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Nasal-Septal Fractures

Anatomy
Bones z Frontal process of maxilla, nasal
spine of frontal bone
z Paired nasal bones
z Vomer
z Perpendicular plate of the
ethmoid

Anatomy (cont.)
Cartilagez Lower lateral cartilage
z Upper lateral (Alar) cartilage
z Septal cartilage
z Sesamoid cartilages

Pathogenesis
Variablesz The patients age (tissue flexibility)
z The amount of force applied
z The direction of the force
z The nature of the striking object

Frontal Impact
Plane Iz Fracture of nasal tip
z Small dorsal hump with supertip
depression
Plane IIz High fracture of nasal bones
z Dorsal depression
z Septal buckling with flattened
appearance of the nose

Frontal Impact (cont.)


Plane IIIz Fracture of nasal bones, frontal process
and anterior nasal spine
z Comminuted, lateralized
z Marked nasal depression
z Columellar retraction
z Medial canthal relaxation with
telecanthus

Lateral Impact
Plane Iz Unilateral nasal bone depression
z Elevation of contralateral nasal
bone
z Septal buckling
z C or S shaped deformity of nasal
dorsum

Lateral Impact (cont.)


Plane II/IIIz Fracture extension to frontal
process
z Marked displacement of septum
and dorsum
z Medial maxillary wall depression

Septal Fracture
z Vertical

with anterior fracture


z Horizontal with posterior fracture
z S and C shaped deformities with
healing
z Telescoping of segments prevents
closed reduction

History
z Force,

direction of impact
z Epistaxis
z External deformity
z Prior nasal injury, dysfunction
z Pre-injury photographs

Exam
z Nasal

deviation
z Mucosal or skin lacerations
z Ecchymosis, hematoma
z Lid edema, chemosis
z Subconjunctival hemorrhage
z Telecanthus, CSF rhinorrhea

Exam (cont.)
z Topical

decongestion
z Debridement of clots
z Internal and external palpation
z Exam of cartilaginous nose
z Roentgenograms
z Photographic documentation

Clinical Decisions
Open versus closed reduction
Closed Reductionz Unilateral or bilateral fracture of the
nasal bones
z Fracture of the nasal-septal complex
with nasal deviation less than one half
the width of the nasal bridge.

Clinical Decisions (cont.)


Open Reductionz Extensive fracture-dislocation of the nasal
bones and septum
z Nasal pyramid deviation exceeding one half
the width of the nasal bridge
z Fracture-dislocation of the caudal septum
z Open septal fractures
z Persistent deformity after closed reduction

Clinical Decisions (cont.)


Local versus general anesthesia
Timing of reductionz < 3-6 hours- immediate reduction
z < 2-3 weeks- closed reduction
z > 3 weeks- delayed 3-6 months

Anesthesia
z 4%

cocaine
z Epinephrine soaked pledgets
z IV or oral sedation
z EMLA cream - time consuming
z General anesthesia

Instruments
z Asch/Walsham

forceps
z Large Kelly clamps
z Elevators- Boies/Ballinger
z Various intranasal specula
z Headlight

Reduction
Elevate fragment with anterolateral force
z Completion of the fracture
z External digital molding
z Reduction of septum is critical
z Asch/Walsham forceps to elevate
fracture and reduce septum
z

Trouble Shooting

z Overriding

cartilage fragments
z Post reduction instability
z C-shaped septal fracture
z Converting to an open reduction

Post-Op
z Silastic

splints
z Intranasal placement of packing
z External splint application
z Packing out 2-3 days, silastic-10
days
z External splint off when fracture
stable

Subacute Open Reduction


Hemitransfixion, lateral intercartilaginous
incisions
z Elevation of dorsal skin and periosteum
z Exposure of cartilage segments
z Reduction of cartilage- scoring, suture
z Maxillary crest involvement- trapdoor
z

Complicated Fractures
z Open

sky approach
z Use preexisting lacerations when
possible
z Depressed comminuted fractureswires versus miniplates
z Wound closure
z Prophylactic antibiotics

Delayed Repair
Complicated due to scarring, fibrosis
z Common problems: Dorsal hump, C/S
shaped septum, saddle deformities,
septal displacement, fallen or deviated
tip
z Common solutions: Excision of hump,
cartilage grafting, calvarial grafts,
osteotomies
z

Children
Physical differences- projection, cartilage:
bone, growth centers
z Small fracture--- obstruction with age
z Edema, anxiety tend to obscure fracture
z Operative intervention- cosmesis,
obstruction
z Digital compression
z Neonatal fracture-dislocation
z

Early Complications
z Septal

hematoma
z Infections- antibiotic prophylaxis
z Epistaxis- cautery, packing, ligation
z CSF Rhinorrhea
z Emphysema of the face, neck

Late Complications
Organization of hematomas- airway
obstruction
z Synechia- divide if symptomatic
z Obstruction of the nasal vestibule
z Residual osteitis
z Malunion
z Naso-facial disproportion
z

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