Introduction
Compound fronto-orbital depressed fractures (FODFs) are fractures that have cut lacerated wounds (CLWs) on the overlying skin, which may or may not include galea. In these types of fractures, the depressed fragment encompasses the frontal as well as the orbit. The repair of such a defect, if indicated, can be challenging and will require a multidisciplinary approach. Surgical indication of these fractures is cerebrospinal fluid (CSF) rhinorrhea, exposed brain matter through the wound, underlying contusion/hematoma, frontal sinus fracture (both inner and outer table), vision impairment, and cosmetic disfigurement.
Orbit walls are made laterally by the zygomatic frontal process, medially by the frontal process of the maxilla, superiorly by the frontal bone, and inferiorly by the maxilla. When associated with frontal bone fracture, most commonly, superior and lateral wall fractures are seen. Fractures of the fronto-orbital buttress can cause significant cosmetic deformity.[1] Especially when underlying hematoma or brain injury is present, the focus of primary intervention is to save the patient's life, and cosmetic concerns are secondary. Delayed repair of these defects is very difficult.
Due to the compound nature of the defects, there is a belief that it increases the risk of infections when repaired in a single sitting. On the contrary, this has been proved in many studies[2]
[3]
[4]
[5]
[6]
[7]
[8] that early (< 48 hours) or primary fixation of comminuted compound fractures with titanium implants (such as low-profile plates [LPPs] and screws) is safe and recommended for a good functional repair. Cases in which the wound is dirty and contaminated with foreign bodies should receive thorough saline lavage and wound debridement as the earliest intervention and then closing the skin defect over the fracture. In these cases, the role of primary fixation is still unclear.
These patients are managed with perioperative and postoperative broad-spectrum intravenous antibiotics. Due to the absence of guidelines for the management of FODF, different institutes have different guidelines.
Hence, through this case series of patients, we want to highlight the importance of correct alignment of frontal orbital bone pieces, dural repair, and anterior cranial fossa (ACF) base repair to prevent CSF leak. Also, some repairs are difficult, and the surgeon may not be able to achieve good cosmetic outcomes due to severe bone loss and contamination. However, neurological outcome and prevention of infection is a priority in these cases. We also present a treatment algorithm that will help clinicians to make decisions regarding repairs.
Methods and Materials
Data Collection
This is a consecutive case series of patients with FODF operated by a single surgeon (RG, senior resident in training) over a period of 1 year (2021–2022) under the guidance of senior consultants at our institute.
This series includes 10 cases that caused gross fronto-orbital malalignment and were associated with CLW on overlying skin. Cases without orbital fracture components were excluded.
Surgeries were done by neurosurgeons without help of plastic and maxillofacial surgeon ([Fig. 1]). All patients were managed with perioperative and postoperative broad-spectrum antibiotics (ceftriaxone, metronidazole, amikacin) for 3 weeks.
Fig. 1 Hospital policy for the management of compound depressed fractures. CSF, cerebrospinal fluid.
Patient follow-up was done either on an outpatient basis or telephonically and electronically shared photographs by the patients.
Surgical Steps
After induction and intubation, necessary venous and arterial access was taken, and the patient was positioned. The surgical steps comprised the following:
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Marking of skin incision: In cases with scalp CLW, an incision was fashioned using the same; in cases with bilateral frontal involvement, standard bicoronal incision was used.
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Raising of skin flap and harvesting pedicled vascularized pericranial graft and exposing bone fragments.
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Peripheral burr hole and elevation of depressed fragments with or without craniotomy.
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Removal of foreign bodies if any; thorough saline irrigation; frontal sinus cranialization, if exposed.
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Dural defect identification and durotomy if underlying hematoma or contusion.
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Repair of dural defect primarily or augmented by pericranial graft.
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Joining the comminuted fragments using LPPs and screws.
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Reduction of fracture and replacement of bone flap so as to reconstruct the supraorbital rim and lateral orbital wall (use of titanium mesh may or may not be required, depending upon bone loss and presence or absence of infection).
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Subgaleal drain placement and wound closure in layers (galea beneath the CLW is sutured separately).
These are the standard surgical steps followed in all these procedures, with a few extra techniques used, which are discussed later.
