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8/12/2019 Nasal Fx 9805
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8/12/2019 Nasal Fx 9805
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Anatomy
Bones -
Frontal process of maxilla, nasal spine
of frontal bone
Paired nasal bones
Vomer
Perpendicular plate of the
ethmoid
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Anatomy (cont.)
Cartilage-
Lower lateral cartilage
Upper lateral (Alar) cartilageSeptal cartilage
Sesamoid cartilages
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Pathogenesis
Variables-
The patients age (tissue flexibility)
The amount of force appliedThe direction of the force
The nature of the striking object
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Frontal Impact
Plane I-
Fracture of nasal tip
Small dorsal hump with supertip
depressionPlane II-
High fracture of nasal bones
Dorsal depression
Septal buckling with flattened appearance
of the nose
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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
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Lateral Impact
Plane I-
Unilateral nasal bone depression
Elevation of contralateral nasal boneSeptal buckling
C or S shaped deformity of nasaldorsum
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Lateral Impact (cont.)
Plane II/III-
Fracture extension to frontal process
Marked displacement of septum anddorsum
Medial maxillary wall depression
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Septal Fracture
Vertical with anterior fracture
Horizontal with posterior fracture
S and C shaped deformities with
healing
Telescoping of segments prevents
closed reduction
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History
Force, direction of impact
EpistaxisExternal deformity
Prior nasal injury, dysfunction
Pre-injury photographs
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Exam
Nasal deviationMucosal or skin lacerations
Ecchymosis, hematomaLid edema, chemosis
Subconjunctival hemorrhageTelecanthus, CSF rhinorrhea
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Exam (cont.)
Topical decongestionDebridement of clots
Internal and external palpationExam of cartilaginous nose
RoentgenogramsPhotographic documentation
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Clinical Decisions
Open versus closed reductionClosed Reduction-
Unilateral or bilateral fracture of the nasalbones
Fracture of the nasal-septal complex with
nasal deviation less than one half the widthof the nasal bridge.
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Clinical Decisions (cont.)
Open Reduction-
Extensive fracture-dislocation of the nasal bones
and septum
Nasal pyramid deviation exceeding one half thewidth of the nasal bridge
Fracture-dislocation of the caudal septum
Open septal fractures
Persistent deformity after closed reduction
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Clinical Decisions (cont.)
Local versus general anesthesiaTiming of reduction-
< 3-6 hours- immediate reduction< 2-3 weeks- closed reduction
> 3 weeks- delayed 3-6 months
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Anesthesia
4% cocaineEpinephrine soaked pledgets
IV or oral sedationEMLA cream - time consuming
General anesthesia
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Instruments
Asch/Walsham forcepsLarge Kelly clamps
Elevators- Boies/BallingerVarious intranasal specula
Headlight
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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
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Trouble Shooting
Overriding cartilage fragments
Post reduction instabilityC-shaped septal fracture
Converting to an open reduction
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Post-Op
Silastic splints Intranasal placement of packing
External splint applicationPacking out 2-3 days, silastic-10 days
External splint off when fracture stable
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Subacute Open Reduction
Hemitransfixion, lateral intercartilaginousincisions
Elevation of dorsal skin and periosteum
Exposure of cartilage segments
Reduction of cartilage- scoring, suture
Maxillary crest involvement- trapdoor
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Complicated Fractures
Open sky approachUse preexisting lacerations when
possibleDepressed comminuted fractures- wires
versus miniplates
Wound closure
Prophylactic antibiotics
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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
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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
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Early Complications
Septal hematoma Infections- antibiotic prophylaxis
Epistaxis- cautery, packing, ligationCSF Rhinorrhea
Emphysema of the face, neck
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Late Complications
Organization of hematomas- airwayobstruction
Synechia- divide if symptomatic
Obstruction of the nasal vestibule
Residual osteitis
Malunion
Naso-facial disproportion