Fractures of the Nasal

Fractures and Trauma of the NasalIgor T. Hutabarat1Pembimbing Dr. Ali Sundoro, SpBP-RE108-01-10

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Nasal Skin: Blood Supply & Innervation4408-01-10

Nasal Skeleton5Rigid, thickMobile, thinNasalValveNasal Skeleton

6OS VOMERPerpendicular plate of palatine boneMedial crus alar cartilageSeptal Kartilage

Anatomy - Nasal Valve7PATOPHYSIOLOGYThe injury caused by a blow to the nose varies by following factors :

Patients age (tissue flexibility)The amount of force appliedDirections of the forceThe nature of the striking object

8General ConsiderationCommon soft tissue injuries include lacerations, ecchymosis, and hematoma of external or internal nose. Skeletal injuries comprise fractures, dislocations, and fracture dislocations.Dislocations injuries can involve any articulation of the external nasal skeleton or the septum9General ConsiderationNasal fractures can be open, closed, or both.The pattern of nasal fractures varies with the direction of applied forces; there is a distinct difference between frontal and lateral forces.A force of 25 to 75 pounds per square inch is needed to produce a nasal #10

Types of Fractures11Unilateral Type12

Multiple fracture Of nasal pyramid13

Bilateral fracture and nasal bone depression or dislocation14

Compression and septal fracture (Caudocranial direction trauma)Frontal forcesThe injuries varies from minor (lower margin of nasal bones) to marked (flattening of the external skeleton)These injuries are classified according to depth as frontal planes 1, 2 or 3.Plane 2 and 3 fractures also can involve the septum15

Frontal Force16Acc w/ Septal FractureLateral forcesLateral forces can caused only a depressed fracture of the ipsilateral nasal bone or can be strong enough to out fracture the contralateral nasal bone as well. Cartilaginous attachments to the nasal bones or maxilla can be separated. 17

Lateral Force18

Types of Fractures08-01-1019

Inferior Force20

Patterns of Fractures21

Septal Fracture22Diagnosis Nasal FracturesHistory of nasal trauma and bleeding suggests a probable nasal fractureIntranasal examination after decongestion is the key step for diagnosing septal dislocations or hematomaPalpation of the external nose for tenderness, mobility, and stability is the most reliable step for d/ pyramid #23Radiographic studies may be helpful in assesing nasal fractures, but they are reliable only when correlated with physical examination findings.Photographic documentation of nasal fractures is an important part of the medico-legal record24

Radiograph of Nasal Fracture25

Ultrasonography

26TREATMENT GOALRestore satisfactory appearanceRestore nasal airway patencyReplace septum in the midlinePreserve nasal valve integrityPrevent postoperative stenosis, septal perforation, columellar retraction, and saddle deformity

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28 Emergency Nasal fracturesEmergency

Severe bleeding

Septal fracture-dislocation causing nasal airway obstruction in neonate (obligate nasal breathing)Management

Cautery, packing, vessel ligation

Closed reduction using cotton swabs; no nasal packing29 Emergency Nasal fracturesEmergency

Septal hematoma in a child

CSF rhinorrhea

Visual impairmentManagement

Incision and drainage immediately, as tissue destruction begins within 48 hoursNeurosurgical consultation immediately

Ophthalmologic consultation immediately30

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The Indications for Closed Reduction1.Unilateral or bilateral fracture of the nasal bones 2.Fracture of the nasal-septal complex with nasal deviation less than one-half the width of the nasal bridge

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Topical Anesthesia34

Topical Anesthesia35

Instruments36

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Closed Reduction38

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Open reduction is generally recommended for1.Extensive fracture-dislocation of the nasal bones and septum 2.Nasal pyramid deviation exceeding one-half the width of the nasal bridge 3.Fracture-dislocation of the caudal septum 4.Open septal fractures 5.Persistent deformity after closed reduction

40Delayed ManagementProcedures: Rhinoplasty Septorhinoplasty Open Septorhinoplasty

Surgery is delayed for > 3 months after prior closed or opened fracture reduction

Fracture line stabilized & matured fibrosis41

Hemitransfixion Incision42

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Nasal Stenting44

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Nasal Fractures in ChildrenChilds nose more cartilaginous and more flexibleRadiograph less helpfulDislocation, greenstick fracture, & septal hematoma more commonRadical procedures are contraindicated, but open procedure could be done with limited resection46Nasal Fractures in ChildrenIn order of frequency the signs and symptoms of nasal injury in children : 1.Epistaxis 2.Nasal dorsum edema 3.Periorbital ecchymosis 4.Nasal dorsum tenderness 5.Abnormal radiograph 6.Visible nasal deformity 7.Nasal bone crepitus. 4748

Highlights

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