Illustrative Cases
All the cases that are discussed here suffered from comminuted fractures of the unilateral or bilateral fronto-orbital buttress. All patients underwent primary repair of depressed fragments in a single sitting. Only functional outcomes and cosmetic results have been discussed, and neuropsychological disturbances due to frontal lobe injury are not discussed. Summary of all the cases is presented in [Table 1] and few representative cases are discussed in detail.
Table 1
Summary of the cases and their outcomes
|
S. no
|
Age/Sex
|
Mechanism of injury
|
Type of fracture
|
CSF rhinorrhea
|
Indications of surgery
|
Timing of surgery
|
Frontal sinus cranialization
|
Surgery
|
Follow-up
|
|
1*
|
25/M
|
RTA
|
Closed comminuted
|
No
|
Deformity
|
< 24 hours
|
Yes
|
Primary repair with LPP
|
1 year: No infection; vision normal; cosmesis satisfactory
|
|
2
|
21/M
|
RTA
|
Compound comminuted
|
No
|
Contusion; deformity
|
< 24 hours
|
Yes
|
Primary repair with LPP
|
1 year: Visible implant over eyebrow after 6 months and 1 year; vision normal
|
|
3[#]
|
22/M
|
RTA
|
Compound comminuted
|
No
|
Deformity; sinus fracture
|
48–72 hours
|
Yes
|
Primary repair with LPP
|
No infection; vision normal; cosmesis satisfactory
|
|
4
|
50/M
|
RTA
|
Closed comminuted
|
No
|
Frontal sinus fracture
|
48–72 hours
|
Yes
|
Primary repair with sutures
|
1 year: Wound discharge at 6 months of follow-up controlled with oral antibiotics; no osteomyelitis; vision normal; left supraorbital rim defect
|
|
5
|
50/M
|
RTA
|
Compound comminuted
|
Yes
|
Deformity; sinus fracture
|
24–48 hours
|
Yes
|
Primary repair with LPP and sutures
|
1 year: No infection; no rhinorrhea; right eye vision loss; cosmesis not satisfactory
|
|
6*
|
28/M
|
RTA
|
Compound comminuted
|
Yes
|
Extradural hematoma
|
< 24 hours
|
Yes
|
Primary repair with LPP
|
1 year: No infection; no CSF rhinorrhea; vision normal; cosmesis satisfactory
|
|
7
|
26/M
|
RTA
|
Compound comminuted
|
No
|
Deformity
|
48–72 hours
|
Yes
|
Primary repair with LPP
|
–$
|
|
8
|
27/M
|
Assault
|
Compound comminuted
|
Yes
|
Rhinorrhea; sinus fracture
|
48–72 hours
|
Yes
|
Primary repair with sutures
|
1 year: No infection; no CSF rhinorrhea; vision normal; cosmesis satisfactory
|
|
9*
|
55/M
|
RTA
|
Compound comminuted
|
No
|
Deformity; sinus fracture
|
24–48 hours
|
Yes
|
Primary repair with LPP and sutures
|
1 year: Postoperative CSF rhinorrhea resolved with lumbar drain; long-term follow-up not present
|
|
10
|
18/M
|
RTA
|
Closed comminuted
|
No
|
Deformity; contusion
|
< 24 hours
|
Yes
|
Primary repair with LPP and sutures
|
1 year: No infection; vision normal; photophobia present; cosmesis satisfactory
|
Abbreviations: CSF, cerebrospinal fluid; LPP, low-profile plate; RTA, road traffic accident.
*Inside-out fixation of lateral orbital wall.
# Exchange cranioplasty.
Note: $- patient could not be contacted.
Case 1: Inside-Out Fixation Technique of Fracture Fragments
This is a 25-year-old male with a history of road traffic accident (RTA) and presented with a Glasgow Coma Scale (GCS) of E3M6V4; there was no CSF rhinorrhea. Preoperative computed tomography (CT) scans showed a closed comminuted fracture of the left fronto-orbital complex ([Fig. 2]). The patient underwent left frontal craniotomy and elevation of depressed fragments, orbital wall reconstruction, and frontal sinus cranialization with the repair of the underlying dural defect. Surgery was done within 24 hours of injury. Postoperative scans are showed in [Fig. 2]. The vision was normal in both eyes, pre- and postoperatively.
