Techniques and Surgical Nuances of Management of Comminuted Fronto-Orbital Depressed Fractures: A Single-Surgeon Experience

Abstract

Compound fronto-orbital depressed fractures (FODFs) are complex fractures involving the frontal and orbital bones, with associated lacerated wounds on the skin. Repairing such fractures is challenging and requires a multidisciplinary approach. Surgical indications include cerebrospinal fluid rhinorrhea, exposed brain matter, frontal sinus fractures, vision impairment, and cosmetic disfigurement. The repair is typically done using titanium implants (low-profile plates [LPPs] and screws) for a good functional outcome. In this case series of 10 patients operated by a single surgeon (RG), we present different techniques for repairing FODF. Early surgery (< 48 hours) was performed to minimize infection risk. Surgical steps included elevation of depressed fragments, dural repair, and reconstruction of orbital walls using LPP. Some cases required inside-out fixation or suture fixation for better alignment of fragments. Autograft was used for severe bone loss. The results showed good functional outcomes with minimal infection rates. Primary single-stage repair using titanium implants provided satisfactory cosmesis. The use of inside-out repair and sutures was beneficial in specific cases. In conclusion, primary repair of FODF with titanium implants is safe and effective, reducing morbidity and cost. Early surgery and proper techniques are crucial for successful outcomes. Longer follow-up is needed to assess long-term viability and bone resorption.

Keywords

compound fronto-orbital depressed fractures - orbital wall reconstruction - dural repair - early surgery - cosmesis

Publikationsverlauf

Artikel online veröffentlicht:
02. Juli 2024

• References

• 1 Kim YH, Kang DH. Restoration of the fronto-orbital buttress with primary bone fragments. Korean J Neurotrauma 2019; 15 (01) 11-18
• 2 Marbacher S, Andres RH, Fathi AR, Fandino J. Primary reconstruction of open depressed skull fractures with titanium mesh. J Craniofac Surg 2008; 19 (02) 490-495
• 3 Nadell J, Kline DG. Primary reconstruction of depressed frontal skull fractures including those involving the sinus, orbit, and cribriform plate. J Neurosurg 1974; 41 (02) 400-207
• 4 Neville IS, Amorim RL, Paiva WS, Sanders FH, Teixeira MJ, de Andrade AF. Early surgery does not seem to be a pivotal criterion to improve prognosis in patients with frontal depressed skull fractures. BioMed Res Int 2014; 879286
• 5 Li X, Qian C, Yang S, Chen Y, Sun W, Wang Y. Cranial reconstruction with titanium clamps in frontal comminuted depressed skull fractures. J Craniofac Surg 2013; 24 (01) 247-249
• 6 Lee TT, Ratzker PA, Galarza M, Villanueva PA. Early combined management of frontal sinus and orbital and facial fractures. J Trauma 1998; 44 (04) 665-669
• 7 Awadalla AM, Ezzeddine H, Fawzy N, Saeed MA, Ahmad MR. Immediate single-stage reconstruction of complex frontofaciobasal injuries: part I. J Neurol Surg B Skull Base 2015; 76 (02) 108-116
• 8 Eom KS. Single-stage reconstruction with titanium mesh for compound comminuted depressed skull fracture. J Korean Neurosurg Soc 2020; 63 (05) 631-639
• 9 Wylen EL, Willis BK, Nanda A. Infection rate with replacement of bone fragment in compound depressed skull fractures. Surg Neurol 1999; 51 (04) 452-457
• 10 Braakman R. Depressed skull fracture: data, treatment, and follow-up in 225 consecutive cases. J Neurol Neurosurg Psychiatry 1972; 35 (03) 395-402
• 11 Jennett B, Miller JD. Infection after depressed fracture of skull. Implications for management of nonmissile injuries. J Neurosurg 1972; 36 (03) 333-339
• 12 Curry DJ, Frim DM. Delayed repair of open depressed skull fracture. Pediatr Neurosurg 1999; 31 (06) 294-297
• 13 Rehman L, Ghani E, Hussain A, Shah A, Noman MA. , Khaleeq-Uz-Zaman Infection in compound depressed fracture of the skull. J Coll Physicians Surg Pak 2007; 17 (03) 140-143
• 14 Piccolino P, Vetrano S, Mundula P, Di Lella G, Tedaldi M, Poladas G. Frontal bone fractures: new technique of closed reduction. J Craniofac Surg 2007; 18 (03) 695-698
• 15 Van Loock K, Menovsky T, Kamerling N, De Ridder D. Cranial bone flap fixation using a new device (Cranial LoopTM). Minim Invasive Neurosurg 2011; 54 (03) 119-124