Primary reconstruction of depressed frontal bone fracture including cranialization of frontal sinus and repair of forehead skin: a case report and literature review

Introduction

Traumatic brain injuries (TBIs) are significant causes of morbidity and mortality, affecting approximately ten million people worldwide (1). The two primary factors contributing to TBIs are motor vehicle accidents (MVAs) and falls. There has been a rising incidence of skull fractures among patients with TBIs, leading to unfavorable neurological outcomes (2). One type of cranial fracture is a depressed skull fracture (DSF), which typically occurs due to blunt head trauma. DSFs occur when both the inner and outer tables of the skull are displaced simultaneously. These fractures can be classified as closed or open (compound), depending on whether the overlying scalp and galea are disrupted. Complex depressed fractures additionally involve a tear in the dura mater (3). DSFs are considered surgical emergencies that require prompt management to reduce morbidity and mortality (4). Surgical management of DSFs includes wound debridement, elevation of the depressed bone fragments, sufficient irrigation, evaluation of any intracranial pathologies, skull reconstruction, and repair of venous sinuses if needed (4,5). In this report, we describe a case of a young patient involved in an MVA, which resulted in multiple scalp lacerations and an open mid-forehead wound measuring 1 cm × 1 cm. This wound displayed visible bone fragments and active bleeding, with some brain tissue protruding through the defect. Fortunately, the patient had a favorable functional outcome following surgery. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-85/rc).

Case presentation

A 21-year-old male was brought to our emergency department at Dammam Medical Complex a few hours after an MVA. Upon initial assessment, the patient was tachycardic, with a Glasgow Coma Scale (GCS) score of 14/15, and he was moving all of his limbs freely. A few minutes later, he experienced a generalized tonic-clonic seizure, which was controlled with propofol and a loading dose of phenytoin 20 mg/kg. Subsequently, he was intubated due to a decreased level of consciousness and bradycardia. He was started on one inotropic agent, along with two liters of normal saline and a bolus of 20% mannitol. Significant physical examination findings were multiple scalp lacerations and an open mid-forehead wound measuring 1 cm × 1 cm, with visible bone fragments and pulsating active bleeding, as well as protrusion of some brain tissue through the lacerated wound. After the patient was resuscitated and stabilized, he was taken for a comprehensive computed tomography (CT) scan. The head CT revealed multiple comminuted and depressed fractures of the frontal bone, involving both the anterior and posterior walls of the frontal sinus. Additionally, there were fractures involving the ethmoid sinus and the right superior orbital roof (see Figure 1A-1I). The patient was shifted for an urgent surgical exploration, which included wound debridement, DSF elevation, and reconstruction. A bi-coronal skin incision was planned to address the two frontal cut wounds and lacerations (see Figure 2A,2B). The surgical procedure began with a skin incision, followed by dissection of the galea and bilateral temporalis muscles. The skin flap was reflected forward and covered with wet gauze. Midline DSF bone fragments were noted, particularly on the right side (see Figure 2C,2D). These bone fragments were removed cautiously to avoid injuring the underlying brain tissue or causing a dural tear. Two burr holes were created on the superior aspect of the depressed fracture on both sides, followed by a craniotomy. The craniotomy bone flap was removed, and the depressed fractured fragments were elevated. The frontal sinus was exposed, and cranialization was performed using a curette to remove the retained materials. The sinus was filled with Surgisnow (fibrillar) (see Figure 2E). The inner table was elevated, and the brain began to pulsate. A small dural tear was sutured, and thorough irrigation was carried out. The craniotomy bone flap and fragments were soaked in pethidine for 10–15 minutes. For primary reconstruction, the patient’s bone fragments and a portion of titanium mesh were used to cover the remaining defect (see Figure 2F). Due to the absence of screws and plates, holes and suturing techniques were employed for the reconstruction. After achieving hemostasis, the plastic surgery team assisted with wound closure to repair the wide mid-frontal wound. Post-operatively, the patient received vancomycin 1 g every 12 hours for 5 days and meropenem 1 g every 8 hours for 4 days until blood and wound cultures returned negative. A post-operative head CT was performed (see Figure 3A-3D), and the patient was discharged with a GCS of 15/15, showing no neurological deficits. The patient was prescribed a maintenance anti-seizure medication (ASM), phenytoin 100 mg tid, for 6 months. Frequent clinic visits were scheduled to monitor therapeutic levels and ensure the patient remained seizure-free. A follow-up electroencephalogram (EEG) was planned to rule out the presence of any seizure focus before discontinuing the ASM. Six months after the surgery, a follow-up head CT (see Figure 3E-3H) showed a satisfactory and stable scan. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 Pre-operative non-enhanced head CT scans. (A-C) Soft tissue axial views showing depressed frontal skull fracture with no acute intra/extra-axial hematoma. (D-F) Bone window axial views showing multiple frontal depressed skull fractures involving outer and inner tables of frontal sinus with hemosinus. (G,H) Bone window coronal views showing multiple frontal depressed skull fractures extending to the right superior orbital roof. (I) Bone window sagittal view showing the depth of depressed frontal skull fracture exceeding the thickness of the calvarium. CT, computed tomography.

