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Craniofacial/Pediatric: Review article

Frontal Sinus Fractures: Evidence and Clinical Reflections

Lopez, Christopher D. MD*; Rodriguez Colon, Ricardo BS; Lopez, Joseph MD, MBA*; Manson, Paul N. MD*; Rodriguez, Eduardo D. MD, DDS

Author Information
Plastic and Reconstructive Surgery - Global Open: April 2022 - Volume 10 - Issue 4 - p e4266
doi: 10.1097/GOX.0000000000004266
  • Open
  • SDC
  • UNITED STATES
  • Practical Reviews

Abstract

Takeaways

Question: Despite significant advances in the management of frontal sinus fractures a paucity of large-cohort data remains. The purpose of our study was to present an evidence-based overview of frontal sinus fracture management and outcomes.

Findings: Over the past 25 years, there have been no significant changes in the fracture patterns, mechanisms of injury, treatment, or overall complications of frontal sinus injuries. However, more complications were seen in patients with nasofrontal outflow tract injury, highlighting the importance of this anatomic area.

Meaning: Frontal sinus fracture management is a challenging clinical situation that should be guided by thorough assessment of the fracture pattern and associated fractures.

INTRODUCTION

Frontal sinus fractures constitute 5%–15% of all craniomaxillofacial fractures.1–4 Landmark advances in management include division of fracture subtypes based on anatomic components (eg, anterior versus posterior wall), establishing the importance of fracture displacement, nasofrontal outflow tract (NFOT) involvement, presence of cerebrospinal fluid (CSF) leak, and computed tomography (CT) imaging for management.5,6 Indeed, statistically powered data have established that the degree of NFOT injury is critical for predicting frontal sinus fracture complications.7 Injury severity has dramatically lessened since the advent and adoption of vehicular safety belts and airbags.8 Consequently, a contemporary shift in paradigm secondary to less-severe injury patterns has resulted in the adoption of conservative approaches that preserve the sinus, such as nonsurgical management of posterior table fractures and endoscopic repair of NFOT and/or posterior tables fractures.9–13 Although valuable, the utility of these reports are unclear, given that the majority of these reports are underpowered, heterogenous, and often contradictory.

Large-cohort studies have helped define the relationship between the extent of NFOT injury and fracture patterns, in addition to their effects on complication rates.7 Statistically significant data support an evidence-based treatment algorithm for management of frontal sinus fracture. Obstruction is the most clinically significant radiographic finding of NFOT injury; the majority of patients with NFOT injury who developed complications had evidence of obstruction at the time of presentation.6,8 When obstruction was present with an additional radiographic finding indicative of NFOT injury, either anterior ethmoid cell fracture and/or frontal sinus floor fracture, rates of complications after observation, and reconstruction management in these patients was 100%.7 These findings collectively suggest that management of NFOT with evidence of obstruction, and in particular with additional radiographic evidence of NFOT injury, should focus on obliteration and cranialization. Observation, however, can be done safely in the absence of NFOT obstruction. Since this large-cohort study in 2008, there have been few additional studies of similar scale, limiting innovation on evidence-based management guidelines.

The paucity of large-cohort data investigating frontal sinus fractures has made it challenging to provide updated, evidence-based management guidelines. Indeed, recent reports favoring endoscopic approaches13 have been contested on account of limited cohorts and other factors such as a paucity of severe fracture patterns.14 To date, the need for large-scale data remains unaddressed. The largest retrospective cohort is from 2008 and includes more than 850 patients,7 while the next-largest report, from 2000, is less than a third of that size. Very few studies, the most recent of which is from 2013, have included more than 100 patients.3,15–19 A comprehensive synthesis of the data currently available has yet to be presented. To aid surgical decision-making, this article presents a systematic, evidence-based review of all frontal sinus fracture reports in the literature and offers perspectives based on both data and extensive experience from the senior authors, in addressing this unique clinical challenge.

METHODS

Literature Search

A comprehensive search in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed, querying two databases (PubMed and Medline) through 2020. The following search terms “frontal sinus” AND “fracture” OR “trauma” OR “injury” OR “involvement” were utilized, and additional articles were extrapolated from identified articles.