Fig. 2 Case 1. (A) Preoperative computed tomography of the brain, which shows a depressed left fronto-orbital fracture. (B) Surface-shaded display (SSD) reconstructed image shows fractured left fronto-zygomatic suture with depressed fronto-orbital buttress. (C) Postoperative SSD reconstructed image where the orbital ridge has been reconstructed with the satisfactory alignment of fragments using low-profile plates. (D) Red arrow shows the inside-out fixed fronto-zygomatic suture.
A good approximation of fracture fragments was achieved, and the orbital wall was reconstructed using inside-out fixation of LPP on the inner table along the lateral wall of the orbit. At 1-year follow-up, there was no sign of infection, cosmesis was satisfactory, and vision was normal.
This inside-out fixation is a useful technique that can be used when the fronto-zygomatic suture is fractured, and fragments are displaced and difficult to reduce. Also, in patients with CLW over eyebrows, mini-plates cannot be placed beneath the laceration because of the risk of implant exposure and infection.
Some of the cases done with these techniques are shown here, in [Fig. 3], showing a good reduction of displaced fractures of the lateral orbital wall.
Fig. 3 Set of images showing the inside-out technique of fixing displaced fronto-orbital buttress fracture. Images A-C shows minimally displaced fracture at fronto-zygomatic suture, fixed adequately with inside-out technique. Images D-F and images G-I shows good reduction of severely displaced frature of fronto-zygomatic suture using similar technique.
Case 2: Primary Rigid Fixation of Fracture Fragments
This 21-year-old male patient had a history of RTA. His GCS was E2M5V2 on presentation. Preoperative scans are shown in [Fig. 4]. The patient suffered from a comminuted compound fracture of the right fronto-orbital complex. He underwent right frontal craniotomy and elevation of depressed fracture, evacuation of frontal contusion, dural repair, cranialization of the frontal sinus, and intradural ACF base repair. Surgery was done within 24 hours, and fragments were primarily fixed with LPP.
Fig. 4 (A) Preoperative computed tomography (CT) of brain shows a right frontal displaced fracture with an underlying contusion. (B) Preoperative surface-shaded display (SSD) reconstructed image, which shows fracture of the zygoma and fronto-orbital buttress. (C) Postoperative SSD reconstructed image with good approximation of the fracture fragments is seen with low-profile plate over the bony prominence; inside-out fixation was not done. (D) Postoperative CT brain shows a good approximation of fragments and contusion evacuated.
The patient was E3M6V4 at discharge without a CSF leak, and vision was normal in both eyes.
Despite gross deformity, a good approximation of edges was seen. It was possible due to adequate exposure of the entire fronto-orbito-zygomatic complex. At 1-year follow-up, the patient underwent second reexploration for visible metallic implant over the lateral angle of the eyebrow.
A few of the cases showing such gross deformity were repaired using similar techniques shown in [Fig. 5].
Fig. 5 Rigid fixation with low-profile plate with a good approximation of fracture fragments.
Case 3: Exchange Cranioplasty
This 22-year-old patient with a history of RTA was E3M6V4 on presentation. The preoperative scan is shown in [Fig. 6]. The patient had a left frontal and supraorbital ridge compound comminuted fracture. He underwent bifrontal craniotomy and elevation of depressed fracture along with evacuation of frontal contusion, and intradural ACF base repair. The surgery took place more than 48 hours after injury; primary repair was with LPP and use of exchange cranioplasty, as small bone fragments over the fracture site were discarded. A small piece from the left temporal region was harvested and was used to reconstruct the supraorbital ridge. The patient was asymptomatic at 1-year follow-up.
Fig. 6 (A) Preoperative computed tomography (CT) of brain shows left frontal hematoma with depressed fronto-orbital fracture. (B) Preoperative surface-shaded display reconstructed image where comminuted fracture of the left orbital rim is seen. (C) Red curved arrows show the site of autograft, and, due to severe comminution, the original bone could not be used. Hence graft was reshaped according to the requirement and was implanted. (D) Postoperative CT brain shows good approximation and evacuated hematoma.
