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Nasal-Septal Fractures

Nasal-Septal Fractures. Francis B. Quinn, M.D. Herve’ J. LeBoeuf, M.D. Anatomy. Bones - Frontal process of maxilla, nasal spine of frontal bone Paired nasal bones Vomer Perpendicular plate of the ethmoid. Anatomy (cont.). Cartilage- Lower lateral cartilage

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Nasal-Septal Fractures

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  1. Nasal-Septal Fractures Francis B. Quinn, M.D. Herve’ J. LeBoeuf, M.D.

  2. Anatomy Bones - • Frontal process of maxilla, nasal spine of frontal bone • Paired nasal bones • Vomer • Perpendicular plate of the ethmoid

  3. Anatomy (cont.) Cartilage- • Lower lateral cartilage • Upper lateral (Alar) cartilage • Septal cartilage • Sesamoid cartilages

  4. Pathogenesis Variables- • The patient’s age (tissue flexibility) • The amount of force applied • The direction of the force • The nature of the striking object

  5. Frontal Impact Plane I- • Fracture of nasal tip • Small dorsal hump with supertip depression Plane II- • High fracture of nasal bones • Dorsal depression • Septal buckling with flattened appearance of the nose

  6. Frontal Impact (cont.) Plane III- • Fracture of nasal bones, frontal process and anterior nasal spine • Comminuted, lateralized • Marked nasal depression • Columellar retraction • Medial canthal relaxation with telecanthus

  7. Lateral Impact Plane I- • Unilateral nasal bone depression • Elevation of contralateral nasal bone • Septal buckling • C or S shaped deformity of nasal dorsum

  8. Lateral Impact (cont.) Plane II/III- • Fracture extension to frontal process • Marked displacement of septum and dorsum • Medial maxillary wall depression

  9. Septal Fracture • Vertical with anterior fracture • Horizontal with posterior fracture • S and C shaped deformities with healing • Telescoping of segments prevents closed reduction

  10. History • Force, direction of impact • Epistaxis • External deformity • Prior nasal injury, dysfunction • Pre-injury photographs

  11. Exam • Nasal deviation • Mucosal or skin lacerations • Ecchymosis, hematoma • Lid edema, chemosis • Subconjunctival hemorrhage • Telecanthus, CSF rhinorrhea

  12. Exam (cont.) • Topical decongestion • Debridement of clots • Internal and external palpation • Exam of cartilaginous nose • Roentgenograms • Photographic documentation

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

  14. Clinical Decisions (cont.) Open Reduction- • Extensive fracture-dislocation of the nasal bones and septum • Nasal pyramid deviation exceeding one half the width of the nasal bridge • Fracture-dislocation of the caudal septum • Open septal fractures • Persistent deformity after closed reduction

  15. Clinical Decisions (cont.) Local versus general anesthesia Timing of reduction- • < 3-6 hours- immediate reduction • < 2-3 weeks- closed reduction • > 3 weeks- delayed 3-6 months

  16. Anesthesia • 4% cocaine • Epinephrine soaked pledgets • IV or oral sedation • EMLA cream - time consuming • General anesthesia

  17. Instruments • Asch/Walsham forceps • Large Kelly clamps • Elevators- Boies/Ballinger • Various intranasal specula • Headlight

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

  19. Trouble Shooting • Overriding cartilage fragments • Post reduction instability • C-shaped septal fracture • Converting to an open reduction

  20. Post-Op • Silastic splints • Intranasal placement of packing • External splint application • Packing out 2-3 days, silastic-10 days • External splint off when fracture stable

  21. Subacute Open Reduction • Hemitransfixion, lateral intercartilaginous incisions • Elevation of dorsal skin and periosteum • Exposure of cartilage segments • Reduction of cartilage- scoring, suture • Maxillary crest involvement- “trapdoor”

  22. Complicated Fractures • “Open sky” approach • Use preexisting lacerations when possible • Depressed comminuted fractures- wires versus miniplates • Wound closure • Prophylactic antibiotics

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

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

  25. Early Complications • Septal hematoma • Infections- antibiotic prophylaxis • Epistaxis- cautery, packing, ligation • CSF Rhinorrhea • Emphysema of the face, neck

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

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