Selection Criteria

Two independent reviewers (CDL, RRC) analyzed all queried results for relevancy. Any conflicts between the two reviewers were discussed and a consensus was agreed upon. Articles reporting on data regarding frontal sinus fracture injuries, management, and outcomes were included. We excluded studies that lacked relevant information on mechanism of injury (MOI), fracture pattern, and management, along with non-English articles, cadaveric studies, case reports, technical papers, and abstracts/conference proceedings.

Data Extraction and Analysis

Included articles were examined, and data on MOI, fracture pattern, fracture management, NFOT involvement, CNS injury, and complications were recorded. Additional patient information was collected, including patient sample size, demographics, and follow-up length. Lastly, author and year of publication were documented. Studies that included the same subset of patients as a larger study by the same group were counted only once with the larger study included, so as to not double count patients and subsequently bias the data. We used a two-sided unpaired student t-test to assess for difference in means of continuous variables, and the Pearson chi-square test to assess for difference in proportions between categorical variables. All statistical analyses were performed using IBM SPSS (version 26), and statistical significance was reported as a P value less than 0.05.

RESULTS

Description of Studies

Our initial database search based on our search parameters yielded 449 articles, but only 53 met inclusion criteria and were included in our study (Fig. 1). We organized included articles into 5-year increments for analysis. One article was from 1991 to 1995, four from 1996 to 2000, six from 2001 to 2005, 11 from 2006 to 2010, 20 from 2011 to 2015, and 11 from 2016 to 2020. The majority of patients included in these articles were men in their early 30s (Table 1). The majority of articles were classified as below level II quality of evidence, based on Oxford’s Level of Evidence, and included retrospective reviews, systematic reviews, and case reports. A risk of bias assessment was performed using the National Institute of Health Quality Assessment Tool for Case Series Studies; all studies were deemed to be of acceptable quality.

Table 1. - Demographics of Included Studies
Year Range No. Studies Age (mean ± SD) Total No. Presented Time to Follow-up (mo) No. Men % Men No. Women % Women
92–95 1 29.6 5 9 3 60 2 40
96–00 4 32.3 ± 4.8 101.7 ± 61.9 55.7 ± 32.7 88.8 ± 55.2 87.4 ± 6.4 13.0 ± 8.0 12.6 ± 6.4
01–05 6 32.5 ± 5.3 17.3 ± 13.1 20.4 ± 14.7 15.0 ± 10.6 88.8 ± 7.2 2.3 ± 2.9 11.1 ± 7.2
06–10* 11 33.2 ± 6.2 127.7 ± 245.8 12.2 ± 5.6 47.7 ± 39.3 90.1 ± 6.9 7.1 ± 7.1 9.9 ± 6.9
11–15* 20 34.3 ± 3.3 44.7 ± 64.9 18.0 ± 18.8 42.2 ± 58.2 87.0 ± 12.9 6.5 ± 9.7 13.0 ± 12.9
16–20* 11 33.0 ± 4.5 57.0 ± 81.3 20.8 ± 14.0 53.7 ± 76.1 87.5 ± 16.2 8.0 ± 9.1 15.0 ± 10.8
*Articles in which gender was not identified.

F1
Fig. 1.:
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart of included studies.

Mechanism of Injury

The most common MOIs were passengers in motor vehicle accidents (MVA) and blunt trauma (assault and falls), with each reported in 47 articles (88.7%). We identified a trend toward a decrease in the average number of frontal sinus fractures due to MVA, from 53.6% (218/407) in 1996–2000 to 33.3% (209/627) in 2016–2020, along with an increase in blunt trauma, from 28.8% (117/407) in 1996–2000 to 42.1% (264/627) in 2016–2020 (Table 2). This difference was not statistically significant (MVA P = 0.942, blunt trauma P = 0.815).

