NASAL BONE NASAL BONE FRACTURES FRACTURES GRAND ROUNDS GRAND ROUNDS DR. ASHISH GUPTA DR. ASHISH GUPTA
NASAL BONE NASAL BONE FRACTURESFRACTURES
GRAND ROUNDSGRAND ROUNDS
DR. ASHISH GUPTADR. ASHISH GUPTA
HistoryHistory
Chote SinghChote Singh 37yr/ Male37yr/ Male ElectricianElectrician LudhianaLudhiana H/O Fall from height on 10H/O Fall from height on 10thth Aug’08 Aug’08 H/O Nasal & Oral bleedH/O Nasal & Oral bleed
On ExaminationOn Examination
Laceration Bridge of nose 1x1cmLaceration Bridge of nose 1x1cm Edema face mid thirdEdema face mid third Crepitus +Crepitus + Maxilla/ Mandible- NormalMaxilla/ Mandible- Normal Systemic Examination: Systemic Examination:
ChestChest CVSCVS P/AP/A Skull & SpineSkull & Spine Skeletal SystemSkeletal System
Nasal FracturesNasal Fractures
Most common of all facial Most common of all facial fractures.fractures.
Injuries may occur to other Injuries may occur to other surrounding bony structures.surrounding bony structures.
3 types:3 types: DepressedDepressed Laterally AngulatedLaterally Angulated ComminutedComminuted
Facial Bone FracturesFacial Bone Fractures
TYPETYPE Closed Closed OpenOpen GreenstickGreenstick ComminutedComminuted UndisplacedUndisplaced DisplacedDisplaced
LOCATION:LOCATION: Upper FaceUpper Face Middle thirdMiddle third Lower third Lower third
(Mandible)(Mandible)
LocationLocation
Upper FaceUpper Face Frontal Frontal Temporal Temporal Frontal sinusFrontal sinus Supraorbital Supraorbital
ridgeridge
Middle thirdMiddle third Nasal bone & Nasal bone &
septumseptum Maxillary sinusMaxillary sinus Orbital boneOrbital bone ZygomaZygoma Zygomatic archZygomatic arch Maxilla (Leforte Maxilla (Leforte
I, II, III)I, II, III) Alveolar Alveolar
ProcessProcess Maxillary Maxillary
DentitionDentition
Mandible
• Dentition
• Alveolar Process
• Symphysis
• Corpus/ body
• Angle
• Ascending ramus
• Condyle
• Coronoid process
CLASSIFICATION OF CLASSIFICATION OF FRACTURES ON AN FRACTURES ON AN
ANATOMICAL BASISANATOMICAL BASIS
CENTRAL REGIONCENTRAL REGION
1. Fractures of Nasal 1. Fractures of Nasal bones &/or nasal bones &/or nasal septum-a)Lateral nasal septum-a)Lateral nasal injury b)Anterior nasal injury b)Anterior nasal injuryinjury
2. Fractures of the frontal 2. Fractures of the frontal process of the maxillaprocess of the maxilla
3. Fractures of types 1 & 2 3. Fractures of types 1 & 2 which extend into which extend into ethmoid boneethmoid bone
4. Fractures of types 1, 2 4. Fractures of types 1, 2 & 3 which extend into & 3 which extend into the frontal bonethe frontal bone
LATERAL REGIONLATERAL REGION
1. Fractures involving 1. Fractures involving Zygomatic bone, arch & Zygomatic bone, arch & Maxilla, Excluding dento-Maxilla, Excluding dento-alveolar componentalveolar component
FRACTURES NOT INVOLVING THE OCCLUSION
FRACTURES INVOLVING THE FRACTURES INVOLVING THE OCCLUSIONOCCLUSION
Dento- Alveolar FracturesDento- Alveolar Fractures Supra-Zygomatic:Supra-Zygomatic:
Le Forte III (High level or Craniofacial Le Forte III (High level or Craniofacial dysjunction)dysjunction)
Sub-Zygomatic: Sub-Zygomatic: Le Forte I (low level or Guerin)Le Forte I (low level or Guerin) Le Forte II (Pyramidal) Le Forte II (Pyramidal)
a. a. Nasal bonesNasal bones Depressed #Depressed #
due to frontal blowdue to frontal blow
““open book #”open book #” Angulated #Angulated #
due to lateral blowdue to lateral blow
UL depression of BL UL depression of BL # with deviation of # with deviation of nasal bridgenasal bridge
b.b.SeptumSeptum
buckling, buckling, dislocation, #dislocation, #
Depressed -Unilateral or Depressed -Unilateral or bilateralbilateral
Open book- ChildrenOpen book- Children Fracture at jn. of thick Fracture at jn. of thick
upper & thin lower portionsupper & thin lower portions ComminutedComminuted Fracture dislocationFracture dislocation Comminuted fractures with Comminuted fractures with
fracture of frontal process fracture of frontal process of maxillaof maxilla
TYPES:TYPES:
Pathophysiology:Pathophysiology:
Blunt Trauma: Most CommonBlunt Trauma: Most Common Vehicular accidentsVehicular accidents AltercationsAltercations Sports-related traumaSports-related trauma Occupational injuriesOccupational injuries FallsFalls Animal BiteAnimal Bite
Penetrating Trauma:Penetrating Trauma: Gunshot woundsGunshot wounds StabbingsStabbings ExplosionsExplosions
Mass, density, and shape of the striking object, Mass, density, and shape of the striking object, as well as speed of impact, directly affect type as well as speed of impact, directly affect type and severity of facial injury.and severity of facial injury.
