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Nasal fracture


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Nasal fracture

  2. 2. CONTENTS • Introduction • Surgical anatomy • Biomechanics • Classifications • Epidemiology • Diagnosis and Evaluation • Management • Controversies • Conclusion
  3. 3. INTRODUCTION • Fractures of the maxilla, nose, zygomatic complex and associated bones are commonly referred to as fractures of the middle third of the facial skeleton.
  4. 4. • Nose is a prominent facial structure and nasal bone fractures are the most common facial fractures. • Compared to the any other facial bone, less energy is required to fracture the nasal complex. • The frequency of nasal fractures is high and often unnoticed by both maxillofacial surgeons and patients.
  6. 6. The nose External nose Bony part Carilagenous part Nasal cavity Floor Roof Lateral wall Medial (septal) wall
  7. 7. Skeleton of External Nose Bony part : Nasal bone Frontal process of maxilla Nasal part of frontal bone Cartilaginous part : Septal cartilage. Lateral nasal cartilage. Major alar cartilage. Minor alar cartilage.
  9. 9. Vomar • Roughly triangular bone. • Forms the inferior and posterior part of nasal septum. • Superior border articulates with perpendicular plate of ethmoid bone.
  10. 10. Ethmoid • Perpendicular plate forms the superior portion of nasal septum • Horizontal plate forms the roof of nasal cavity • Laterally; Scroll shaped projections on either side of the nasal septum called the superior and middle nasal conchae
  11. 11. Blood supply
  12. 12. Nerve supply Innervation of the nasal cavityInnervation of the external nose
  13. 13. BIOMECHANICS OF NASAL FRACTURES Nasal fractures occur in one of two main patterns-  From a lateral impact  From a head-on impact
  14. 14. In lateral impact , the nose is displaced away from the midline on the side of the injury.
  15. 15. In head-on impact , the nasal bones are pushed up and splayed so that the upper nose (bridge) appears broad, but the height of the nose is collapsed (saddle-nose deformity).
  16. 16. • Approximately 80% of fractures occur at the lower one third to one half of the nasal bones. This area represents a transition zone between the thicker proximal and thinner distal segments. Surgical Treatment of Facial Injuries by Kazanjian and Converse, 1959.
  17. 17. • Rowe & Killey ‘s classification. • Strance & Robertson’s classification. • Harrison’s classification. • Murray & Maran’s pathological classification. • Rorich et al’s classification. • AO classification. CLASSIFICATIONS
  18. 18. Rowe and Killey (1968) described fractures of the nasal bones and/or nasal septum according to the pattern of disturbance and the degree of displacement of the nasal structures found when the nose fractures are dependent upon the direction and degree of the forces applied. I. Lateral nasal injuries II. Anterior nasal injuries Drawback- They only explained the impact factor not about the force or involvement of the bone.
  19. 19. Strance & Robertson (1979) classified nasal bone fractures based on direction of injury. 1. Lateral blow – frequently occurring. 2. Frontal impact – less frequently occurring. Plane i. Plane ii. Plane iii.
  20. 20. Plane i
  21. 21. Plane ii Plane iii
  22. 22. In 1979 , Harrison classified nasal fracture which included subclasses to include fractures of the nasal tip and anterior nasal spine, fractures of the dorsum with or without septal deflection, and comminuted nasal fractures with management.
  23. 23. • Class 1: Chevallet fractures • Very little force is sufficient to cause a fracture of nasal bone. • It has been estimated to be as little as 25-75 pounds / sq inch. • Class I fractures are mostly depressed fractures of nasal bones.
  24. 24. • Clinically this fracture will present as a depression over the nasal bone area. There may be tenderness and crepitus over the affected nasal bone. • Radiological evidence may or may not be present. In fact class I fracture of nasal bone is purely a clinical diagnosis.
  25. 25. CLASS II FRACTURES • These fractures cause a significant amount of cosmetic deformity. • In this group not only the nasal bones are fractured, the underlying frontonasal process of the maxilla is also fractured. The fracture line also involves the nasal septum.
  26. 26. CLASS III FRACTURES: • These are the most severe nasal injuries encountered. This is caused by high velocity trauma. • It is also known as naso orbital fracture / naso ethmoidal fracture. (Naso orbito ethmoid fracture)
  27. 27. • Murray and Maran (1986) described a pathological classification of nasal fractures following experiments on fifty cadavers. They have devised a more complicated system based on seven types of fractures; this system emphasizes the deviation of the nasal pyramid from the midline as being a clinical predictor of treatment outcome.
