Transcript Document

MANAGEMENT OF FRACTURE
OF THE NASAL BONES.
DR OLUTAYO JAMES BDS, MMI, FMCDS
Senior Lecturer,
Oral and Maxillofacial Surgery Department,
Faculty of Dental Sciences,
College of Medicine,
University of Lagos
Surgical Anatomy
• The nasal bone is one important bone of the
nasoorbitoethmoidal (NOE) complex
• The skeletal foundation of NOE complex consists
of a strong triangular frame .
• On each side of the triangle ,the frontal process of
the maxillary bone and the nasal process of the
frontal bone are united above at the glabella by the
frontal bone .
• The triangle is completed inferiorly by premaxilla
The nasoorbitoethmoidal (NOE)
complex
The nasoorbitoethmoidal (NOE)
complex
Nasal Complex
1) Osseous framework –
Paired Nasal bones
2) Cartilaginous framework The upper lateral cartilage
The lower lateral cartilage
The lobular or Alar cartilage.
3) The septum, which is comprised of cartilage
and bone.
Osseous Frame work
•
•
•
•
•
Consist of Two nasal bones
Convex from above downward
Convex from side to side
Their length varies from 8 to 33 mm
Width superiorly varies from 2 to17 mm and
inferiorly from 7 to 24 mm.
• The inner surfaces are concave form side to side
and traversed above downward by a groove for
the anterior ethmoidal nerve
Osseous Frame work
• The paired nasal bones articulate in the midline with each
other (internasal suture)
• Laterally, both borders articulates with the frontal process of
the maxillae (Naso-maxillary suture)
• The superior border is thick and serrated and articulates with
the nasal process of the frontal bone. (Naso-frontal Suture)
Osseous Frame work
Osseous Frame work
• The thinner, caudal portion of the nasal bones is notched and
articulates with the upper lateral cartilages.
• This area is vulnerable to fracture and dislocation.
Nasal Complex
Osseous Frame work
• Medially where the two bones articulates with one another, they
are thicker above than bellow and are prolonged posteriorly to
form a vertical crest
• This form part of the septum of the nose and articulates from
above downward with the nasal spine of the frontal bone, the
perpendicular plate of the ethmoid and the cartilage of the nasal
septum
Cartilaginous Framework- Upper
nasal Cartilage
• Trapezoid in shape – wrongly term "triangular
cartilage".
• Its anterior margin is thicker than the posterior
and the upper part is continuous with the
cartilage of the septum
• Lower part is separated from this cartilage by a
narrow fissure
• The superior margin is attached to the nasal
bone and frontal process of maxillae
Nasal Complex - Cartilaginous Framework
Blood suply
FRACTURE OF THE NASAL BONES
Nasal fractures
• The third most common fracture of the human skeleton
• The most commonly fractured bony structures of the maxillofacial
complex
• Likewise, the most commonly missed facial fracture
• Protruding position coupled with its relative lack of support
• May include associated fractures of the nasal cartilages and/or the
nasal septum.
• They may be associated with fractures of the ascending process of
the maxilla.
• They can often occur in association with NOE and frontal sinus
Nasal fractures
Epidemiology
• Nasal fractures account for greater than 50% of all facial
fractures in adults
• Brazil - nasal fractures were also most common facial injuries,
(51.3%), followed by the zygomatic-orbital complex
(25.4%).(Cavalcanti and Melo)
• Nigeria - ??
Clinical Significance
• Most nasal fractures cause significant bleeding.
• Proper techniques for hemostasis should be applied prior to
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 facial fractures.
Aetiology
• Blunt trauma –
sport injury,
RTC,
physical altercations
Personal injury
• High velocity injuries –
blasts,
gun shot
Signs and Symptoms
•
•
•
•
•
•
•
Facial oedema
Billateral circumorbital ecchymosis
Subconjuctival ecchymosis
Deviation of nose
Epistaxis / caked clotted blood
CSF leakage
Nasal blockage r/o pre-existing nasal deformities
Classification
• There is no standardized, world-wide accepted classification
for nasal fractures.
• Ondik et al 2009 and AO provide a simple classification systems
based on clinical findings
Ondik et al 2009
AO Classification : Laterally displaced fractures
• Occur secondary to a lateral blow to
the nose.
• The nasal bones are pushed
medially on the side of the impact
and laterally on the contralateral
side.
• They make up the majority of nasal
fractures.
• Most of them can be managed by
closed reduction.
Posteriorly depressed fractures
• Posteriorly depressed fractures
occur secondary to a direct blow
over the nasal bones,
• which are pushed inside to the
ascending process of the maxilla.
• The nasal septum is always
involved.
• This type of fracture can be
associated with NOE fractures.
Disarticulation of upper lateral cartilage
• A disarticulation of upper lateral
cartilage
• Usually due to a localized strong
blow to the central third of the
nose, as in car accidents with
the steering wheel hitting the
nose.
• The upper lateral cartilage can
be avulsed from the bone.
Anterior nasal spine fracture
• Can occur in isolation or in
association with other nasal
fractures.
• Displaced fractures are often
associated with nasal septum
dislocations and/or fractures.
• Occurs in association to degloving
injuries of the upper labial vestibule
as in a steering wheel injury.
• Isolated anterior nasal spine
fractures do not usually require
treatment.