Table 2. - Mechanisms of Injury per 5-Year Increments
Years Total No. Patients MOI MVA Passenger MOI MVA Pedestrian MOI Motorcycle MOI Blunt Trauma MOI Gunshot MOI Other MOI Unknown
92–95 5 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (40.0%) 3 (60.0%)
96–00 407 218 (53.6%) 0 (0.0%) 1 (0.3%) 117 (28.8%) 27 (6.6%) 44 (10.8%) 0 (0.0%)
01–05 104 44 (42.3%) 2 (1.9%) 6 (5.8%) 31 (29.8%) 1 (1.0%) 14 (13.5%) 6 (5.8%)
06–10 1405 627 (44.6%) 68 (4.8%) 140 (10.0%) 267 (19.0%) 73 (5.2%) 215 (15.3%) 15 (1.1%)
11–15 893 341 (38.2%) 15 (1.7%) 55 (25.6%) 229 (25.6%) 9 (1.0%) 231 (25.9%) 13 (1.5%)
16–20 627 209 (33.3%) 42 (6.7%) 0 (0.0%) 264 (42.1%) 29 (4.6%) 77 (12.3%) 6 (1.0%)
Totals 3441 1439 (41.8%) 127 (3.7%) 202 (5.9%) 908 (26.4%) 139 (4.0%) 583 (16.9%) 43 (1.2%)

Fracture Pattern

Nondisplaced anterior table fractures (29.6%) were the most frequently reported fracture type, followed by nondisplaced anterior table and posterior table (AT/PT) fractures (25.6%), and displaced AT/PT fractures (24.5%) (Table 3). We found a statistically significant change in displaced posterior table fractures over the study period (P = 0.041); all other fracture patterns demonstrated no statistically significant difference in prevalence.

Table 3. - Frontal Sinus Fracture Type per 5-Year Increments
Years AT AT Displaced PT PT Displaced AT/PT AT/PT Displaced
92–95 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 5 (100.0%)
96–00 82 (20.2%) 130 (31.9%) 9 (2.2%) 3 (0.7%) 39 (9.6%) 140 (34.4%)
01–05 45 (43.3%) 34 (32.7%) 0 (0.0%) 0 (0.0%) 14 (13.5%) 11 (10.6%)
06–10 402 (28.6%) 162 (11.5%) 38 (2.7%) 28 (2.0%) 353 (25.1%) 414 (29.5%)
11–15 316 (35.4%) 108 (12.1%) 34 (3.8%) 0 (0.0%) 261 (29.2%) 173 (19.4%)
16–20 173 (27.6%) 68 (10.9%) 70 (11.2%) 0 (0.0%) 214 (34.1%) 101 (16.1%)
Totals 1018 (29.6%) 502 (14.6%) 151 (4.4%) 31 (0.9%) 881 (25.6%) 844 (24.5%)
P values 0.740 0.090 0.416 0.041 0.744 0.220
AT, anterior table; PT, posterior table.
The bold p-value denotes statistical significance of posterior table displacement.

Interventions

We found nonoperative management to be the most common form of management (32.9%), followed by reconstruction (27.8%), obliteration of the frontal sinus (18.8%), and cranialization (17.2%) (Table 4). There was no statistically significant difference in the frequency of management type used from 1995 to 2020.

Table 4. - Management Type per 5-Year Increments
Years Reconstruction Cranialization Obliteration Osteoneogenesis Nonsurgical Other
92–95 0 (0.0%) 0 (0.0%) 5 (100.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
96–00 133 (32.7%) 68 (16.7%) 96 (23.6%) 11 (2.7%) 97 (23.8%) 2 (0.5%)
01–05 37 (35.6%) 5 (4.8%) 44 (42.3%) 0 (0.0%) 18 (17.3%) 0 (0.0%)
06–10 248 (17.7%) 300 (21.4%) 345 (24.6%) 22 (1.6%) 471 (33.5%) 3 (0.2%)
11–15 405 (45.4%) 144 (16.1%) 110 (12.3%) 0 (0.0%) 230 (25.8%) 4 (0.5%)
16–20 132 (21.1%) 76 (12.1%) 48 (7.7%) 0 (0.0%) 317 (50.6%) 54 (8.6%)
Totals 955 (27.8%) 593 (17.2%) 648 (18.8%) 33 (1.0%) 1133 (32.9%) 63 (1.8%)

Complications

The overall complication rate of all studies was 9.3%. When comparing the complication rate between those with NFOT injury with those without, we found a higher complication rate associated with NFOT involvement (P < 0.001) (Fig. 2). However, we found no difference in complication rate across the forms of management in patients with NFOT injury (all P values > 0.05). There was an increase in complications with longer clinical follow-up (Fig. 3).

