaluation for globe injury and extraocular muscle entrapment 1, 4

Surgical Timing

• Definitive treatment should be performed as early as safely possible once life-threatening injuries are stabilized 2, 8
• Management of ongoing hemorrhage or intracranial hypertension takes precedence over frontal bone fracture repair 1

Common Pitfalls and Caveats

• The posterior table is thin and delicate, easily fractured despite the anterior table's ability to withstand up to 1,000 kg of force 1
• Displaced posterior table fractures often indicate dural disruption and communication between frontal sinus and anterior cranial fossa 4
• Medial frontal sinus floor fractures typically involve the cribriform plate, requiring heightened vigilance for CSF leak 1, 4
• Traditional bicoronal approaches carry risks of unsightly scarring, alopecia, paresthesia, and temporal hollowing 7
• Conservative management is only appropriate for undisplaced fractures without duct involvement or CSF leak 5

Follow-Up Considerations

• Monitor for delayed complications including mucocele formation, osteomyelitis, and chronic sinusitis 1, 2
• Assess cosmetic outcomes and functional restoration of sinus drainage 2, 5
• Long-term imaging surveillance may be warranted for complex fractures 5