Nasal septum dislocations and/or fractures
• 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.
• With more significant forces the septum will be fractured.
• Nasal septal injuries often lead to nasal airway compromise.
• The need for repair is individualized based on the patient’s
symptoms.
• Septal injuries may result in a loss of support of the cartilaginous
nasal dorsum which can require cosmetic reconstruction.
Diagnosis
• History of the patient, physical examination and imaging.
• The direction and strength of the impact should be noted.
• Pre-existing 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.
Physical examination
Intranasal anatomy assessment
• Done using a nasal speculum, looking
for a septal deviation, mucosal
laceration and/or septal hematoma.
• The presence of a significant septal
hematoma requires immediate
drainage.
Septal hematomas
•
•
•
•
•
•
This is a common and serious complication of nasal trauma.
These are collections of blood in the subperichondrial space.
This places pressure on the underlying cartilage
Resulting in irreversible necrosis of the septum.
The patient also becomes predisposed to infection.
A saddle deformity may develop from loss of tissue.
Septal hematomas :
• The main symptom is severe nasal obstruction
• On examination the septum appears swollen and boggy
• The swollen area should be palpated with a cotton-tipped
applicator.
• If a hematoma is present it should be compressible.
• The presence of a significant septal hematoma requires
immediate drainage.
Septal hematomas: Drainage procedure
• Septal hematomas must be drained immediately upon their
being found.
• Cotton pledgets soaked in 2% lignocaine are used for topical
anesthesia.
• A scalpel incision must be made to allow drainage.
• A small Penrose-type drain is placed to prevent re-accumulation.
• Finally, nasal packing is placed.
• The patient should be started on oral antibiotics
Imaging
• Plain films of the nose.
• The greatest weakness of plain films is their inability to assess
the injury for correct management.
• The management of nasal bone fractures is based primarily on
clinical assessment of appearance and function.
• CT scans are - helpful to make a more accurate diagnosis of
nasal bone fractures.
Imaging
Management of a nasal bone fracture
Dependent upon multiple factors including:
(1) Age of the patient,
(2) Time since injury,
(3) Necessity for acute versus delayed reduction,
(4) Choice of anesthesia
(5) Approach (open vs. closed reduction)
Treatment
Close Reduction
• Less invasive
• Simpler
• Accuracy of reduction can not be directly evaluated
• 15% to 50% of those having closed reduction of a nasal
fracture will ultimately undergo revision rhinoplasty
Instruments commonly used for closed
treatment of nasal fractures
• Asch septum-straightening forceps
• Walsham septum-straightening
forceps
• Boies nasal fracture elevator
• Mayo hemostat with rubber tubing
• Killian nasal septum speculum
Choice of anaesthesia
Local anesthesia
• Closed reduction of nasal fractures can be performed under local
anesthesia in the majority of patients.
• The nasal cavity should be prepared with cotton pledgets moistened
in a solution with topical anesthetic with vasoconstrictor.
• Local anesthetic is injected to block the infraorbital nerve.
• IV sedation can be added for the comfort of the patient.
General anesthesia
• General anesthesia is an option according to the surgeon’s and/or
patient’s preference.
In laterally displaced fractures
• Commonly laterally displaced fractures on one side are
medially depressed on the other side.
• Place an instrument (eg, Boies elevator) in the depressed side
along the lateral wall of the nose to a point below the nasal
frontal angle.
• Place a finger along the lateral side of the nose above the
depressed area.
Reduction of nasal bones
Reduction of nasal bones
• In this case the elevator is
placed in the nose and lifts
the nasal dorsal pyramid
anteriorly, while
simultaneously the thumb
and index finger put medial
pressure on the displaced
frontal processes of the
maxillae.
Reduction of the nasal septum
• The Asch or Walsham septumstraightening forceps are used to
straighten the nasal septum.
• Grasp the nasal septum with the
blades of the instrument and
gently manipulate the septum
into proper alignment.
Nasal bones
• After reduction, adhesive strips or
POP 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 prior to placing the
external splint.
Removal of pickings 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.
• (Various surgeons leave these in place from anywhere between
5-10 days).
• The patient should be prescribed antibiotic treatment for as
long as the nasal packs are in place.
ORIF
Open Reduction and Internal Fixation
• better cosmetic results
• For old fractures
• Secondary rhinoplasty
Fixation
• Micro plates
• Resorbable plates
Indication
• Severe comminution of the nasal bones and septum
• Associated orbital wall or ethmoid bone fractures
• Nasal pyramid deviation that exceeds one half the width of the
nasal bridge
• Caudal septum fracture dislocation
• Open septal fractures
• Fractures examined 3 weeks or longer after the injury occurred
Surgical Approach
•
•
•
•
•
•
•
Intercartilaginous incision
Inverted Y incision
Subciliary incision
Upper labial vestibular incision
hemitransfixion incision
Existing laceration
H shaped incision not popular again
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 for at least 10 days following NOE fracture
repair.
• Ice packs
Medication
•
•
•
•
Analgesia as necessary
Antibiotics.
Nasal decongestant may be helpful for symptomatic improvement.
Steroids, in cases of severe orbital trauma, may help with
postoperative oedema.
• Ophthalmic ointment should follow local and approved protocol.
Acknowledgement
• AO CMF surgical site
• All slides with this logo