This technique is useful when severe bone loss is seen over the orbital ridge and even the orbital roof. Instead of using a titanium implant to cover the defect, which would have increased the risk of infection, an autograft was used.
Case 4: Suture Fixation of Fracture Fragments
This 26-year-old male patient had an RTA and was E3M5V2 on presentation. The preoperative scan is shown in [Fig. 7]. The patient had a closed comminuted fracture of the bilateral frontal and left supraorbital ridge. He underwent bifrontal craniotomy and elevation of fractured fragments along with evacuation of left frontal contusion, and dural repair with frontal sinus cranialization. Surgery happened more than 48 hours after the injury, with primary repair with a silk suture ([Fig. 7]). Due to unavailability of metallic implants, sutures were used. The patient was E4M6V5 on discharge without a CSF leak. At 6-month follow-up, he had a left supraorbital ridge defect with superficial wound infection that responded well to oral antibiotics. No osteomyelitis was seen in the CT scan. He was asymptomatic at 1-year follow-up.
Fig. 7 (A) Preoperative computed tomography of brain shows left fronto-orbital depressed fracture with an underlying contusion. (B) Preoperative surface-shaded display (SSD) reconstructed image showing the same findings. (C) Postoperative SSD reconstructed image shows displaced fracture fragments and poor approximation. (D) Image showing bony defects and contusion evacuated.
The piece of frontal bone adjoining nasion can be seen displaced and lifted, leaving a bone defect, and an approximation of the rest of the pieces was also not tightly fixed. These kinds of cases require adequate bone exposure till fronto-nasal suture and fixing the fractured fragments with LPP or a titanium implant if severe comminution is present.
Fixing bone with sutures can be used as an adjunct to decrease the number of LPPs being used, although simple cases can be done with sutures alone with a satisfactory result ([Fig. 8]).
Fig. 8 Image shows suture fixed fracture fragments. (A) Fracture was not causing any significant displacement of the fronto-orbital buttress. (B) Postoperative surface-shaded display reconstructed images show a good approximation of fracture fragments.
Case 5: Severely Comminuted Fracture
This 50-year-old male patient had RTA and presented with ExM5V4 on presentation. The patient suffered from a severely comminuted compound fracture of the right fronto-orbital complex along with complex ACF base fractures with CSF rhinorrhea ([Fig. 9]). He underwent bifrontal craniotomy and elevation of depressed fragments, right orbital roof advancement, and intradural ACF base repair. Surgery was done between 24 and 48 hours of injury, with primary repair with LPP and sutures.
Fig. 9 (A) Preoperative surface-shaded display (SSD) reconstructed image showing comminuted fracture of the right frontal bone and right fronto-orbital buttress with extensive anterior cranial fossa fractures (not shown). (B) Postoperative SSD reconstructed image shows attempted repair of the orbital rims with bifrontal craniotomy flap.
Due to severe comminution, the repair was difficult. Longer LPP was used to reconstruct the orbital rim, and smaller fragments were discarded. At 1-year follow-up, patient had right eye vision loss and no sign of infection or CSF leak. However, cosmesis was not satisfactory due to severe bone loss.
The priority in these cases is to prevent postoperative CSF leak and infection. Functional repair is warranted in these cases, and cosmetic repair is an added bonus.
Discussion
The case series presented here contains a spectrum of cases, from easily reducible fractures to severe bone losses. Three patients had CSF rhinorrhea preoperatively, and three patients did not have scalp lacerations. All repairs were done within 72 hours of the trauma. Frontal sinus cranialization was done for all cases, and the bone flap was fixed primarily in all cases in a single sitting. Since these cases were operated by a single surgeon over time, a learning curve is expected, especially in this anatomically complex region.
The most common mode of trauma in these patients remains RTA and assault, and it is not uncommon to see scalp lacerated wounds and foreign bodies embedded in the wound. Patients presenting late may also harbor subclinical or symptomatic infection. Despite that, attempts have been made to shorten the time between injury and intervention, which will curb the infection rates and will lead to a satisfactory repair.