Figure 2 Intra-operative images. (A,B) Bi-coronal skin incision designed to involve the two right-sided wound lacerations. Mid-forehead opened skin defect with visible bone fragments are shown. (C) Skin flap reflected forward, showing comminuted and depressed frontal skull fracture. (D) Focused figure over the depressed frontal skull fracture. (E) Bilateral two superior corner burr hole sites, removal of bone fragments and removal of craniotomy flap, frontal sinus cranialization filled with fibrillary (part of fibrillary is visible, see white arrow). (F) Primary frontal bone reconstruction using patient’s bone fragments and a portion of titanium mesh to covers the remaining defective part inferiorly. This image is published with the patient’s consent.

Figure 3 Post-operative non-enhanced head CT scans. (A,B) Day 1 post-op, soft tissue axial cuts showing expansion of normal brain parenchyma with no intra-cranial injuries. (C,D) Day 1 post-op, bone window axial cuts showing frontal skull and sinus fracture repair. (E) Six months post-op, bone window sagittal view demonstrating a stable frontal sinus repair. (F) Six months post-op, bone window axial view showing frontal skull fracture repair. (G) Six months post-op, bone window coronal view showing the healed right-sided orbital roof fracture. (H) Six months post-op, soft tissue cut axial view showing a preserved grey-white matter junction with no intra-axial injuries. This image is published with the patient’s consent. CT, computed tomography.

