Nasal fractures



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NASAL FRACTURES


  • most common type of facial fracture and the third most common fracture of the human skeleton

    • weakest bone and in a central and prominent position

  • high incidence of posttraumatic nasal deformity (14 to 50 percent).

  • Factors that contribute to suboptimal aesthetic and functional end results include timing, edema, undetected preexisting nasal deformity, and occult septal deviation/injury.

  • Patients with traumatic septal deviation have a high chance of requiring secondary surgery - 40 to 42 percent had a significant septal deformity at 3 months that required septorhinoplasty.


Pathogenesis of nasal fractures

  • A strong force from any direction can comminute the nasal bones, giving rise to the “open book” type of fracture.

  • When fracture of the thick bone at the root of the nose occurs, it is usually associated with fractures of other parts of the facial skeleton


Pathogenesis of septal fractures

  • three septal zones with thicker cartilage where it attaches to bone -dorsoposterior, basal, and caudal.

  • central caudal portion of the septum is thin.

  • The thicker, posterior septal cartilage provides the primary support for the nasal dorsum.

  • Low-velocity injuries usually lead to septal fractures or dislocations along the vomerine groove; high-velocity injuries or frontal impacts result in more extensive septal fractures through the thin central region of the quadrangular cartilageprogressive distortion of fractured septal cartilage caused by the release of locked internal stresses

  • septum does not remain straight after manipulation and that the nasal bones tend to unite in the direction of the deviated septum.

  • Acute open reduction with submucous septal resection results in an improved long-term cosmetic and functional outcome due to the alleviation of overlapped, interlocking fragments of the septum that usually resulted in the secondary nasal bone deformity.

  • Thus septum is the key structure with which to align/correct and optimize nasal fracture management and to minimize secondary deformity


Classification (Rohrich)
Type 1 Simple – Unilateral

Type 2 Simple – Bilateral

Type 3 Comminuted

A - unilateral

B – bilateral

C – frontal

Type 4 Complex – includes septum

A – septal hematoma

B – open laceration

Type 5 NOE


Management

Important to establish- Cause of the trauma (the 4 main causes of nasal trauma are personal assault, sport injuries, personal accidents, and road accidents)



  1. History of previous facial injuries

  2. Any prior nasal deformity

  3. History of nasal obstruction

  • Complete nasal assessment (bony and septum), use of outpatient controlled general anesthesia, and primary septal reconstruction in cases with severe septal fracture dislocation

  • internal examination requires halogen lighting, good suction, a nasal speculum, vasoconstrictive anesthesia, and a 30-degree, 3-mm rigid nasal endoscope of type III or greater.

  • Drain septal hematomas - reduces fibrosis and subsequent septal distortion, abscess, and complete necrosis with saddle nasal deformity.

  • If the patient is seen in the first 3 to 6 hours (before significant distorting edema sets in), reduction of the fractured nose should be performed immediately.

  • Soft tissue edema usually masks mild-to-moderate nasal fracture and hinders any immediate closed reduction, so the patient has to be reassessed 3 to 4 days later

  • Reduction should be done within 10 days of the trauma for adults and within 7 days for children

Indications for closed reduction in adult patients are



  1. unilateral or bilateral nasal bone fracture

  2. fracture of the nasal-septal complex with nasal deviation less than half the width of the nasal bridge.

Indications for open reduction



  1. extensive fracture-dislocation of the nasal bones and septum

  2. nasal pyramid deviation exceeding one half the width of the nasal bridge,

  3. fracture and dislocation of the caudal septum

  4. open septal fracture,

  5. persistent deformity after closed reduction.



  • Anaesthesia

    • GA vs local anaesthetic

    • Most studies found local anesthesia to be as clinically effective as and less expensive than general anesthesia for closed reduction.

  • Local anaesthesia

    • topical intranasal solution using pledgets soaked with a vasoconstrictive agent (ie, 1:100 000 epinephrine) and an anesthetic (ie, 4% cocaine or 2% lidocaine) for nasal mucosa anesthesia and hemostasis.

    • externally infiltrative field anesthesia to the nasal dorsum is as effective as and better tolerated than bilateral specific internal blocks of the infraorbital, infratrochlear, and external nasal nerves.

    • externally infiltrative field anesthesia -bilateral percutaneous infiltration over the whole of the bony dorsum with a total of 4 mL of 0.5% bupivacaine and 1:200 000 adrenaline

    • alternative to the external percutaneous method involved the application of a eutectic mixture of local anesthetic cream, containing lignocaine and prilocaine, to the nasal bridge to induce topical skin anesthesia, with concomitant intranasal cocaine,

    • Oral or intravenous sedation may be given to enhance the anesthesia.

  • Method

    • Reduction nasal bones

      • reduction of external nasal bones to their anatomic position is initially accomplished by recreating the fracture; molding the nasal bones with the fingers is the simplest approach

      • Impacted nasal bones require instrumentation for reduction and restoration of nasal length, which is the most critical dimension to regain.

      • The Walsham forceps are designed for the reduction of impacted nasal bones, whereas the Asch forceps are designed for reduction of the nasal septum, although they may also successfully restore the alignment of impacted nasal bones.

      • To avoid the mucosal damage caused by these instruments, some surgeons prefer to use a less traumatic Boies elevator

      • Comminuted nasal bones may be reduced and dorsal-posterior intranasal packing with gel foam used to prevent collapse after reduction.

    • Relocating septum

      • Attempt to get it back into the vomerine groove





      • nonreducible posteroinferior or anterior septum is considered for acute septal reconstruction

      • hemitransfixion or Killian incision is made on the side of the dislocation, and the bilateral inferior mucoperichondrial flaps are developed.

      • Further access to the fracture line is gained through a lateral intercartilaginous incision. The dorsal skin is lifted off the upper lateral cartilage and the periosteum is pulled away from the nasal bones

      • Intranasal and external splints are used for 5 to 7 days, as are prophylactic antibiotics (Cephalexin) and 3-day steroid dose packs to reduce postreduction nasal ede

      • An inferior and posterior septal resection to dislodge and align the septum and/or to implement septal repositioning may be performed with anterior septal spine figure-of-8 sutures