A 33 year old male presents to the ED reporting he was assaulted last night. He is unsure what weapons were used, and is complaining of pain to his head and face. He reports a loss of consciousness during the assault. He denies pain or injuries to his extremities, visual changes, hearing loss, neck pain. His exam is significant for a lacrosse ball sized injury to his left forehead above his eyebrow. Pupils are equal, reactive and circular, EOMs intact, no midline tenderness in the cervical/thoracic/lumbar spine, no hemotympanum, no otorrhea/rhinorrhea, no facial instability, no nasal deformity or dental injury. No signs of injury on chest, back, abdomen or extremities, neurologic exam is unremarkable and intact in all 4 extremities, gait steady. You obtain CT imaging of the facial bones, head and neck, which reveal:
Diagnosis: isolated anterior table frontal bone fracture
- Mechanism: high-energy mechanism required to generate force, ie: unrestrained motor vehicle crashes, assault with blunt objects (bricks, baseball bat)
- High occurrence for concomitant injuries in facial bones, intracranial injury, cervical spine injury and ocular injuries
- Incident of intracranial injury up to 87% and ocular injuries up to 25%
- If extension into the temporal bones, patients require hearing and facial nerve function evaluation
- Important to evaluate the anterior and posterior tables of the frontal sinus as involvement of the posterior table requires surgical repair
- Dura is attached to the posterior table, surgical repair required to prevent complications such as pneumocephalus, CSF leak or infection
- Consider nonaccidental trauma especially in children, elders, pregnant women
- Management of isolated anterior table frontal bone fracture: sinus precautions, augmentin course, ENT/plastics follow up
References:
Hedayati T, Amin DP. Trauma to the Face. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.
Gaillard F, Bell D, Frontal sinus fracture. Reference article, Radiopaedia.org
