treatment of nasal fracture by paul of aegina
TRANSCRIPT
Jeffrey S. Fichera MS PA-C
The Ear, Nose, Throat and Plastic Surgery Assoc. Inc.
Facial Injuries in SportsFacial Injuries in Sports
The Athletic Trainer must be prepaired to manage facial injuries, including
ContusionsAbrasionsLaserationsNasal fractures
Facial Injuries in SportsFacial Injuries in Sports
Septal hematomasAuricular hematomsRuptured tympanic membranesFractures of the facial bones
Sports AcitiviesSports Acitivies
Account for 3% to 29% of all facial injuriesApprox. 10% to 42% of all facial fractures60% to 90% of injures occur in male
participants between 10 and 29 years old.
Mechanism of InjuryMechanism of Injury
Direct Impact – with another players body part (eg, head, fist, elbow)
Equipment (eg, ball, puck, goalpost, handlebars )
The Ground ( eg, wrestling mat, gym floor)Enviroment ( eg, tree, outfield wall )
Return-to-PlayReturn-to-Play
Treament requires knowledge of the injury
Type and serverity of injury
Physicial demands of the sport
Initial Exam and EvaluationInitial Exam and Evaluation
Pertinent History
Physicial Exam
Remember the “ WOW FACTOR ”
Soft-Tissue InjuriesSoft-Tissue Injuries
Contusions
Abrasions
Lacerations
ContusionsContusions
Most commonly encountered facial injury
Results from blunt trauma to the face
Treatment aimed at minimizing inflammatory response ( ice, nonsteroidals)
AbraisionsAbraisions
Partial-thickness disruptions of the epidermas
Commonly results from blunt trauma or sudden forcible friction
Always consider underlying injury40% of all Tetanus (1998-2000) resulted
from abrasions and lacerations
Nasal InjuriesNasal Injuries
Epistaxis
Septal Hematoma
Fracture
EpistaxisEpistaxis
80% of all nose bleeds are from the anterior source ( ie. Kiesselbach’s Plexus )
20% are posterior and usually a disease of the middle aged and elderly
Nasal Blood SupplyNasal Blood Supply
Why the WOW FACTOR?External Carotid
– Facial artery ( 2 branchs ant. Septum, ala )– Internal maxillary ( most important )
Terminal branch of EC gives rise to– Sphenopalatine
– Nasopaltine
– Greater palatine
Nasal Blood SupplyNasal Blood Supply
Internal Carotid– Opthalmic artery
Anterior and Posterior ethmoid artery
Nasal Blood SupplyNasal Blood Supply
EPISTAXISEPISTAXIS
Cosider nasal fracture as source of epistaxis.
Athlete may report having heard a “crunch” or “crack”.
Nasal fractures are diagnosed clinically.
Focus of Initial TreatmentFocus of Initial Treatment
HemostasisMinimizing swellingTreatment of Nasal Fracture
– Ice and Pain control– Aspirin contraindicated– Nasal decongestants for up to 3 days– Nasal fractures are reduced or refered to ENT
in 3 – 5 days.
Anterior EpistaxisAnterior Epistaxis
Best controlled by slightly reclining the patient and applying direct pressure to the nasal septum for 5 to 10 min.
Apply ice to the back of the neck may help by causing reflex vasoconstriction
Persistent EpistaxisPersistent Epistaxis
Occasionally requires nasal packing with:– Mericel Sponge
Topical Antibiotic Topical Coagulant
– FloSeal
– May use phenylephrine hydrochloride or oxymetazoline hydrochloride for vasoconstriction
Return to PlayReturn to Play
Can be immediate if bleeding is controlled.Custom face shields, helmets with face
masks, or protective devices should be worn for 4 weeks after injury.
Noncontact sports, return to play can be immediate if hemostasis controlled.
Nasal FractureNasal Fracture
Complications from Nasal Complications from Nasal FractureFracture
Chronic nasal obstructionDeviated septumSeptal hematoma
– Must Rule Out
Septal HematomaSeptal Hematoma
Bulging bluish mass Genarally form within
hours after injury Requires prompt I&D,
nasal pack and antibiotics
Must refer to ENT if present
Nasal FractureNasal Fracture
Septal DeviationSeptal Deviation
Ear InjuriesEar Injuries
Contusions caused by shearing forces applied to the external ear are common.
Most common in wrestling.Mechanism of injury is blunt trauma against
the wrestling mat.RESULT = AURICULAR HEMATOMA
The External EarThe External Ear
Auricular HematomaAuricular Hematoma
Diagnosis established by early– Ecchymosis– Erythema and pain– Palpable collection of
fluid– Swelling of external
ear with loss of anatomical landmarks
Auricular HematomaAuricular Hematoma
Early TreatmentEarly Treatment
Ice apllied eary with continued compression can minimize the risk of developing an auricular hematoma.
If hematoma present – prompt aspiration required
Treatment OptionsTreatment Options
Aspiration with 18 or 20-gauge needleIncision and Drainage using sterile
techniqueCompression applied for 7 to 14 days
– Dental roll with through & through sutures.– Antibiotics for 7 – 10 dayes recommended– Cephalosporins
Auricular HematomaAuricular Hematoma
I & D Evacuation of
hematoma
Auricular HematomaAuricular Hematoma
Dental Roll Application
Auricular HematomaAuricular Hematoma
Auricular HematomaAuricular Hematoma
Return to PlayReturn to Play
Noncontact sports may return to play immediately
Contact sports require ear protection and athletes may return to play 48 hours after dental rolls are removed.
ComplicationsComplications
Pressure necrosis of the underlying cartilage by seperating the perichondrial blood supply from the underlying cartilage, results in CAULIFLOWER EAR.
Cauliflower EarCauliflower Ear
Tympanic Membrane Tympanic Membrane PerforationPerforation
Most common Cause – pressure caused from OM
Blunt trauma – BarotraumaSwimming, diving, highaltitude changes,
direct contact to the ear
TM AnatomyTM Anatomy
Normal TMNormal TM
TM PerforationTM Perforation
TM PerforationTM Perforation
TM PerforationTM Perforation
TM Perforation SymptomsTM Perforation Symptoms
May be Asymptomatic orHearing lossVertigoBloody or serous dischargeDiscomfort worsened by wind or cold
DiagnosisDiagnosis
Always consider if mechanism of injury present.
Otoscopic evaluation
TreatmentTreatment
Keep ear canal dryENT evaluationAudiogramOtic drops may be requiredReturn to play will depend on sport and
symptoms
Facial FracturesFacial Fractures
75 % of facial fractures occur in the:– Mandable– Zygoma– Nose
All Facial Fractures Require Referal
DiagnosisDiagnosis
Type Mechanism of injury
Signs and Symptoms
Mandible Trauma to lower face
Malocclusion, abnormal mandibular movement
DiagnosisDiagnosisZygoma Blunt trauma to
the cheekPain, swelling; ecchymosis over fracture site; numbness along infraorbital nerve
Nasal Direct or glancing blow
Heard “crack”; ecchymosis; tearing; epistaxis; crepitus
DiagnosisDiagnosis
Zygomatic Arch Blunt trauma to cheek
Central depression or asymmetry of cheek bone; trismus
Maxilla or LeFort’s
High-velosity shearing force to midface
Elongated, distored face; mobile maxilla; maloccusion
DiagnosisDiagnosisOrbital Blowout Direct trauma to
globe (eg, from ball, elbow)
Periorbital edema; ecchymosis; subconjunctival hemorrhage; numbness along infraorbital nerve; diplopia;
Decreased upward gaze; sunken globe
Questions ?Questions ?