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Anatomy

Bones -

Frontal process of maxilla, nasal spine

of frontal bone

Paired nasal bones

Vomer

Perpendicular plate of the

ethmoid

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Anatomy (cont.)

Cartilage-

Lower lateral cartilage

Upper lateral (Alar) cartilageSeptal cartilage

Sesamoid cartilages

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Pathogenesis

Variables-

The patients age (tissue flexibility)

The amount of force appliedThe direction of the force

The nature of the striking object

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Frontal Impact

Plane I-

Fracture of nasal tip

Small dorsal hump with supertip

depressionPlane II-

High fracture of nasal bones

Dorsal depression

Septal buckling with flattened appearance

of the nose

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Frontal Impact (cont.)

Plane III- Fracture of nasal bones, frontal process and

anterior nasal spine

Comminuted, lateralized

Marked nasal depression

Columellar retraction Medial canthal relaxation with

telecanthus

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Lateral Impact

Plane I-

Unilateral nasal bone depression

Elevation of contralateral nasal boneSeptal buckling

C or S shaped deformity of nasaldorsum

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Lateral Impact (cont.)

Plane II/III-

Fracture extension to frontal process

Marked displacement of septum anddorsum

Medial maxillary wall depression

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Septal Fracture

Vertical with anterior fracture

Horizontal with posterior fracture

S and C shaped deformities with

healing

Telescoping of segments prevents

closed reduction

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History

Force, direction of impact

EpistaxisExternal deformity

Prior nasal injury, dysfunction

Pre-injury photographs

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Exam

Nasal deviationMucosal or skin lacerations

Ecchymosis, hematomaLid edema, chemosis

Subconjunctival hemorrhageTelecanthus, CSF rhinorrhea

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Exam (cont.)

Topical decongestionDebridement of clots

Internal and external palpationExam of cartilaginous nose

RoentgenogramsPhotographic documentation

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Clinical Decisions

Open versus closed reductionClosed Reduction-

Unilateral or bilateral fracture of the nasalbones

Fracture of the nasal-septal complex with

nasal deviation less than one half the widthof the nasal bridge.

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Clinical Decisions (cont.)

Open Reduction-

Extensive fracture-dislocation of the nasal bones

and septum

Nasal pyramid deviation exceeding one half thewidth of the nasal bridge

Fracture-dislocation of the caudal septum

Open septal fractures

Persistent deformity after closed reduction

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Clinical Decisions (cont.)

Local versus general anesthesiaTiming of reduction-

< 3-6 hours- immediate reduction< 2-3 weeks- closed reduction

> 3 weeks- delayed 3-6 months

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Anesthesia

4% cocaineEpinephrine soaked pledgets

IV or oral sedationEMLA cream - time consuming

General anesthesia

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Instruments

Asch/Walsham forcepsLarge Kelly clamps

Elevators- Boies/BallingerVarious intranasal specula

Headlight

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Reduction

Elevate fragment with anterolateral force Completion of the fracture

External digital molding

Reduction of septum is critical

Asch/Walsham forceps to elevate fracture

and reduce septum

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Trouble Shooting

Overriding cartilage fragments

Post reduction instabilityC-shaped septal fracture

Converting to an open reduction

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Post-Op

Silastic splints Intranasal placement of packing

External splint applicationPacking out 2-3 days, silastic-10 days

External splint off when fracture stable

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Subacute Open Reduction

Hemitransfixion, lateral intercartilaginousincisions

Elevation of dorsal skin and periosteum

Exposure of cartilage segments

Reduction of cartilage- scoring, suture

Maxillary crest involvement- trapdoor

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Complicated Fractures

Open sky approachUse preexisting lacerations when

possibleDepressed comminuted fractures- wires

versus miniplates

Wound closure

Prophylactic antibiotics

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Delayed Repair

Complicated due to scarring, fibrosis Common problems: Dorsal hump, C/S

shaped septum, saddle deformities, septal

displacement, fallen or deviated tip

Common solutions: Excision of hump,

cartilage grafting, calvarial grafts,osteotomies

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Children

Physical differences- projection, cartilage: bone,growth centers

Small fracture--- obstruction with age

Edema, anxiety tend to obscure fracture

Operative intervention- cosmesis, obstruction

Digital compression

Neonatal fracture-dislocation

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Early Complications

Septal hematoma Infections- antibiotic prophylaxis

Epistaxis- cautery, packing, ligationCSF Rhinorrhea

Emphysema of the face, neck

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Late Complications

Organization of hematomas- airwayobstruction

Synechia- divide if symptomatic

Obstruction of the nasal vestibule

Residual osteitis

Malunion

Naso-facial disproportion