F2
Fig. 2.:
Complication rate based on the presence of NFOT injury.
F3
Fig. 3.:
Relationship of complications and follow-up length.

DISCUSSION

Frontal Sinus Management

The management of frontal sinus fractures remains challenging and often necessitates interdisciplinary collaboration from specialties such as plastic surgery, neurosurgery, and otolaryngology. We briefly summarize currently available treatment options below, which range from observation to cranialization.

Conservative management often includes clinical follow-up with CT scans or endoscopic treatments to recanalize the NFOT.20 Patients can also be started on nasal decongestants to promote drainage from the sinuses.21 If complications ultimately arise, these patients are often managed endoscopically.11,22,23

Obliteration involves removal of all the mucosa in the sinus, burring of sinus walls to eliminate mucosal invaginations, plugging of the NFOT, and filling of the sinus cavity with either fat, muscle, bone, or alloplasts, effectively removing the sinus as a functional unit. The choice of obliteration material is controversial. Bone grafts encourage ossification of the sinus, while galeal and pericranial flaps provide vascularized tissue to the site of injury3,24–26 (Fig. 4). Conversely, fat (a nonvascularized option) relies on the vascular bed of the sinus for vascularization, which in cases of comminuted fractures has decreased blood supply. Additionally, some may choose to do nothing following stripping of the mucosa and allow for osteoneogenesis of the sinus, with the bone forming scar tissue.27

F4
Fig. 4.:
Intraoperative view of pericranial flap for NFOT obliteration. Published with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.

Cranialization, first described in 1978 by Donald and Bernstein, involves the surgical removal of the nasofrontal ducts, posterior table of the frontal sinus, and all mucosa within the sinus.28 This results in brain expansion into the sinus space, which becomes part of the intracranial cavity. Cranialization facilitates wide exposure and access to the cranial base, both of which are important in assessing and repairing complex facial fractures. Moreover, this procedure allows for elimination of the sinus, and consequently removes a potential source of long-term complications (Figs. 5, 6).

F5
Fig. 5.:
Intraoperative cranialization. *Denotes the frontal sinus cavity. Published with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.
F6
Fig. 6.:
CT scan following cranialization with calvarial bone graft seal. Published with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.

The last operative form of management (reconstruction) can be performed either open or endoscopically. In reconstruction, the NFOT and mucosa are preserved, and the fracture is stabilized. Open reconstruction employs traditional surgical access to the sinus, often through a coronal incision, whereas newer endoscopic approaches require a smaller incision. Fractures that are more displaced and associated with a contour deformity are more likely to be managed via an open approach. Endoscopic approach limits in the extent of fracture reduction possible. Currently, there is a lack of studies that directly compare clinical outcomes of the two approaches.29

Intervention Selection

Treatment decisions often depend on several key factors: the fracture pattern (type, comminution, degree of displacement), NFOT injury, neurological status at the time of presentation, and the presence of CSF leak.1,3,6,30–35 Consistent with previously published literature, our findings showed an increase in complication rate with NFOT injury, which further supports the importance of through evaluation of the NFOT involvement. Preoperatively, a thorough evaluation consists of CT imaging to assess for obstruction, frontal sinus floor fracture, and associated anterior ethmoid complex fracture.36–38 Interestingly, we found no difference in complication rate between the various forms of management when looking only at patients with NFOT injury. This highlights the importance of assessing the extent of associated injuries and the patency of the NFOT to aid in selecting the appropriate management.