  28. 28. • Rorich et al (2000) proposed a simple classification that might guide treatment Type Description I Simple unilateral 2 Simple bilateral 3 Comminuted a) Unilateral b) Bilateral c) Frontal process of maxilla 4 Complex a) Associated with septal hematoma b) Associated with open nasal laceration 5 Associated NOE fracture/midface fracture
  29. 29. AO (Arbeitsgemeinschaft fur Osteosynthese) surgery provides a simple classification system based on clinical findings (2009) 1. Laterally displaced. 2. Posteriorly depressed fractures 3. Disarticulation of upper lateral cartilage 4. Anterior nasal spine fracture 5. Involvement of nasal septum
  30. 30. Laterally displaced fractures Posteriorly depressed fractures
  31. 31. Disarticulation of upper lateral cartilage Anterior nasal spine fracture
  32. 32. • The nasal septum is almost always involved in nasal fractures and must be evaluated to determine if treatment is necessary. • If the impact force is weak, nasal bone displacement is usually present without septal fractures. Involvement of nasal septum
  33. 33. Epidemiology • Rowe and Killey (1968) analysed 629 middle third fracture and the relative frequency of nasal fracture was 6.99%. • Fights and sports injuries are the most common causes of nasal fractures in adults, followed by falls and vehicle crashes. • Physical abuse should be considered when evaluating children and women with nasal fractures. • Nasal fractures may occur in isolation, but are commonly associated with other facial injuries and fractures.
  34. 34. Clinical Significance • Most nasal fractures cause significant bleeding. • Proper techniques for haemostasis should be applied before any diagnostic procedure and any definitive treatment. • Prompt appropriate treatment to prevents functional and cosmetic changes. • Because of the nose's central location and proximity to important structures, the clinician should carefully search for other facial injuries in the presence of nasal fractures.
  35. 35. • Diagnosis should be made with history of the patient, physical examination and radiographic investigation. The direction and strength of the impact should be noted. • Preexisting nasal or septal deformities should also be considered. • A history of nasal bleeding may indicate a mucosal laceration. Skin laceration over the nasal area may guide fracture diagnosis to the specific anatomical area. Diagnosis
  36. 36. Physical examination
  37. 37. A B
  38. 38. Radiological investigation The usual facial radiographs may not clearly reveal a nasal fracture. a. In 1957 Gillies and Millard recommended Waters ( occipitomental ) view. b. Lateral view c. CT scans accurately demonstrate most nasal fractures and their displacement.
  39. 39. • Management of nasal fracture can do in two ways 1) Emergency management 2) Surgical management Management
  40. 40. Emergency management • Elevation of the head • Use of cold compresses in the peri orbital and nasal regions can be helpful for subside the edema. • Nasal packing is the most common method of controlling bleeding within the nose. The packing should be placed precisely at the bleeding site(s) to provide uniform pressure over the entire area.
  41. 41. • In most patients packing will control nasal bleeding. After 2 to 5 days the packing can be removed. • Posterior nasal pack is needed when obstruction of the airway because of hemorrhage into the nasopharynx .
  42. 42. Anterior Nasal Packing • This packing is done if localized bleeding is profuse or bleeding point is not localize. • Use of a ribbon gauze soaked with liquid paraffin(1 m gauze; 2.5 cm gauze in adult and 12 mm in children). • It can be done with vertical layer and horizontal layer. • It can be removed with 24 hour and can be kept upto 2-3 days. • Systemic antibiotic should be given to prevent sinus infection and toxic shock syndrome.
  43. 43. Posterior Nasal Packing Epistaxin balloon.Smaller (10ml) posterior ballon and bigger (30ml) anterior balloon are inflated. Channel of catheter provides airway for nasal breathing. •Foley catheter, and insert the device into the nostril. • Visualize the catheter tip in the back of the throat. Inflate the balloon with up to 10 mL of sterile water • Withdraw the balloon gently until it seats posteriorly. •Pack the anterior nasal cavity with a balloon device or layered ribbon gauze. • Apply a padded umbilical clamp across the catheter to prevent alar necrosis and to keep the balloon from dislodging.
