NASO ORBITO ETHMOIDAL FRACTURE

-Preethi.G CRRI

INTRODUCTION: Fractures of the middle third of

the facial skeleton are known as maxillofacial skeletal injuries and they are associated with varying degrees of injuries of soft tissue.

The facial skeleton is divided into three parts:

-Upper third -Middle third -Lower third

Middle third of facial skeleton:

The naso-orbito-ethmoidal region is situated in the central upper mid face.

It consists of a strong triangular frame.

Due to the complexity and the density of the anatomic components of the area, the fracture in this region has been a great challenge in maxillofacial trauma.

Successful results depend upon knowledge of the complex anatomy and ability to provide correct early management.

Anatomy and applied aspects:

Osteology

Soft tissue anatomy

OSTEOLOGY Nasal bones Ethmoid Frontal process of maxilla Medial orbital rim and wall Other bones involved: Perpendicular and

cribriform plate of ethmoid Nasal process of frontal

bone. Sphenoid bone.

4 cavities involved: Cranium Orbits Nasal MaxillaStrength: Vertical buttress: frontal process

of maxilla Horizontal buttress:

superior/inferior orbital rims.

The main structural buttress is the frontal process of the maxilla and internal angular process of the frontal bone, supplemented by the thick proximal portion of the nasal bone.

This reinforced pillar provides a central skeletal framework to which more delicate bones are joined.

The medial orbital wall is made up of lacrimal bone and the delicate lamina papyracea of the ethmoid bones posteriorly.

These structures are susceptible to communition,allowing for a medial displacement of the orbital contents after blunt trauma(medial blowout).

Superiorly, thin ethmoid bones form part of the floor of the anterior skull base, in this region dural injury and resultant CSF leakage is possible.

The ethmoid bone is located posterior to the nasal bones,the ethmoid air cells are present at birth and enlarge to adult size by the age 12 years.

ETHMOID BONE

The overall growth and size of ethmoid complex is highly variable among individuals.

The ethmoid labyrinth separates the orbits from the nasal cavity ,while the fovea ethmoidalis forms the roof of the ethmoid sinuses laterally.

Soft tissue anatomy Medial cathal ligament Lacrimal drainage apparatus Associated vessels.

Medial canthal ligament The medial canthal

ligament (MCT) is a crucial soft tissue component of NOE complex.

It arises from the anterior and posterior lacrimal crest and frontal process of maxilla.

MCT surrounds the lacrimal sac and diverges to become the orbicularis occuli muscle.,

tarsal plate, and suspensory ligaments of eyelids.

The tendon splits around the lacrimal sac and attaches to the anterior and posterior lacrimal crests, as well as to the frontal process of maxilla.

The canthal tendon diverges to become the pretarsal ,preseptal, and orbital orbicularis oculi muscle.

The action of the muscles and tendon thus allow for pumping action of the lacrimal sac and ducts allowing for propagation of tears through nasolacrimal system.

In addition, the MCT acts as a suspensory sling for the globe, maintaining its support along with the lateral canthal tendon.

A normal intercanthal distance is

30-35 mm ,which is approximately half of the interpupilary distance and is equivalent to the width of the nasal base.

Lacrimal system: Has the potential to be disrupted

on a NOE fracture especially a comminuted one.

The system consists of a lacrimal gland situated in the superolateral anterior portion of the orbit and two lacrmial canaliculi that drain the eye via puncta that are situated in the medial aspect of each eye.

The sac drains into the inferior meatus via the nasolacrimal duct.

The duct is around 20 mm in length half of which is bony.

The portion of the nasolacrimal system that is most prone to damage is the bony nasolactimal duct.

The cribriform plate is loacted approximately 1 cm inferior to the fovea ethmoidalis and it formss the roof of the nasal cavity medially.

Buttress The horizontal

buttress is divided into the superior horizontal buttress and the inferior horizontal buttress, which consists of the frontal bone, superior orbital rims and inferior orbital rims.

