1 Principles top
The goal of frontal sinus fracture management is to create a safe sinus, restore facial contour, and avoid short and long term complications.
The goal of open reduction is to reapproximate the bone fragments into their premorbid position and use internal fixation hardware to maintain them in their position.
2 Reduction topenlarge
The anterior table of the frontal sinus is normally convex. Compressive forces on the frontal bone deform the convexity into a concavity. This may or may not result in fracture comminution.
Mobilization of the depressed bone fragment(s) may require significant effort to overcome compressive forces between bone fragments.
There are several techniques to reduce the fragments:
- Mobilizing the bone fragments using an elevator
Inserting a screw into a bony fragment and reducing it by pulling it outwards
Minimally comminuted fractures may be stable after a simple reduction. Interfragmentary resistance may alleviate the need for internal fixation.
More comminuted fractures often require removal of bone fragments to achieve fracture reduction.
Pearl: identification of explanted bone fragments
Final orientation of any removed bone fragments can be challenging. Placing the explanted segments on a rough sketch of the skull made with a sterile pen will maintain orientation until re-implantation. Outline each segment and the overall shape of the defect.
The bone fragments should be kept moist until they are re-placed.
Pitfall: trapped mucosa
Comminuted fractures can result in trapped mucosa within fracture lines. This can result in sinusitis, or late mucocele formation.
Any redundant or injured mucosa at the periphery of the fracture or on isolated bone fragments should be removed.
If removal of anterior table bone fragments is required, the defect should be used to inspect the frontal recess and assure that it is not injured.
Pearl: trimming fragments
Traumatic distortion of fracture segments may make it difficult to realign them. While every effort should be made to maintain the integrity of each bone fragment, it may be necessary to trim the edge of a fragment to allow for fracture reduction.
3 Fixation topenlarge
Bone fragments should then be repositioned and fixed with internal fixation hardware.
Stability can generally be achieved with thin titanium plates. This will minimize the risk of visibility/palpability of the implants. The number of plates will be dictated by the stability of the reduction.
Alternatively, one long curved plate might be used to secure several fracture segments.