Discussion

Frontal bone fractures account for 5–15% of maxillofacial fractures (6). One of the most common causes of frontal depressed fractures is MVAs, particularly those involving high-energy impacts to the forehead (6-8). Other causes include sports-related injuries such as martial arts or boxing (6,9), alleged assaults, and falls from heights (6). Due to the thickness of the frontal bone, a substantial amount of force, ranging from 800 to over 2,200 pounds, is typically required to cause a fracture (10), which is often the result of blunt trauma (6). Consequently, associated intracranial injuries are expected (10), including intraparenchymal, epidural, or subdural hematomas, dural tears resulting in cerebrospinal fluid (CSF) leaks, and cerebral contusions (9). Additionally, ophthalmological injuries such as diplopia, retinal detachment, and blindness, as well as maxillofacial injuries including pan-facial fractures, midface fractures, and orbital wall fractures, can occur (9). Fractures that involve the frontal sinus, orbit, or the middle or posterior cranial fossae have the highest rates of mortality and complications (11). The standard management approach for DSFs typically involves surgically elevating the depressed bone. However, it can cause fatal hemorrhage if the depressed bone fragments obstruct a tear in the venous sinus. Therefore, surgical intervention for DSFs located over major venous sinuses remains controversial (12,13). There are no specific guidelines in the literature regarding the ideal timing for surgical intervention in cases of DSFs, and this remains a topic of significant debate (3,7,14). However, previous reports indicate that complications from DSFs tend to arise within 48 hours following trauma (7,14). In a study by Ahmad et al. (12), which involved 90 patients with moderate to severe head injuries accompanied by DSFs who underwent urgent surgical decompression, it was found that 73 patients (81.1%) had a good recovery. Only five patients (5.5%) experienced moderate disability based on the Glasgow Outcome Scale (GOS) (12). This suggests that earlier surgical intervention, even in cases of moderate to severe TBIs, is associated with better prognosis and surgical outcomes (12). In contrast, a retrospective study involving 40 patients divided into two groups- those who underwent surgery within 24 hours (early surgery) and those who had surgery after 24 hours (late surgery)- reported no significant difference between these groups in terms of unfavorable outcomes, late post-traumatic seizures (PTSs), disturbances in smell and taste, or mortality (3). However, patients with concomitant intracranial pathologies, such as hematomas, will require early surgical evacuation (3). The management of frontal DSFs is individualized based on various factors. These factors include the location and severity of the injury (such as involvement of the anterior table, posterior table, or both), the GCS at the time of presentation, and the presence of CSF leaks, bleeding, or intracranial injuries causing mass effect. Additionally, the presence of other systemic injuries and damage to the nasofrontal duct (NFD) are considered (6,7,10,15). The primary objectives of surgical intervention for frontal bone and sinus fractures are to re-establish the barrier between the intracranial structures and the frontal sinus, to prevent both long-term and short-term complications—such as the formation of mucoceles—and, if possible, to restore or completely remove the NFD, all while ensuring a satisfactory cosmetic outcome (10,15). Three key indications for surgical intervention in cases of frontal sinus fractures include the presence of a CSF leak, blockage of NFD, and significantly displaced fractures of the posterior table that exceed the thickness of one cortical layer (14). In cases where posterior table fractures involve more than 25% of the area or are severely displaced or comminuted, cranialization is necessary. This approach allows direct visualization to repair any tears in the dura, thereby reducing the risk of CSF leaks. Furthermore, it facilitates the thorough removal of any retained mucosa from the frontal sinus, lowering the chances of mucopyocele or mucocele formation (10). For anterior table fractures that are severely comminuted, obliteration is required (10). Numerous management algorithms for frontal sinus fractures have been proposed in the literature. Most of these algorithms consider the extent of bone injury, type of fractured bone, NFD involvement, and the presence or absence of CSF leak (14,15). Figure 4 illustrates a management algorithm for frontal sinus fractures (14). With improper management of frontal bone fractures, severe complications could arise, particularly those involving posterior table fractures, such as meningitis, encephalitis, CSF leak, cavernous sinus thrombosis, tears in the dura, and brain abscess (10,15). The conventional approach to treating patients with compound comminuted depressed fractures involves the following steps: wound debridement, fracture elevation, removal of residual bone fragments, sufficient irrigation, evaluation of any intracranial associated pathologies, and a secondary delayed cranioplasty (16). It is important to note that there is no difference in the infection rate between an immediate single-stage reconstruction with titanium mesh for compound comminuted DSF and a delayed secondary cranioplasty (16). However, single-stage reconstruction offers advantages regarding safety, cost-effectiveness, and improved psychological and cosmetic outcomes (16). Different types of autografts and alloplasts are used to obliterate the frontal sinus. Alloplasts include materials such as gel foam, oxidized cellulose, bioglass, methyl methacrylate, hydroxyapatite cement, and calcium sulfate. Autografts consist of adipose