Mechanism of Septal InjuryMechanism of Septal Injury
Clinical FeaturesClinical Features
1.1. Depression/ angulationDepression/ angulation
2.2. Periorbital ecchymosisPeriorbital ecchymosis
3.3. EpistaxisEpistaxis
4.4. TendernessTenderness
5.5. CrepitusCrepitus
6.6. Loss of Pyramidal supportLoss of Pyramidal support
7.7. Septal deviation/ obstruction (hematoma)Septal deviation/ obstruction (hematoma)
8.8. Tenderness at base of columellaTenderness at base of columella
Nasal FracturesNasal Fractures
Ask the patient:Ask the patient: ““Have you ever broken your nose Have you ever broken your nose
before?”before?” ““How does your nose look to you?”How does your nose look to you?” ““Are you having trouble breathing?” Are you having trouble breathing?”
Conventional X-Ray Conventional X-Ray ExaminationExamination
Lateral view of Nasal bonesLateral view of Nasal bones Occlusal view of nasal bonesOcclusal view of nasal bones
OCCLUSAL VIEW LATERAL VIEW
# site# site Nasal BoneNasal Bone
SymptomsSymptoms Nose is crookedNose is crooked
Nose bleedNose bleed
Physical findingsPhysical findings DeformityDeformity
EpistaxisEpistaxis
EcchymosisEcchymosis
CrepitusCrepitus
X- RaysX- Rays Nasal bone- lateral & Occlusal viewsNasal bone- lateral & Occlusal views
DiagnosisDiagnosis
TreatmentTreatment
Closed reductionClosed reduction: : Unilateral or bilateral fracture of the nasal bones Unilateral or bilateral fracture of the nasal bones Fracture of the nasal septal complex that is Fracture of the nasal septal complex that is
deviated less than one half of the width of the nasal deviated less than one half of the width of the nasal bridgebridge
Open reduction:Open reduction: Extensive fractures Extensive fractures Deviation of the nasal pyramid greater than one Deviation of the nasal pyramid greater than one
half of the width of the nasal bridge half of the width of the nasal bridge Displaced fracture of the caudal septum Displaced fracture of the caudal septum Open septal fracture Open septal fracture
Manual ReductionManual Reduction
Closed reductionClosed reduction
Ice packs and head elevationIce packs and head elevation If the reduction is not to be performed If the reduction is not to be performed
immediately, then a period of 3-5 days immediately, then a period of 3-5 days precedes further evaluation. precedes further evaluation.
Fractures that are not displaced do not Fractures that are not displaced do not require treatment. require treatment.
30% of patients have a deviation that was 30% of patients have a deviation that was present prior to injury, in many cases, present prior to injury, in many cases, obtaining photographs for review is helpful obtaining photographs for review is helpful
Closed ReductionClosed Reduction
Open reduction: Plating/ Wire Open reduction: Plating/ Wire fixationfixation The septum is the key The septum is the key
structure that may prevent structure that may prevent the reduction of the nasal the reduction of the nasal pyramid. In patients in whom pyramid. In patients in whom the septal fragments are the septal fragments are interlocked, the inability to interlocked, the inability to reduce the septum results in reduce the septum results in the bony pyramid remaining the bony pyramid remaining deviated. deviated.
Approach: Approach: Hemitransfixion. Hemitransfixion. Raise mucoperichondrial flaps. Raise mucoperichondrial flaps. Access the dorsum by bilateral Access the dorsum by bilateral
intercartilaginous incisions. intercartilaginous incisions. Elevating the periosteum off Elevating the periosteum off
the nasal bones because the the nasal bones because the fractured segments may fractured segments may become unstable, devitalized, become unstable, devitalized, or lost or lost
COMPLICATIONS COMPLICATIONS
EARLYEARLY LATELATE
EdemaEdema Subperichondraial fibrosis Subperichondraial fibrosis
Ecchymosis Ecchymosis Thickening of septum Thickening of septum
EpistaxisEpistaxis Synechiae b/w septum & turbinates Synechiae b/w septum & turbinates
Partial nasal obstructionPartial nasal obstruction
Hematoma Hematoma Obstruction of nasal vestibuleObstruction of nasal vestibule
InfectionInfection OsteitisOsteitis
MalunionMalunion
To Operate or Not To????To Operate or Not To????