Although our findings lack statistical significance, which we believe is due to the heterogeneity of the reported data, we observed some changes in the literature that we present qualitatively in this study. Namely, for certain fracture patterns, there has been an increase in the use of more conservative approaches, such as observation and endoscopic technique. In patients with frontal sinus fractures not requiring surgical intervention, yet with NFOT obstruction, it is possible to manage these patients expectantly with medical therapy and observation. In the literature, a small prospective study found around 70% of these will have spontaneous ventilation of the frontal sinus.23 However, this was a prospective study with a mean follow-up of 17.8 months. Therefore, it could not identify mucoceles, a serious long-term complication of frontal sinus fracture management that can take over a decade to develop. In those that do not spontaneously ventilate, they can often be successfully managed with endoscopic approaches.23 Moreover, in patients without NFOT injury, previous work has shown the efficacy of observation in select patients with several different fracture patterns, including displaced and nondisplaced anterior wall, displaced and nondisplaced posterior wall, and nondisplaced AT/PT wall fractures.7 Our data support this trend toward observation and endoscopic management for select patient populations; however; our findings on increased rates of complications in patients with NFOT involvement further demonstrate the need to thoroughly evaluate extent of fracture involvement before pursuing conservative management.

Challenges

The array of injuries associated with frontal sinus fractures may complicate management of these fractures. Frontal sinus injuries often result from high energy injuries, as the frontal bone requires double the force of other facial bones to fracture39 (Fig. 7). Consequently, injuries causing frontal sinus fractures can also cause associated midfacial fractures or extend posteriorly as frontobasilar fractures, in addition to intracranial and bodily injuries, all of which complicate the management of these patients.39–41 Importantly, frontobasilar fractures have been shown to be associated with two potentially significant acute complications (CSF fistula and meningitis), further complicating management.4 Anatomically, frontal sinus fractures prove challenging to manage, both due to the location of the frontal sinus and its association with the intracranial space via the diploic veins (veins of Breschet).42 Furthermore, some of the complications are often difficult to predict and quantify, and may not present until a decade after initial injury6,43–45 (Figs. 8, 9).

F7
Fig. 7.:
CT image of severe comminuted anterior table and posterior table fracture. A, Sagittal view. B, Axial view. Published with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.
F8
Fig. 8.:
CT scan showing mucocele. A (sagittal view) and B (axial view) demonstrate mucocele communication with the remnant frontal sinus (red arrow). C (coronal view) demonstrates mucocele (red arrow) causing displacement of left eye prosthesis. Published with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.
F9
Fig. 9.:
Intraoperative mucocele. Published with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.

Guiding Principles of Management

Currently, numerous treatment algorithms exist with little consensus on the ideal treatment algorithm.5,6,46,47 Moreover, as demonstrated by this article, no significant difference exists among selected interventions or associated complication rates under similar clinical conditions. Together, these findings highlight that no single evidence-based approach to managing frontal sinus fractures currently exists. However, from the senior authors’ extensive experience with these fractures, a lack of long-term follow-up data likely plays a significant role in this outcome. Chronic indolent infections that require intervention have been reported over a decade after initial frontal sinus management, yet follow-up data available in the literature range from 9 to 55 months. In the senior authors’ experience, it is the key to identify certain factors for the successful management of these fractures and prevention of long-term complications. Preoperative management should utilize CT imaging to assess fracture extent, associated fractures, NFOT obstruction, and CSF leak. Intraoperatively, adequate visualization best ensures successful surgical management and aids in prevention of long-term complications. The frontal sinuses are lined with mucosa and communicate with the nasal cavity via the NFOT. The mucosa produces secretions that are swept toward the nasal cavity by cilia located on the surface of the sinuses. From the senior authors’ experience, there is likely a critical area of mucosa that needs to be injured to compromise sinus function. The injured mucosa becomes scarred, and the cilia of the sinus likely do not regenerate, compromising the ability to properly sweep sinus contents. However, the extent of injury/percentage of damage to the frontal sinus required remains unknown. Violation of these mucosal surfaces or disruption of sinus outflow can result in complications if not managed properly. Specifically, successful cranialization and obliteration require meticulous burring of the mucosa and careful plugging of the NFOT. Pouring methylene blue into the sinus and observing for release out of the nose can be used for intraoperative NFOT evaluation. Furthermore, if there is unilateral NFOT obstruction, the contralateral side can provide adequate drainage. However, in addition to confirming patency of the contralateral side, presence of any bony septum between the frontal sinus cavities must be assessed and taken down if present. Complications such as mucoceles, which usually result from improper fracture management, may not present for years. Presentation may include pressure or mass-like symptoms, in addition to more indolent symptoms, such as visual disturbances, nasal obstruction, or pain resulting from bone destruction.6,44,48,49

