Dr.

Supreet Singh Nayyar, AFMC 2011

Nasal Fractures for more topics, visit [Link]

History

 First recorded 5000 years ago during the early Pharonic period in Ancient Egypt
 Edwin Smith papyrus
o Repositioning of deviated nasal bones by fingers or elevators
o Insertion of splints
o External dressings

Epidemiology

 3rd most fractured bone

 Most common facial fracture
 Isolated fractures of the nasal pyramid - 40 percent of all facial fractures
 Often sustained along with other fractures of the facial skeleton
 25-75 lb/in2 force required for nasal fracture
 M:F :: 2:1
 Peak incidence 15-30 yrs
 Refracture rates 5 % (in previous rhinoplasty for nasal # cases)
 Childhood - greenstick nature
 Compound and comminuted fractures – elderly

Aetiology
 Assaults
 Contact sports
 Adventurous leisure activities
 Road traffic accidents

Pathophysiology

 Direction of impact
o Lateral forces
 More frequent cause of nasal injuries (66%)
 Ipsilateral depressed fracture
 Outfracture opposite nasal bone
o Frontal
 Greater force for impact from front
 Open book fracture

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 Dr. Supreet Singh Nayyar, AFMC 2011

 Depressed nasal dorsum

 Force
o High velocity – associated facial fractures
 Nature of the striking object
 Patient's age
o Younger adults - dislocation of major segments
o Older individuals- more comminution of brittle, osteopenic nasal bones
o Children - greenstick fractures
 Anatomical differences
o Thinner nasal bone below the intercanthal line -- fractured more easily than
thicker bone of the nasal root
o Cartilaginous
 Absorb greater amount of force
 But more exposed – higher chances of injury
o Septal
 Thinnest portions
 Superior septal angle
 Central-dorsal area of the quadrangular cartilage
 Posterior portion perpendicular ethmoid plate

 C-shaped fracture through the cartilaginous septum and perpendicular plate – higher
chances of failure of reduction

Associated Injuries

 Epiphora -- disruption of the nasolacrimal drainage 0.2%

 Widening of the intercanthal distance -- detachment of the medial canthal tendons
 Le Fort's fracture
 Zygomaticomaxillary complex fracture
 Frontal sinus fracture
 Cribriform plate fracture
 Dural tears
o Pneumocephalus
o CSF rhinorrhea

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 Dr. Supreet Singh Nayyar, AFMC 2011

Classification

 Grading system for extent of lateral deviation of nasal pyramid

o Five grade system:
 Grade 0 :Bones perfectly straight
 Grade 1 :Bones deviated less than half of the width of the bridge of
the nose
 Grade 2 :Bones deviated half to 1 full width of the bridge of the nose
 Grade 3 :Bones deviated greater than one full width of the bridge of
nose
 Grade 4 :Bones almost touching the cheek

 Pattern of fracture
o Class 1
 Low- moderate degree force
 Simplest form
 Depressed fracture segments
 Remain in position (due to its inferior attachment to the upper
lateral cartilage)
 Septum generally not involved
 More severe variant
 Both nasal bones & septum involved (below 0.5cm from the
dorsum)
 Fracture line
o Parallel to nasomaxillary suture ipsilateral to the side of
the applied force
o To a point approximately two-thirds along length of the
nasal bone, where the bone becomes much thicker
o Fracture line then connects across towards
contralateral side and runs parallel and just below the
dorsum

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 Dr. Supreet Singh Nayyar, AFMC 2011

o Cartilaginous septum is fractured approximately 0.5 cm

below the dorsum (vertically backwards) and this
aspect of the injury may extend posteriorly into the
bony septum through the perpendicular plate of the
ethmoid and skull base (Chevallet #)

 In children greenstick type –nasal deformity may develop at puberty

 Class 1 fractures tend not to cause gross lateral deviation
 May not even be perceptible
 Deformity generally results from a persistently depressed fragment,

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 Dr. Supreet Singh Nayyar, AFMC 2011

which is often due to impaction of the flail segment beneath the

residual nasal bone

o Class 2 Fractures
 Greater force
 Significant cosmetic deformity
 Nasal bones , frontal process of maxilla & septum involved, surrounding
structure remain intact
 As a rule of thumb, if the nasal dorsum is deviated laterally greater than
half the width of the nose (grade 2 or greater fracture), then a septal
fracture must also be present
 Gross flattening & widening of dorsum
 C-Shaped fracture of septum
 'C-shaped' fracture that extends from the quadrangular cartilage beneath
nasal tip, posteriorly through to the perpendicular plate of ethmoid, then
may extend through the lower part of the perpendicular plate of the
ethmoid to the anterior border of the vomer and then forward into the
inferior part of the quadrilateral cartilage (Jarjavay)

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 Dr. Supreet Singh Nayyar, AFMC 2011

