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The prominence and delicate structure of the nose make it vulnerable to a broad
spectrum of injury, which accounts for why it is the most frequently fractured facial
Most common facial fracture (between 40–50%).
3rd most common fracture of the bony skeleton
Force required to create a fracture of the nasal structure is small, possibly as little
as 25 pounds of pressure
Why to worry ?
Although these injuries often do not appear to be severe, the mistake of undertreating nasal
trauma can lead to significant long-term problems. External deformity, nasal obstruction, septal
perforation and other complications (e.g., chronic sinusitis) will persist and sometimes worsen
months or years after the original insult.
Injuries in children may also lead to devastating growth retardation of the nose and midface.
Thoughtful assessment and proper management of nasal injuries can reduce the risk of these
sequelae, thereby reducing the need for delayed corrective septorhinoplasty.
Physical fights, assaults , domestic violence.
Falls (common in children)
Motor vehicle accidents
Falls from syncope or impaired balance in the elderly and etc.
Any history of a fall or force directed toward the mid face
Details of the injury either assault or any RTA (mechanism, speed, location,
direction of force , any restraining force)
Was there an epistaxis at the time of trauma? Or any watery discharge
Loss of sense of smell ( can also be due to oedema hence should be re assessed
after the oedema subsides)
Was there a previous history of facial trauma or surgery?
The difference from the nasal appearance before the trauma (for medicolegal
and future treatment as well. )
Was there a previous functional impairment in breathing before the trauma? etc.
Direction of the force:
Frontal direction : in fracture of the lower margin of the nasal bones
High frontal : nasal orbital ethmoid fracture
Heavier force : severe flattening or splaying of the nasal bones and fracture of the
Lateral forces : depression of the ipsilateral nasal bone, out fracture of the
contralateral nasal bone
• If twisted or buckled : the fractured bony and/or
cartilaginous fragments are often interlocked,
septum dislocated off the maxillary crest Note. This
is important to identify because achieving an
adequate result with a closed technique may be
impossible in such a situation.
• Children’s noses: mostly cartilaginous and their
nasal bones are softer and more compliant,
absorbing little of the energy from the force of
trauma. It is also a common fact that birth trauma
could be the cause for septal deviations in these
patients. Septal hematoma is more common in
children. In children it is better to avoid open
reduction procedures and stick to closed
ROWE & KILEY (1968)
Described fractures of the nasal bones & or nasal septum
according to the impact only:
1. Lateral nasal injuries
2. Anterior nasal injuries
Drawback : only included the impact factor & nothing else (not
the force or bone involved)
Various weights were dropped on cadavers noses & the
resultant fractured nasal pyramid was dissected out.
The fracture lines are described & particular reference is
directed to the involvement of the septum in grossly deviated
CLASS 1 CLASS 2 CLASS 3
mostly depressed fractures of nasal
These # cause a significant amount
of cosmetic deformity.
high velocity trauma.
AKA nasoorbital #/naso ethmoidal #..
The # line runs parallel to the dorsum
of the nose and naso maxillary suture
and joins at a point where the nasal
bone becomes thicker
In this group not only the nasal
bones are fractured, the underlying
fronto nasal process of the maxilla is
Ethmoidal labyrinth & orbit is intact
These fractures are always associated
with Le Fort fracture of the upper
face involving the maxilla also
Ethmoid being thin & full of air cells
forms a low resistence ‘crumple
Clinically :present as a depression
over the nasal bone area. tenderness
and crepitus over the affected nasal
bone. Radiological evidence may or
may not be present.
Clinically : telecanthus is seen &
medial canthal ligament may be
disrupted from lacrimal crest.
Epiphora can also be there due to
lacrimal crest injury.
MARKOWITZ ET AL CLASSIFICATION :NOE
ON THE BASIS OF MEDIAL CANTHAL TENDON & DEGREE OF COMMUNITION OF THE FRAGMENTS OF BONE
OF ITS ATTACHMENT:
TYPE 1 : #LINE LEAVES A CENTRAL SEGMENT OF BONE WITH MCT ATTACHED.
TYPE 2: INVOLVES CUMMUNITION OF THE CENTRAL SEGMENT BUT MCT REMAINS FIRMLY ATTACHED TO A
DEFINABLE SEGMENT OF BONE.
