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
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
Septal Fracture
z Vertical
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.
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
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