Nasal and Nasal
Complex Fractures
Primary
Management
Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com
Introduction
The upper midface area comprises mainly the nasoorbito- 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
ofMASUDI:BDS.HDD.FIBMS.post-traumatic/post-operative
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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
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 .Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com
•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.
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
Dr.GALIB
MASUDI:BDS.HDD.FIBMS.from 6 months to 81 years
( male
498, female 223), from
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these cases Nasal and Naso Orbito Ethmioldal 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.
Research Chart.
Personal information :
Name:
Address:
Date of admission:
Age:
Tel. No:
Sex:
Occupation:
Date of discharge:
Preoperative information:
Medical history:
Cause of injury:
Radiographic investigations:
Laboratory investigations:
Operative information;
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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:
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Postoperative information:
Numerical rating scale:
0
1
2
3
No complications :
Postoperative follow up :
4
5
6
7
8
9
10
Worst possible Complications:
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
Dr.GALIB MASUDI:BDS.HDD.FIBMS.staged repair involving
early neurosurgical
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procedures and debridement of bone fragments ,
dural repair and closure soft tissue laceration
followed by delayed facial repair.
Nasal injuries:
Surgical anatomy:
A: Osseous framework:
External:
Internal:
B: Cartilaginous
framework:
External:
Internal
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Classification of superficial
appearance of the nose:
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Classification of nasal injuries
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Radiology & Ultra
sonography
Plain radiological view
A:Waters viewDr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com
B: Lateral view
Computed Tomography (C.T. scan)
Ultrasonography
Isolated nasal injuries:
Clinical evaluation & intervention:
Lateral nasal injuries
Anterior nasal injuries
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Naso ethmoidal fractures
Surgical anatomy of NOE
Clinical assessment
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Classification of naso ethmoidal injuries
Isolated bilateral nasoethmoidal fractures
Isolated unilateral nasoethmoidal injuries
Combined naso ethmoidal injuries
Combined unilateral nasoethmoidal injuries
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Radiological assessment of nasoethmoidal
injuries
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Surgical approach
Through an existing laceration
H shaped approach
Dr.GALIB MASUDI:BDS.HDD.FIBMS.Bilateral Z approach http://galibmas.blog.com
Midline vertical approach
W shaped approach
Coronal approach
Midface degloving
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Technique for repair
The bony skeleton
The frontal process of the maxillary bone
Nasal cap
Dr.GALIB MASUDI:BDS.HDD.FIBMS.The medial canthal
ligament
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Nasolacrimal system
Management of orbital involvement
associated with NOE fractures
Orbital Bony Anatomy
Midfacial Buttresses
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Orbital hemorrhage
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Cases
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Extensive NOE injury due to
terrorist attack by explosive car
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Isolated NOE injury
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NOE injury associated with foreign body
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Extensive NOE injury
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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
Dr.GALIB MASUDI:BDS.HDD.FIBMS.early trauma repair lead to good cosmetic and functional results ,no
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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 .
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%
Dr.GALIB MASUDI:BDS.HDD.FIBMS.Trauma patients : total no. of patients
58.5%
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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
0
General
Maxillo facial
attendence
299
0
Trauma
Patients 422
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Trauma Patients
General Maxillo - facial attendence
,0
Nasal & NOE
injuries, 53
Total No. of the
patients, 721
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Total No. of the patients
Nasal & NOE injuries
Nasal & NOE
injuries, 53
,0
Trauma
patiens, 422
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Trauma patiens
Nasal & NOE injuries
Bilateral eye
ball
envolvment 6
Unilateral
envolvment
14
Eye ball
enolvment
20
Dr.GALIB MASUDI:BDS.HDD.FIBMS.Spared eye
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ball 16
800
700
Male
600
Female
Total no.
500
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400
300
200
100
0
Total no. of patients
Trauma patients
Nasal & NOE injuries
Nasal
40
35
30
25
20
Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com
15
Total No.
Female
10
Male
5
0
RTA
Assaults
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
Dr.GALIB MASUDI:BDS.HDD.FIBMS.secondary special examination
,particularly to verify the
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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.
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 partDr.GALIB
to a MASUDI:BDS.HDD.FIBMS.near anatomical state .
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•Macroscopic aspects of fracture repair.
•Fracture healing and bone graft repair.
•Histological aspects of fracture repair.
• Biochemical and molecular aspects of bone
healing .
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 .
Dr.GALIB MASUDI:BDS.HDD.FIBMS.-
•the growth of tertiary trauma centers
had two important consequences,
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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.