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
Most studies found local anesthesia to be as clinically effective as and less expensive than general anesthesia for closed reduction.
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.
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.
Attempt to get it back into the vomerine groove
nonreducible posteroinferior or anterior septum is considered for acute septal reconstruction
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