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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
Nasal-Septal Fractures

Francis B. Quinn, M.D.

Herve’ J. LeBoeuf, M.D.

anatomy
Anatomy

Bones -

  • Frontal process of maxilla, nasal spine of frontal bone
  • Paired nasal bones
  • Vomer
  • Perpendicular plate of the ethmoid
anatomy cont
Anatomy (cont.)

Cartilage-

  • Lower lateral cartilage
  • Upper lateral (Alar) cartilage
  • Septal cartilage
  • Sesamoid cartilages
pathogenesis
Pathogenesis

Variables-

  • The patient’s age (tissue flexibility)
  • The amount of force applied
  • The direction of the force
  • The nature of the striking object
frontal impact
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
frontal impact cont
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
lateral impact
Lateral Impact

Plane I-

  • Unilateral nasal bone depression
  • Elevation of contralateral nasal bone
  • Septal buckling
  • C or S shaped deformity of nasal dorsum
lateral impact cont
Lateral Impact (cont.)

Plane II/III-

  • Fracture extension to frontal process
  • Marked displacement of septum and dorsum
  • Medial maxillary wall depression
septal fracture
Septal Fracture
  • Vertical with anterior fracture
  • Horizontal with posterior fracture
  • S and C shaped deformities with healing
  • Telescoping of segments prevents closed reduction
history
History
  • Force, direction of impact
  • Epistaxis
  • External deformity
  • Prior nasal injury, dysfunction
  • Pre-injury photographs
slide11
Exam
  • Nasal deviation
  • Mucosal or skin lacerations
  • Ecchymosis, hematoma
  • Lid edema, chemosis
  • Subconjunctival hemorrhage
  • Telecanthus, CSF rhinorrhea
exam cont
Exam (cont.)
  • Topical decongestion
  • Debridement of clots
  • Internal and external palpation
  • Exam of cartilaginous nose
  • Roentgenograms
  • Photographic documentation
clinical decisions
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.
clinical decisions cont
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
clinical decisions cont1
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
anesthesia
Anesthesia
  • 4% cocaine
  • Epinephrine soaked pledgets
  • IV or oral sedation
  • EMLA cream - time consuming
  • General anesthesia
instruments
Instruments
  • Asch/Walsham forceps
  • Large Kelly clamps
  • Elevators- Boies/Ballinger
  • Various intranasal specula
  • Headlight
reduction
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
trouble shooting
Trouble Shooting
  • Overriding cartilage fragments
  • Post reduction instability
  • C-shaped septal fracture
  • Converting to an open reduction
post op
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
subacute open reduction
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”
complicated fractures
Complicated Fractures
  • “Open sky” approach
  • Use preexisting lacerations when possible
  • Depressed comminuted fractures- wires versus miniplates
  • Wound closure
  • Prophylactic antibiotics
delayed repair
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
children
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
early complications
Early Complications
  • Septal hematoma
  • Infections- antibiotic prophylaxis
  • Epistaxis- cautery, packing, ligation
  • CSF Rhinorrhea
  • Emphysema of the face, neck
late complications
Late Complications
  • Organization of hematomas- airway obstruction
  • Synechia- divide if symptomatic
  • Obstruction of the nasal vestibule
  • Residual osteitis
  • Malunion
  • Naso-facial disproportion