Timing of the Surgery
Early repair is desirable to decrease infection rates in compound fractures. There seems to be no well-defined optimal time limit as to when the repair is relatively safe. Some authors have mentioned less than 48 hours to be adequate,[1]
[8]
[9]
[10] after which infection rates start increasing.[11] Curry and Frim[12] studied the effects of delayed repair in open depressed fractures in seven patients, where patients underwent cerebral perfusion pressure based treatment in the intensive care unit and broad-spectrum antibiotic therapy. The delay was 4 to 12 days long. None of the patients suffered from postoperative infection, CSF leak, or meningitis after a year-long follow-up. Similarly, Neville et al[4] compared early (< 24 hours) and late (> 24 hours) surgery outcomes and concluded that there was no statistically significant difference between the groups. Nadell and Kline found in their series that rather than the late presentation, the condition of the scalp is more important.[3] Risk factors of infection of comminuted compound fractures identified by Rehman et al are the presence of a dural defect, free bone fragments, and late presentation (> 8 hours).[13] Adequate wound debridement, good dural closure, and early surgery with perioperative antibiotics remain the key factors to avoiding infection. The consensus from these studies was that surgery should take place within 24 to 48 hours of the injury.
In our series of patients, two patients had wound infection 6 months after the surgery (cases 2 and 4), and the other seven patients did not have infection or CSF leak (one patient lost to follow-up). Surgery was done within 24 hours in case 2, discussed later. We recommend that surgery should be planned as early as possible, preferably within 24 hours, as infection rates increase after 48 hours. Pre- and perioperative broad-spectrum antibiotics are of paramount importance in cases of compound fractures.
Methods of Repair and Cosmesis
Kim and Kang[1] studied frontal buttress fracture repair and showed that primary repair with LPP is desirable with good cosmetic outcomes. They compared patients with autograft versus allograft and found that patients were more satisfied cosmetically with an autograft at 6 months of follow-up. They recommended that fractures should be treated with primary bone fragments whenever possible, especially in the pediatric age group.
Marbacher et al[2] and Eom[8] studied the use of titanium mesh in severely comminuted compound fractures as an option for primary single-stage surgery. Both studies concluded that infection rates were very minimal, nil in their series. The protocol was similar to ours, that is, early surgery with primary repair and perioperative antibiotics. Titanium mesh implant was not used in our series, but its use would have been beneficial in the management of cases like illustrative cases 4 and 5. The use of other techniques such as titanium clamps,[5] percutaneous reduction of closed fractures with minimal comminution,[14] and poly-ether-ether-ketone clamp like implants[15] is also described to fix the bone fragments.
In our series, five patients underwent repair using LPP only, which resulted in a good cosmetic outcome. In case 2, the metallic implant was seen exposed over the right eyebrow. The plate was put over the most prominent part of the orbital roof, hence the high chances of exposure. Three patients underwent repair using LPP and silk sutures, out of which one patient had a severe bone loss (case 5), which resulted in a bad cosmetic outcome. One patient had a good cosmetic outcome after 1 year of surgery without any deformity. Long-term result was not available for one patient (recently operated on). Two patients underwent repair using sutures only, one had a deformity of the left supraorbital rim and forehead (case 4), and another patient had a good cosmetic outcome.
Fracture fragment fixation using inside-out repair ([Fig. 3]) can be highly useful, especially when the fracture is on the bony prominences and when there is severe malalignment of fragments. It will avoid implant placement over the bony prominences.
We recommend that primary single-stage repair of fracture fragments with rigid fixation is desirable due to its results and cost-effectiveness. There is a theoretical risk of increased infection rates and hence poor cosmesis when using multiple implants over the poorly chosen area. This can be minimized by the use of silk sutures in selected and simple cases where there is no or minimal wound contamination, as this will bring down the cost of surgery without much difference in the outcome. Using only sutures for adjoining fragments is not recommended when repairing the orbital rim, as this will invariably lead to cosmetic defects and may cause infection.
Conclusion
It is of paramount importance that primary repair of comminuted FODF, compound or closed, is attempted. It will help in the early rehabilitation of the patient recovering from frontal lobe injuries and will avoid second surgery for cranioplasty. It will decrease morbidity and rate of wound infection, provide better cosmesis, and decrease the cost of treatment overall. Despite popular belief, the usage of titanium LPP and mesh implants does not increase the risk of infection. Longer follow-up is needed to determine the degree of bone resorption and long-term viability of the construct.
