Is computed tomography (CT) required for every patient with a frontal bone fracture?

Is CT Needed in All Frontal Bone Fractures?

Yes, CT imaging is required for all suspected frontal bone fractures—multidetector CT (MDCT) of the maxillofacial region without contrast is the gold standard and has replaced plain radiographs as the initial imaging modality. 1, 2

Why CT is Mandatory

CT has completely supplanted plain radiographs because radiographs cannot characterize the full extent of fractures, detect nasofrontal duct involvement, or identify intracranial pathology. 1 In one study, approximately 3% of radiographs that failed to detect skull fractures actually had fractures visible on CT, and critically, half of these patients eventually developed epidural hematomas. 1

Superior Diagnostic Capabilities of CT

• MDCT provides superb delineation of both osseous and soft-tissue structures with high image resolution and thin-section acquisitions that detect subtle nondisplaced fractures. 1

• Multiplanar and 3-D reconstructions allow better characterization of complex fractures and are critical for surgical planning, significantly improving surgeon confidence. 1, 2

• CT acquisition is faster than radiography or MRI and is less reliant on patient positioning. 1

Critical Associated Injuries Requiring CT Detection

Intracranial Injuries (The Primary Concern)

56-87% of frontal bone fractures have associated intracranial injuries, and 8-10% require neurosurgical intervention for subdural or epidural hematoma. 2, 3 This extraordinarily high rate of life-threatening complications makes CT imaging non-negotiable.

• Specific intracranial findings to evaluate include: epidural hematoma, subdural hematoma, cerebral contusions, subarachnoid hemorrhage, pneumocephalus, and posterior table fractures. 3

• Complementary CT head without contrast is essential in addition to maxillofacial CT for complete characterization of frontal bone injuries and associated intracranial pathology. 2, 3

Cervical Spine Injuries

Cervical spine injuries occur in 6-19% of cases with significant maxillofacial trauma, with the likelihood increasing with injury severity. 1, 3 Frontal bone fractures result from direct anterior force that drives the cervical spine into extension, making concomitant cervical spine injury common in high-velocity trauma. 1

Fracture-Specific Complications Requiring CT Identification

• Posterior table fractures indicate potential disruption of the underlying dura and communication between the frontal sinus and anterior cranial fossa. 2, 3

• Nasofrontal duct involvement can lead to mucocele formation and osteomyelitis if not identified and managed surgically. 2, 3

• Cribriform plate involvement may result in CSF leak or chronic sinusitis. 2 CSF rhinorrhea is significantly more frequent with fractures extending to the skull base (p < 0.001). 4

• Orbital roof involvement requires evaluation for globe injury and extraocular muscle entrapment. 2

Clinical Algorithm for Frontal Bone Fracture Imaging

1. Obtain MDCT maxillofacial without contrast as the initial imaging study for any suspected frontal bone fracture. 1, 2

2. Add CT head without contrast to evaluate for intracranial injuries given the 56-87% association rate. 2, 3

3. Include 3-D reconstructions for surgical planning if operative intervention is anticipated. 1, 2

4. Consider cervical spine CT in high-velocity trauma given the 6-19% association with cervical spine injuries. 1, 3

5. Reserve MRI only for specific scenarios not adequately characterized by CT, such as unexplained cranial nerve deficits, suspected CSF leak from skull base fracture, or evaluation of herniated contents through skull base defects. 1

Common Pitfalls to Avoid

• Never rely on plain radiographs alone—they have only 53-82% accuracy and miss critical intracranial injuries. 1, 5

• Do not underestimate the posterior table—it is thin and delicate, easily fractured despite the anterior table's ability to withstand up to 1,000 kg of force. 2

• Vertical fractures carry worse prognosis than non-vertical frontal sinus fractures, with significantly higher mortality rates (18.4% vs 0%, p < 0.05) and deeper skull base extension (62.2% vs 15.7%, p = 0.0001). 6

• Patients can have significant brain injury even with normal neurological examination, and deterioration can occur hours after initial trauma. 3