  44. 44. Surgical management Nasal trauma algorium History : physical and radiographically Fracture No Fracture Discharge Classify fracture
  45. 45. Classify fracture Type I simple Type II simple Type III comminuted Type IV complex (associated septal Hematoma) Type V Significant edema Evaculate /pack septal hematoma irrigate/close wound No Yes
  46. 46. No Yes Significant edema Elevation /ice Reassess in 3-5 days after swelling subsides Fracture reduction •Meticulous septal examination with or without endoscope •Closed reduction
  47. 47. Fracture reduction •Meticulous septal examination with or without endoscope •Closed reduction Type I II III •Antibiotics /steroids •Splints Type IV •Reduce septal fracture/ dislocaton •Consider limited inferior septal reconstruction
  48. 48. Closed reduction is usually reserved for simple, non comminuted nasal fractures, although exceptions can be made . Closed reduction
  49. 49. The indications for closed reduction are: • Unilateral or bilateral fractures of the nasal bone with displacement. • Fractures of the nasal septal complex causing nasal airway compromise. • Closed reduction should be performed as soon as possible, preferably 10-14 days post injury, but may be possible up to 21 days.
  50. 50. Few instruments are needed for fracture reduction. These include I. Asch nasal septal forceps. II. Walsham nasal forceps. III. Boies or Ballengers elevator. IV. Internasal specula. Fracture reduction instruments
  51. 51. Fracture reduction instruments for acute nasal fracture management. From left: Walsham forceps, Asch forceps, Boies elevator, nasal speculum.
  52. 52. In laterally displaced fractures
  53. 53. In centrally depressed fractures
  54. 54. Reduction of the nasal septum
  55. 55. Nasal bones- After reduction, adhesive strips are placed over the skin of the nasal dorsum and the nasal bones are splinted using an external splint that conforms to the patients nose. If the nasal bones are comminuted or loose, they should be supported with an intranasal packing, which should be placed before placing the external splint. Splinting
  56. 56. Nasal septum The nasal septum can be stabilized with splints or packs. Removal of packings and splints Hemostatic packs are removed after 24 hours. Packs that are supporting the nasal bones are left in place as long as the external splint is in place. The patient should be prescribed antibiotic treatment for as long as the nasal packs are in place.
  57. 57. Open reduction Essentially in two conditions , open reduction are performed. • 1st early correction of nasal fractures that could not be properly reduced in a closed fashion. • Secondly correct a previously existing nasal deformity. The latter should be more properly classified as septorhinoplasty to correct an internal and external deformity.
  58. 58. Indications for open reduction are: • Extensive fracture dislocation of the nasal bone and septum. • Fracture dislocation of the lower septum. • Open septal fractures. • Deformity after closed reduction. • Inadequate bony reduction due to deformity. • Combined deformities of septal and alar cartilages
  59. 59. Surgical Approach 1. Through existing laceration. 2. Bicoronal approach. 3. Endonasal a. Transcartilaginous (Intracartilaginous, Cartilage splitting) b. Retrograde c. Bipedicled chondrocutaneous flap (delivery) 4. External (open)
  60. 60. • Use of existing lacerations Nasal fractures are often associated with lacerations. These existing soft-tissue injuries can be used to access directly the nasal bones for management of the fractures.
  61. 61. • Bicoronal approach The bicoronal or bitemporal incision is used to approach the anterior cranial vault, the forehead, and the upper and middle regions of the facial skeleton.
  62. 62. For endonasal and external techniques are accomplished through various incisions strategically placed to allow for careful anatomic dissection of the underlying nasal skeleton. The following incisions can be used: 1. Alar cartilage incisions a.transcartilaginous(intracartilaginous,cartilage splitting) b. intercartilaginous c. marginal 2. Septal incisions a. complete transfixion b. partial transfi xion c. hemitransfixion 3. Transcolumellar incision
  63. 63. 1.Endonasal a. Transcartilaginous Approach- Intracartilaginous incision extending up to and around anterior septal angle into a partial transfixion incision with dissection of vestibular skin off undersurface of lower lateral cartilage.
  64. 64. b. Retrograde Approach- For this approach intercartilagious incision is used. This incision is placed between the caudal end of the upper lateral cartilage and the cephalic margin of the lower lateral cartilage and then carried into the appropriate septal incision.
  65. 65. This edge is brought into full view by retracting the ala with the double ended nasal hook while simultaneously providing gentle pressure with the middle finger over the upper lateral cartilage.
  66. 66. c. Bipedicled chondrocutaneous flap (delivery) - The delivery approach to the tip and lower two thirds of the nose allows for direct view of the lower lateral cartilages, both of which may be viewed simultaneously. Two incisions are required for this technique. i. Intercartilaginous incision ii. Marginal incision
  67. 67. A sharp, angled tip (Converse) scissors are used to dissect the soft tissue plane just above the perichondrium of the lateral crura and dome. Single hook retraction in the dome are aids in dissection here. The lower lateral cartilage with attached, intact vestibular skin is the “delivered” out of the nose as a bipedicled chondrocutaneous flap, with exceptional exposure of the majority of the lower lateral cartilage.