TYPE 3: SEVERE CENTRAL FRAGMENT COMMUNITION WITH DISRUPTION OF THE MCT INSERTION SITES.
On the basis of DIRECTION OF BLOW :Stranc &
Robertson classification :
LATERAL BLOW FRONTAL BLOW
More common Less common
Less severe damage More severe damage and leads to more residual
Better prognosis So associated with poor prognosis.
Plane 1 Plane 2 Plane 3
Damage to anterior nasal spine
anterior septum & lower ends of
More extensive damage to nasal
bone & ascending maxillary
Dislocation & telescoping of the
ULC & septum may also be found.
Septum has significant deviation &
may lack stability to support
Nasal bone & septum is severely
communited & overlapped
Does not involve the orbital rims Associated with other injuries like
midface & cranial base fractures.
Bruising of the skin and subcutaneous tissues
Deviation and asymmetry
Acute edema may hide deformities; however, a careful search for intranasal injury must take place
Patient should be placed in a comfortable, slightly reclined position
Nose should be externally observed from all angles
Bleeding can be controlled with topical cotton pledgets soaked in vasoconstrictors – 0.25%
phenylephrine – 4% cocaine, which also provides anesthesia.
Any open wound
Nasal airway evaluation :
(c) Septal deviation
• Other signs: –
(d)cerebrospinal fluid (CSF) rhinorrhoea
(e) Olfactory disorders
Palpation : Evidence of nasal fracture
Mobility : of the nasal bones is assessed by grasping the dorsum btw two fingers and firmly rocking the
pyramid back & forth
Crepitations can also be felt
Frankfurt horizontal plane : from the superior aspect of EAC to inferior most point of infra orbital rim
Assessment of nasal cavity using speculum via direct visualization or using endoscopy ( use of 0 or
30 degree 4mm rod telescope)
Not entirely necessary
However may provide additional information and rule out the following: –
Push the tip of the nose upward to check for integrity of the septal support system.
Retained blood clots should be removed with suctioning or swabbing using a frazier suction
Plain x ray films High resolution USG CT SCAN
Most commonly done Ultrasound using 10 MHz probe
gives a clear view
In cases of only
Advantage Easily accessible & cheap . Excellent sensivity & specificity
esp regarding lateral nasal wall
Can not be missed even in
prescence of edema
No radiation injury
In injuries involving
Disadvantage Inability to cartilaginous injury esp in
Limited scope that may miss
fracture outside the area of
Can misinterpret normal suture lines ,
vascular indentation lines, &
developmental thinning of nasal
anatromical issues that prevent
adequate trasducer contact
Practitioners who are called upon to treat individuals who have been appropriately stabilized before
consultation must still follow the protocol set forth by the American College of Surgeons Advanced Trauma
Life Support course.
Therefore it is mandatory that every new evaluation begins with an assessment of the ABCs (airway,
breathing, and circulation)
This is especially critical for cases in which narcotics and sedatives may be ordered by the consultant for pain
management or bedside procedures. A patient with a tenuous airway or poor hemodynamic reserve may
unexpectedly experience decompensation if signs such as increasing heart rate, tachypnea, or changing
mental status are not appreciated.
Nose bleeding & septal hematoma should be assessed too
Check for other facial fractures, e.g. orbital rim, mandible
Treatment begins with management of external soft tissue injuries (clean lacerations and carefully repair
Can range from minor mucosal oozing to life threatening large blood vessls bleed.
use of local vasoconstrictors if not controlled then localize the point of bleeding.
Anterior bleed should be cauterized by AgNO3 or may be sealed with gelatrin foam / fibrin glue or other procoagulant
Anterior nasal packaging
• If skull base fracture exists then iatrogenic intracranial injury should be avoided
If fails : then go for anteroposterior packing
Endoscopic Vessel cauterization or angiographic embolization can also be considered.
High risk of complications if left untreated can lead to necrosis if left untreated for 3 days.
Long term complications : saddle deformity, perforation, columellar retraction & nasal bone widening
Needle drainage ASAP & several small openings are left to allow for independent drainage.
