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

Background: Traumatic brain injuries (TBIs) are significant causes of morbidity and mortality worldwide. A compound depressed skull fracture (DSF) occurs when a laceration over the fracture exposes the internal cranial cavity to the external environment. DSFs are considered surgical emergencies that require prompt intervention to reduce morbidity and mortality. Currently, the literature lacks comprehensive information regarding the risks of intracranial infection and seizures, surgical indications, and the impact of surgical management on the functional and neurological outcomes of penetrating craniocerebral injuries (PCCIs). Our case report aims to enhance the existing literature by providing an overview of the management of frontal bone and frontal sinus fractures. We will emphasize key aspects such as the timing of surgery (early delayed), the risks of infection and seizures, and the selection of prophylactic antibiotics. We present a case of PCCI with DSF that resulted in a favorable functional outcome.

Case Description: We present a 21-year-old male who was involved in an MVA with an unknown mechanism and was brought by ambulance to our emergency department at Dammam Medical Complex. Initially, the patient was vitally stable, conscious, alert, and oriented. He had multiple scalp lacerations, including a mid-forehead open wound laceration with bone fragments and some brain tissue protruding out of the lacerated wound defect. After clinical deterioration, the patient underwent an urgent surgical exploration and elevation of skull fracture along with primary skull reconstruction. The mid-forehead wound defect was repaired in collaboration with the plastic surgery team.

Conclusions: Although a depressed frontal skull fracture involving both the outer and inner tables of the frontal sinus needs to be addressed on a case-by-case basis, cranialization of the inner table is preferred. Titanium mesh is a satisfactory alternative in case of inapplicable use of the patient's own bone fragments and chips. Collaborating with the plastic surgery team when dealing with complex mid-forehead wounds is also advisable to ensure optimal cosmetic outcomes. It is advisable to use anti-seizure medications (ASMs) prophylactically to prevent early, but not late, post-traumatic seizures (PTSs). A short course of broad-spectrum antibiotics is recommended in cases of open (compound) depressed fractures.