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Nasal and Nasal Complex Fractures Primary Management. Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com. Introduction

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slide1

Nasal and Nasal Complex FracturesPrimary Management

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide2

Introduction

The upper midface area comprises mainly the naso- orbito- ethmoidal (NOE) region which plays a paramount role in facial expression. Fractures of this area often result in neglected bony defects in the fragile periorbital region with major secondary impairments such as traumatic telecanthus , orbital dystopia, and/or enophthalmos. Permanent cranial nerve deficits also can occur as the result of post-traumatic/post-operative squaele.

Nasal fractures represent the third most commonly broken bone in the body and the most commonly facial bone to be fractured in association with other facial bone in multiple trauma of the face, high percentage of nasal fractures are subclinical or undiagnosed or treated at the time of injury, if it remains untreated or improperly treated a significant long term functional and cosmetic problems may result

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide3

Aims of study

  • To review the primary evaluation and surgical intervention of these injuries .
  • To review the operative techniques used for NOE reconstruction of these injuries according to the etiology .
  • To review the complication encountered in the intermediate phase .
  • To figure out a classification system that best serves the clinician for diagnosis and management NOE Fractures.
  • To evaluate trauma patients to the general attendance to the emergency dep. And out patients clinic in relation to Maxillo facial specialty because of the special type of conflict in our country.

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide4

Meterial & Methods

In this retrospective study which extended from January,2,2007 to January ,2,2008 ,including 721 patients referred as in patients to the Tenth Floor ,Specialized Surgeries Hospital ,patients referred from emergency Dep. Medical City and out patient clinic Specialized Surgeries Hospital of Maxillo _Facial Dep. ,age of the patients range from 6 months to 81 years ( male 498, female 223), from these cases Nasal and NasoOrbitoEthmioldal injuries were 53 (42 male , 11 female ) ages ranging from 6 years to 68 years ,mean age was 30.9 years ,of these 6 patients pure Nasal injuries exclusively due to assaults* ( 4 male,2 female) because closed Nasal fractured are referred to ENT Dep. ,47 patients NOE fractures were treated in our dep. In accordance with early trauma repair protocol.

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide5

Research Chart.

Personal information :

Name: Age: Sex:

Address: Tel. No: Occupation:

Date of admission: Date of discharge:

Preoperative information:

Medical history:

Cause of injury:

Radiographic investigations:

Laboratory investigations:

Operative information;

1;Type of NOE fracture or nasal fracture:

2;Surgical approach:

3;Type of graft used for reconstruction:

a; Autogenous bone graft:

b; Allograft:

4;Time of the operation:

5;Intraoperative complication;

6;Type of suture material:

Postoperative information:

Numerical rating scale:

0 1 2 3 4 5 6 7 8 9 10

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

No complications : Worst possible Complications:

Postoperative follow up :

slide6

Criteria for early trauma repair

Traditionally NOE fractures are associated with other facial bones fractures in term of multiple trauma of the head and neck, there are some to be put to clarify their relations to this types of injuries, surgical approaches to these injuries is staged repair involving early neurosurgical procedures and debridement of bone fragments , dural repair and closure soft tissue laceration followed by delayed facial repair.

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide7

Nasal injuries:

    • Surgical anatomy:

A: Osseous framework:

  • External:
  • Internal:

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

B: Cartilaginous framework:

  • External:

Internal

slide8

Classification of superficial appearance of the nose:

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide9

Classification of nasal injuries

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide10

Radiology & Ultra sonography

Plain radiological view

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

A:Waters view

B: Lateral view

Computed Tomography (C.T. scan)

Ultrasonography

slide11

Isolated nasal injuries:

Clinical evaluation & intervention:

Lateral nasal injuries

Anterior nasal injuries

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide12

Nasoethmoidal fractures

Surgical anatomy of NOE

Clinical assessment

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide13

Classification of nasoethmoidal injuries

Isolated bilateral nasoethmoidal fractures

Isolated unilateral nasoethmoidal injuries

Combined nasoethmoidal injuries

Combined unilateral nasoethmoidal injuries

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide14

Radiological assessment of nasoethmoidal injuries

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide15

Surgical approach

Through an existing laceration

H shaped approach

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

Bilateral Z approach

Midline vertical approach

W shaped approach

Coronal approach

Midfacedegloving

slide17

Technique for repair

The bony skeleton

The frontal process of the maxillary bone

Nasal cap

The medial canthal ligament

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

Nasolacrimal system

slide18

Management of orbital involvement associated with NOE fractures

Orbital Bony Anatomy

Midfacial Buttresses

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide19

Orbital hemorrhage

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide20

Cases

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide21

Extensive NOE injury due to terrorist attack by explosive car

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide24

Isolated NOE injury

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide26

NOE injury associated with foreign body

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide27

Extensive NOE injury

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide29

Results

It is difficult to obtain acceptable classification of NOE fractures based on clinical or radiological presentation because of intermingling between the thin bony frame work and the covering soft tissues(Manson1985) .