  68. 68. 2. External (open)- Marginal and inverted “V” transcolumellar incision used for external approach. Exposure obtained of lower two thirds of the nose using the external approach
  69. 69. Associated fractures Grafting
  70. 70. Midline repositioning of quadrangular cartilage of the septum and the vomer The septum is repositioned in its original midline position together with the quadrangular cartilage and vomer. As small suture may be placed from the anterior nasal spine to the anterior portion of the septum to maintain its reduction.
  71. 71. Closure A quilting stitch using absorbable suture material is passed back and forth through the septum to stabilize the mucosal flap and prevent septal hematoma formation. A few interrupted absorbable sutures are used to re approximate the mucosal incisions.
  72. 72. Post operative care • Postoperative positioning : Keeping the patient’s head in a raised position both preoperatively and postoperatively may significantly improve edema and pain. • Nose-blowing : To prevent orbital emphysema, nose-blowing should be avoided. • Ice packs for reduce the nasal edema.
  73. 73. Complications a) Early complications b) Late complications
  74. 74. • Early complication a. Septal hematoma. b. Edema , ecchymosis and epistaxis . c. Infection. d. Emphysema.
  75. 75. •Late complication a.Untreated hematomas of the nasal septum may become organized, resulting in subperichondial fibrosis and thickening with partial nasal airway obstruction. b.Synechiae may form between the septal and the turbinate in area where soft tissue lacerations occur and the tissues are in contact.
  76. 76. c. Residual osteitis is seen occasionally in compound fractures of the nose or in fracture associated with infected hematomas. Dacryocystorhinostomy may be needed for its correction.
  77. 77. CONTROVERSIES i. Closed Versus Open Reduction. ii. Timing Of The Treatment. iii. Anesthesia.
  78. 78. Closed Versus Open Reduction • Nasal bone fractures can be treated by either closed or open techniques. • Before choosing a method of reduction, the status of the septum must be established. • If the septum is fractured and displaced, attempts at closed reduction often result in unsatisfactory results. • Closed treatment should be reserved for simple unilaterally displaced nasal fractures without any significantly displaced septal fractures.
  79. 79. • Results following closed reduction have been examined in some past reports. • Crowther et al reported the result of closed reduction of nasal fractures with 85% of the patients satisfied with their nasal appearance. • A Danish study reported similar favorable long- term results at 3 years following closed reduction of nasal fractures . • These past reports suggest that in the appropriate patient closed reduction can be an extremely useful modality to treat simple nasal fractures with significant septal pathology.
  80. 80. • There are differences of opinion regarding timing of the treatment of nasal fractures. • If a patient is seen shortly after trauma, before significant edema develops, immediate treatment may be indicated. • Other indications for immediate treatment include the presence of lacerations with exposure of the underlying skeletal or cartilaginous elements or the presence of a septal hematoma that requires immediate drainage. Timing Of The Treatment
  81. 81. • However, many surgeons said to re-evaluate the patient in a number of days before performing definitive treatment. • By re-evaluating a patient a number of days after the trauma, factors that may contribute to postoperative nasal deformity, such as acute edema, unrecognized pre-existing nasal deformity and undetected septal fractures, can better be assessed before surgical intervention (Rohrich RJ et all in 2000).
  82. 82. LOCAL VERSUS GENERAL ANESTHESIA • Reduction of nasal fractures may be performed under local anesthesia supplemented with intravenous sedation or under general anesthesia. • Fracture reduction under local anesthesia is an attractive alternative to general anesthesia because hospitalization and operating room utilization are not required and it is a safe and efficient method to deal with these injuries. • Studies comparing both techniques have determined there are no differences in clinical outcome as far as patient satisfaction.
  83. 83. Conclusion • Skilled management of nasal and septal fractures requires a detail understanding of facial anatomy, causes of injuries, function and aesthetics of the nose, modern operative techniques, timing for reconstruction, setting and anesthesia choices, and possible complications.
  84. 84. • Although most operative repairs have good results, secondary reconstructions are surprisingly common. • Accordingly, long-term follow-up may be helpful in select patients, but most patients should be informed of the possible long-term aesthetic and functional consequences of their injuries.

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