tissue, pericranium, temporalis fascia, lyophilized cartilage, and bone chips (9). Titanium mesh is effective for correcting deep, minor, or significant defects in the frontal bone due to its excellent biocompatibility and high tensile strength, which help reduce postoperative complications (9,10,17). In terms of cosmetic outcomes, titanium mesh provides satisfactory results by restoring a pleasing contour to the frontal skull and facilitating surgery, even in cases involving orbital bone fractures (16,18). One of the most accessible autologous materials to harvest is the pericranial flap, which tends to be highly vascular. This vascularity helps decrease the risk of delayed postoperative infection (10). Postoperative complications associated with comminuted fractures of the anterior wall of the frontal sinus include hardware extrusion, palpability or adherence, deformities in the contour of the frontal bone, and skin thinning. A study has introduced a technique that utilizes two anteriorly based pericranial flaps. This approach serves two main purposes: one flap is used to obliterate the frontal sinus, creating a safe sinus environment, while the second flap helps restore a smooth contour of the forehead. This second flap also covers the hardware, minimizing the risk of hardware extrusion, palpability, and skin thinning (19). Our patient suffered from an open wound fracture, which rendered the area unsuitable for using a pericranial flap due to concerns of infection and lack of sterility. Consequently, we avoided using the pericranial flap and muscle tissue for the same reasons, as these materials could potentially introduce infection and compromise the sterility of the area. Typically, muscle tissue is preferred for sinus obliteration and yields good results; however, muscle degradation can lead to an empty sinus upon long-term follow-up (20). Many surgeons favor abdominal fat grafts due to their lower resorption rates compared to muscle tissue (21). Overall, in straightforward cases, there is typically no significant difference in using any material—whether fat, muscle, or fascia—for plugging the sinus (20,22). In our institution, we utilize Surgisnow for cases involving open wound fractures. Several guidelines in the literature recommend the use of broad-spectrum antibiotics for penetrating craniocerebral injuries (PCCIs). The most commonly reported pathogens include methicillin-sensitive Staphylococcus aureus (MSSA) at 54%, Streptococcus pneumoniae at 15%, and Klebsiella pneumoniae at 15% (23,24). The duration of antibiotic treatment typically depends on the neurosurgeon’s preference (23). If there is no organic debris in the wound, a short course of cefazolin 2 g every 8 hours intravenously is recommended. However, if organic debris is present, a combination of metronidazole 7.5 mg/kg every 6 hours and ceftriaxone 2 g every 12 hours is advised, along with wound debridement if necessary (23,24). For patients with a penicillin allergy, alternatives such as linezolide 600 mg twice daily or vancomycin 30 mg/kg can be considered (24). There is an increased risk of PTSs following moderate to severe TBIs. Early PTS occurs within 7 days after the trauma, while late PTS occurs after 7 days. The use of ASMs can help prevent early PTSs, but they do not prevent late PTSs. Current guidelines recommend phenytoin or, more recently, levetiracetam for preventing early PTSs (25). At our institution, we prescribe either phenytoin or levetiracetam for a period of 6 months, along with regular outpatient follow-up visits to monitor for seizures and to check therapeutic levels of ASMs in the blood. If the patient remains seizure-free for 6 months, we recommend performing an EEG and may begin tapering the ASMs if the EEG results are normal. However, if the patient experiences recurrent seizures during the first 6 months after the trauma, we continue the ASMs for up to two years, with regular outpatient follow-up visits. An EEG will be repeated after two years, and if the results are normal, with no history of seizure episodes, we will consider starting to taper ASMs.

Figure 4 A management algorithm for frontal sinus fracture. This figure was adapted from an Open Access article (14) under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/). NFD, nasofrontal duct; CSF, cerebrospinal fluid.

Conclusions

The frontal bone is quite thick, and a fracture typically requires significant force, such as an MVA involving frontal impact. These fractures are often associated with underlying intracranial injuries. Cranialization is preferred as it allows for the thorough removal of any retained mucosa from the sinus, which reduces the risk of mucocele formation. The frontal sinus fractures algorithm provides a systematic approach to managing future cases. When the patient’s bone fragments and chips cannot be used, titanium mesh is a satisfactory alternative. Single-stage reconstruction is preferred due to its advantages regarding safety, cost-effectiveness, and enhanced psychological and cosmetic outcomes. Collaboration with a plastic surgery team is advisable to ensure optimal cosmetic outcomes in cases of complex mid-forehead open wounds. Early surgical intervention for DSFs is recommended, especially as the patient’s condition starts to deteriorate clinically. However, there was no evidence in the literature that operating within 48 hours would reduce the risk of infection. A short course of broad-spectrum prophylactic antibiotics is recommended, and ASMs should be administered prophylactically to prevent early, but not late, PTSs.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-85/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-85/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-85/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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