 Class 3 fractures
o Most severe due to high velocity
o Also termed as naso-orbito-ethmoidal fracture
o Often associated with
 Maxillary fracture
 CSF leak
o Pathophysiology
 External butresses of nose give way
 Ethmoid Labyrinth collapses on itself
 Causes
 Perpendicular Plate of the ethmoid to rotate
 Quadrilateral Cartilage to fall backwards
 'Pig-snout' appearance
 Foreshortened saddled nose
 Nostrils facing more Anteriorly
 Telecanthus
o Two categories of naso-orbito-ethmoid
 First type
 Anterior Skull base, posterior wall of the frontal sinus and
optic Canal remain intact
 Second type
 Disruption of the posterior frontal sinus wall, multiple
fractures of the roof of the ethmoid and orbit
 May Extend posteriorly to the sphenoid and parasellar
regions

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 Dr. Supreet Singh Nayyar, AFMC 2011

 Multiple dural tears, cerebrospinal fluid leaks

 Pneumocranium and cerebral herniation may complicate

CLINICAL PRESENTATION
History

 Time and mode of injury

 Nasal obstruction
 Change in shape of nose
 History of diplopia, visual disturbance
 Epiphora
 Loose teeth ,altered bite, trismus
 Watery rhinorrhoea, loss of smell
 Past surgery
 Occupational hazards

EXAMINATION

 External
o External deformity  deviation, flattening, bruises, laceration
o Palpate  crepitus, tenderness, step deformity
o Second look
o Detail record of soft tissue laceration
 Anterior rhinoscopy
o Septal deviation/haematoma
o Mucosal laceration

INVESTIGATION
 X-ray skull lateral view
o Proof of injury in litigation
 CT Scan for class 3 #
 Beta2 transferrin

Treatment
Timing
 80% will not require active intervention (includes undisplaced fractures as well)
 Topical vasoconstrictor drops -- helpful to alleviate congestion and obstructive
symptoms
 Re-examination about five days later where uncertainty about need for reduction

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 Dr. Supreet Singh Nayyar, AFMC 2011

 Pre-existing deformity to be assessed

 Continued risk -- occupational hazard, sport or leisure activity
 Indication for active intervention in acute phase
o Significant cosmetic deformity
o Significant nasal obstruction caused by a septal haematoma
 The timing of surgical assessment and subsequent reduction crucial
 Development of fibrous connective tissue within the fracture line-- limiting factor
 Starting at around 10 days to 2 weeks after injury
 Ideally, manipulation should be performed before this point, with some preference
before 10 days
 However, some authors have suggested that attempts to reduce nasal fractures can
be done as far out as three weeks
 A short delay period is also recommended during the first 2 to 3 days to allow for
diminution of swelling so that the nasal bone position may be best appreciated
 Treatment before this delay is reasonable if the patient presents within an hour or
two after injury, before edema has obscured the underlying structure
 In case deformity persists after 3 weeks, septorhinoplasty after 6 mths

Anaesthesia
 GA/LA
 Contentious issue
o Ridder et al -- No difference
o Courtney et al -- Septorhinoplasty in 17.2%(LA),3.2%(GA)
 There are easily identifiable groups of patients who are not suitable for reduction
under local anaesthesia
o Children, patients with low pain thresholds or significant anxiety states
o Delay in presentation

Procedure
 Method of reduction
o Open and Closed
o All class 1 and most class 2 # reduced by Close technique
o All class 3 and some class 2 #reduced by Open technique

 General principle of fracture reduction

o Mobilize fragments first by increasing and then decreasing degree of
deformity
o An initial slight increase in deformity away from the side of the blow to
disimpact the fragments, followed by steady movement back towards and
often slightly beyond the midline is usually required

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 Dr. Supreet Singh Nayyar, AFMC 2011

 Method
o In most cases, firm digital pressure
o Sometimes instruments such as
 Freer
 Hills
 Boeyi’s
 Jokes
 Howarth elevators
 Ashe and Walsham forceps
o Instrument is held so that the index finger of the dominant hand is placed
along instrument in the line of the nose
o In this way, the depth that the instrument has to be inserted into the nasal
cavity is known
o All class 1 and most class 2 fractures can be reduced with these techniques
o For many class 2 fractures, closed reduction alone rarely achieves a
satisfactory result as the final postion of the nasal dorsum reflects the
deformity of the underlying septum
o Splints or packs may be necessary, depending on
 Stability of the reduction
 Surgeon's preference
o Splint or plaster applied to the nasal bridge maintains, to some extent, the
position of the nasal bones and prevents accidental displacement
o Splints are usually kept in place for about seven days
o Advisable to refrain from contact sports for at least six weeks

COMPLICATIONS
 Nasal obstruction
 Valve obstruction
 Septal deviation
 Widened septum
 Nasal tip ptosis
 Epistaxis

For more topics, visit [Link]

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