The management of these complications is a unique but important clinical scenario. In the senior authors’ experience, chronic frontal sinus infections can present as late as a decade after initial frontal sinus management. Factors such as incomplete partitioning of the upper aerodigestive system and the anterior cranial base or insufficient mucosal removal both have been noted to result in indolent infection.6,15,30,35,43 Management frequently involves removal of hardware from prior interventions and sinus reobliteration or ablation. An array of interventions from sinus ablation to sinus reobliteration and nonvascularized bone grafts have been commonly used. However, in the senior authors’ experience, these interventions have limited effectiveness in chronic infections and a more aggressive, definitive approach to these challenges is warranted. Several case series have presented successful management of persistent frontal sinus infections, with free fibular flap in a single stage.45,50,51 The attached hallucis longus obliterates the sinus and occludes the NFOT, while the free fibula bone reconstructs the horizontal buttress. The rich vascular supply of the fibula flap offers a local environment optimized for wound healing and prevention of osteomyelitis, and its mechanical properties offer excellent skeletal stability (Fig. 10).

F10
Fig. 10.:
CT scan free fibula for persistent frontal sinus infection management. Published with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.

At this point of discussion, surgeon comfort level and experience with the array of interventions should be considered. The various forms of frontal sinus fracture management can all be successful, including nonoperative management (when selected under appropriate clinical circumstance) and with meticulous surgical execution (when surgery is chosen). However, in the setting of chronic, indolent infection, free bony tissue transfer can be a powerful, definitive treatment modality that has only been described in limited case series. Expert recommendations and clinical pearls can be found in Tables 5-6.

Table 5. - Expert Recommendations
Preoperative Imaging (CT)
1. Fracture extent
2. NFOT obstruction
 a. Gross outflow tract obstruction
 b. Frontal sinus floor fracture
 c. Anterior table medial wall fracture
3. CSF leak
4. Associated fractures
Intraoperative Visualization
1. NFOT
 a. Can be aided with use of methylene blue
2. Unilateral NFOT obstruction
 a. Assess for bony septum and remove if present
Meticulous surgical technique
1. Burring of mucosa
2. NFOT plugging
Follow-up Clinical sign of mucocele
1. Frontal pressure/mass-like symptoms
2. Forehead erythema
3. Visible purulent drainage
4. Periorbital pain
5. Persistent infections
Indolent signs of mucocele
1. Visual disturbances
2. Orbital dystopia/ocular dysfunction
3. CNS involvement
Prompt identification and management
1. CT imaging
2. Hardware removal and debridement
3. Free fibula for reconstruction
 a. Obliterates sinus
 b. Restoration of horizontal buttress
CNS: central nervous system.

Table 6. - Clinical Pearls
When confronted with a frontal sinus fracture, the fracture pattern should be classified, with attention paid to the involvement and extent of injury to the anterior wall, posterior wall, and NFOT involvement. Treatment decisions will be based on the analysis of fracture classifications following an algorithmic approach, as previously described by Rodriguez et al.14
When the decision to operate is made based on the algorithm, the sooner it is performed the better.
Severe comminution of both the anterior and posterior wall is rarely reconstructable and should be treated with additional concern and have the sinus defunctionalized.
Disruption of a critical amount of the mucosal cilia impairs the normal functioning of the sinus and should be managed with defunctionalization of the sinus and NFOT.

Limitations

Our study is limited by the potential exclusion of any non-English articles or articles not identified by our search parameters. Additionally, the heterogenicity of data reporting and surgical technique makes statistical analysis challenging. Furthermore, the complication rate data are limited by the length of follow-up in each article, as complications associated with frontal sinus fracture may not present for years.

CONCLUSIONS

Frontal sinus fracture management is a challenging clinical situation with varied management techniques. Although, to date, there is no widely accepted treatment algorithm, there are important guiding principles that can be used to guide management selection, such as the fracture pattern and extent of NFOT injury, which should be thoroughly evaluated upon patient presentation.

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