Prophylactic treatment with an antibiotic (e.g., Augmentin or clindamycin)
Splints and transeptal dissolving sutures are placed to obliterate the potential space & prevent re
Untreated may result in intracranial abscess, cavernous sinus thrombosis, or meningitis
TIMING OF REDUCTION
Selection of appropriate timing is very important to obtain the best re-alignment possible
The development of fibrous connective tissue within the fracture line becomes the limiting factor
starting at around 10 days to 2 weeks after injury.
Hence the best time is to start before this phase.
A short period of delay is recommended during first 2-3 days to allow diminution of oedema so that
nasal bone position is best appreciated.
Treatment before this delay is reasonable only if patient comes to medical attention within an hour
or two after injury before edema has obscured the underlying structure.
Closed reduction Open reduction
CR involves manipulation of the nasal bones
without incision & is generally the preferred
OR may include a range of
including septoplasty , osteotomy or
Indication: 1. Unilateral / bilateral # of nasal bones
2. # of nasal septal complex with nasal
deviation of less than half of the width of
1. Bilateral # with dislocation of nasal
dorsum & significant pathological
2. Infracture of nasal dorsum
Anesthesia for closed reduction
Proper pain management has become a very crucial topic these days.
However use of general anesthesia is not very feasible due to the various risks associated with it plus
scheduling conflicts & operating room availability these days.
Therefore alternative plan without sacrificing timely management includes:
• Combination of topical & injected anesthetic agent
After infiltration of c/l side topical soaked pledgets are placed posteriorly along the deep internal branch for 5
minutes to have maximum anesthesia.
To reduce the acidity caused by the injection itself buffering the lidocaine with 7.5% NaHCO3 in a 1 dilution by
Infiltration should be done by a thin needle (27 gauge ) and slowly to lessen the pain from soft tissue dissection
Application of EMLA cream over the nose 1hour before the reduction has in combination with topical has been
proven to be equally effective (less discomfort to patient as well)
Cotton pledegets soaked in 4% cocaine or 0.05%
oxymetazoline combined with 4% topical lidocaine are
placed strategically over the nasal cavity.
1% lidocaine with 1:100,000epinephrine is injected along
the septum, lateral wall & floor of nasal cavity
External nasal branch is blocked by via an inter
cartilaginous injection of the dorsum from rhinion to
Branches of anterior or posterior ethmoid ,
sphenoplataine & nasopalatine nerves
Branches of nasopalatine nerve are blocked with an
injection at the base of columella & nasal tip just inside
the nasal sill.
Most preferred treatment modality
Even if large deviations are seen closed reduction can be attempted prior to rhinoplasty as this would
simplify the task of the plastic surgeon
In mild cases when fragments are still in contact finger manipulation alone is sufficient but in this surgeon
doesn’t have much control & often will fail if there is impaction and can even result in worse deformity than
CARTILAGENOUS CORRECTION WITH CLOSED
The correction of the cartilaginous injuries with CR is often difficult & unsuccessful.
For ULC avulsion with medial displacement : reduction is possible if performed soon after the injury
followed by 10-14 days of internal packing.
If beyond 2 weeks then go for intercartilagenous incision with removal fibrous adhesion .
Is still there is poor response then go for cartilage grafting can be offered.
Causes of failure of closed reduction
Most common cause within 1st week to 10 days is unreduced septal fracture
Beyond 2nd week is fibrous tissue formation causing inadequate remodeling.
Even after proper timely reduction there is persistent deviation,then it can be a
Green stick fracture
GREEN STICK FRACTURE
Conversion of greenstick # to a complete one by osteotomy followed by
application of splint.
Care after reduction
Avoidance of activity that can lead to further trauma for next 6-8 weeks.
Regular nasal saline spray or irrigation are recommended to remove blood and to
Antibiotic coverage should also be given
Refraining from nasal blowing.
A Small gauze wires (26 or more ) passed through pre drilled holes can
secure fragments to stable parts of maxillary of frontal bone
Use of slow absorbing sutures instead wires
Titanium microplates & fibrin glue can also be used (alt bioabsorbale
fixation method that may help in speed wound healing & reduce post op
Use of cantilever bone in case of significant loss of dorsum
Autologus cranial bone or rib bone or cartilage or homograft bone or
cartilage can also be used
Lag screw fixation
Midline repositioning of quadrangular cartilage of the septum and
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.