The patient suffered RTA 26-August-2009 with loss of consciousness and was transferred to the ICU of Shmaisani hospital. The respiratory drive was acceptable, but she has cut wound in the forehead through which lacerated brain was coming out and there was wide-based longitudinal fracture involving the left anterior , middle fossa and dividing the pyramid into two parts and continuing to the occipital bone from the left.  There was severe ecchymosis of both eyes more the left with the medial wall of the right orbit shifted to the left and the medial wall of the left orbit shifted laterally of the medial axis. The ethmoid structures were shifted to the left and the nasal bone and xanthus burst and shifted to the left. There was massive bleeding with CSF from the left ear and both nostrils. There was fracture of the right femur mid-shaft.

The patient had left sided hemiparesis with GCS 12/15. Hb was 6.8 mg/dL. Infusion of blood and FFP was initiated and continued until the Hb became 11.8.

A left frontal approach was used and using the deformed fracture in the frontal bone in the right side, a bony flap was created over the frontal area from the left. The lacerated brain was coming from the mediobasal frontal lobes. The dura over the convexital part of the frontal lobes was intact and pulsating well.

The shifted parts of the medial walls of the orbital walls were repositioned, so that they got accepted position. The flail parts of the xanthus  and nasal bones were returned back and using nylon were approximated to their counterpart of the normal bone.  After that the lacerated brain material stopped to leak out. The bony flap returned back and it was more perfect than during its creation.

Routine closure of the wound and smooth postoperative recovery and the patient sent to the ICU without ventilation.

The patient has longitudinal fracture extending from the right supratrochlear area of the frontal bone down to the right anterior fossa and right middle fossa and cutting the pyramid into two parts and reaching the occipital bone.

This degree of trauma is usually a fatal one, but the presence of a wide gap in the fractured bone, it could allow sufficient drainage of the CSF and blood and lacerated brain material for in time evacuation, permitting the survival of such a case. The age of the patient also playing an integral role in this survival.