C N S deficit mostly associated with RTA injuries while eye ball involvement mostly associated with injuries caused by assaults (graph 3.4) high percentage of trauma patients in relation to general attendant reflecting the special type of conflict in our country(Trauma patient to general attendance 58%).

Primary management of well selected patients depend on criteria of early trauma repair lead to good cosmetic and functional results ,no age groups are spared from the conflict and assaults,the preponderance of male to female ratio because of responsibility of the male to his family in our society ,an overview of the causality indicate mixed type of injuries and multi directional forces that caused most of the injuries due to combination of war ,crime, civil unrest and terrorist attacks .

Most complication resulted from extensive injuries associated with CNS deficit which need delay in treatment more than 10 days allowing time for the thin fragile fragments of bone to undergo resorbsion and start fibrosis which interfere with realignment of the pieces to obtain good cosmetic and functional results .

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide30

Statistical Analyses

Time 2\1\2007-2\1\2008

Total number of patients 721(Male 498 ,Female 223)

Age 9 months – 81 years

N + NOE 53(Male 42,Female 11)

Age 6-68 years(mean age 30.9 years )

Trauma patients 422(Male 314,Female 108)

N +NOE : total no. 7.3%

N+NOE :trauma patient 12.5%

Trauma patients : total no. of patients 58.5%

Male : Female (of referred patients ) 2.23:1

Male : Female(of N+NOE fractures) 2.9:1

Pure Nasal injuries 6 (male 4, female 2)

NOE total 47

RTA 17(male 11,female 6)ratio M: F (1.8 : 1)

Assaults 36 (male 26 , female 10) ratio M:F (2.6 : 1)

Eye ball involvement 20

Spared eye ball 16

Unilateral involvement of the eye ball 14

Bilateral involvement of the eye ball 6

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide37

Discussion

From simple nasal fractures to minimal ethmoid involvement through grossly comminuted fractures with displacement ,all should be considered compound.(Michael, G. ,Stewart 1993).

Gold standard of care for patients with NOE injuries begins with careful clinical evaluation ,detailed radiological examination ,careful ophthalmic examination and secondary special examination ,particularly to verify the function of the lacrimal apparatus ,clinical examination may be difficult due to edema or emphesima ,the traumatic telecanthus and traumatic hypertolerism ,it may be helpful if the surgeon can correlate intercanthal distance to the interpupiliry distance ,distraction test ,CSF leak and the integrity of commonly damaged structures like cornea ,lens ,retina ,EOM movement ,optic nerve function ,ocular reflexes ,swinging light test ,examination of lacrimal apparatus, globe position.

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

slide38

Conclusions

Fracture healing is a dynamic affair that coordinate a host of complex interacting mechanisms then remarkable repair processes highlight the powerfull regenerative abilities of fracture bone which can culminate in restoration of the damage part to a near anatomical state .

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com

  • Macroscopic aspects of fracture repair.
  • Fracture healing and bone graft repair.
  • Histological aspects of fracture repair.
  • Biochemical and molecular aspects of bone healing .
slide39

Suggestions

  • Although the treatment of facial injuries has made dramatic advances of the last decade due to improvement in the knowledge of wound healing , anatomy diagnostic testing and bio- material ,the optimal management of patients who have sustained multiple facial trauma associated with nasal complex fractures need collaborative interdisciplinary approach that incorporates the clinical expertise of number relative specialties.
  • the growth of tertiary trauma centers had two important consequences, severely injured patient are now able to survive there initial physical insult and will require reconstruction of devastating facial injuries and interdisciplinary team can acquired greater experience with managing complex facial trauma because it is challenging to repair, reflecting the interacted nature of the relevant anatomy and the nessacerity of exquisite attention to the detailed required for surgical intervention to restore preinjured appearance and post traumatic deformities which are profound and problematic.

Dr.GALIB MASUDI:BDS.HDD.FIBMS.-http://galibmas.blog.com