The medial vertical buttress consists of the internal angular process of the frontal bone and the bilateral frontal processes of the maxilla.

Blood supply: The blood supplying for the

midface and nasal region comes from the branches of internal and the external carotid arteries.

The anterior and posterior ethmoid arteries descend from the internal carotid artery.

The maxillary artery from the external carotid artery and subsequent branches play a mainstay role for supporting the midface.

Nerve supply The NOE region is innervated by

ophthalmic and maxillary nerves, which are derived from the Trigeminal nerve.

TRIGEMINAL NERVE

OPTHALMIC NERVE

MAXILLARY NERVE

NOE fracture: The nasal bones and underlying

cartilage are susceptible to fractures because the nose maintains a prominent position and central location on the face and because it has a low breaking strength.

Patterns of fractures are known to vary with momentum of the striking object and the density of the underlying bone.(Murray,1994)

As with other facial bones,younger patients tend to have larger nasoseptal fracture segments,whereas older patients are more likely to present with more-comminuted fracture patterns.

(Cummings,1998)

Causes: RTA Sport injuries Fights Work related accidents Falls are the most common cause

of nasal injury in children.

PATHOPHYSIOLOGYViolation of the

primary buttresses of the NOE complex

Comminution of the entire complex may

occur

Telecanthus,enophthalmos,diplopia,midface retrusion

The clinical symptoms associate wit the location and severity of the NOE fracture.

Patients with naso-orbito-ethmoidal (NOE) fractures often have associated facial injuries or panfacial fractures.

CLINICAL FEATURES:

NOE fracture associated with panfacial fractures

Signs and symptoms Gross facial edema

may show firstly in the early stage of fracture, which will result in distortion of soft tissue landmarks.

Laceration in the nose and forehead.

Intracranial involvement. Eye, forehead, and nose pain Forehead paraesthesias Traumatic hypertelorism Mongoloid slant.

Flattened nasal bridge with splaying of nasal complex.

Saddle shaped deformity of nose from side.

Epitaxis. Tenderness ,crepitus

and mobility of nasal complex.

Nasal injuries:

Epitaxis Reduced nasal

projection and height. Septal deviation or

dislocation. Anosmia caused by

damage to the cribiform plate.

Nasal congestion secondary to septal hematoma or bony/cartilaginous deformity.

•Accentuated N-F angle•Decreased dorsal nasal projection•Upturned nasal tip

Enopthalmus

Diploplia

Entrapment

Vertical dystopia

Loss of globe integrity

Associated ocular injuries:

Traumatic telecanthus

Circumorbital oedema and ecchymosis

Subconjuctival haemorrhage.

Possible supra-orbital/supra trochlear nerve parasthesia.

• Oedema, emphysema,

Echymosis Traumatic

telecanthus Orbital dysplasia Rounding of

medial canthal angle

Mongoloid slant

Traumatic telecanthus(IC/IP>1/2)

Lack of eyelid tension-positive bowstring test.

Rounding of the MCT. Shortened palpebral

fissure.

Medial canthal tendon displacement

For telecanthus to occur ,the fracture must involve at least 4 sites:

Medial orbital wall Nasomaxillary butress/inferior

orbital rim Nrontomaxillary junction Lateral nasal bone

Intracranial involvement: Cerebrospinal fistula

Pnemocephalus

CSF rhinorrhoea

CSF leakage: Fracture of floor of anterior cranial

fossa/base of skull. Escape of CSF through Ethmoidal sinus Sphenoidal sinus Cribriform plate Frontal sinus

Communication between

Meninges Nose Paranasal sinuses Dural laceration Later becomes

epithelised to Fistula Blood clot of brain

tissue may obstruct fluid passage.

After lysis of clot or increased intracranial pressure leakage is seen.

Mobile midface fractures often creates pumping action –because of increased CSF leakage.

Classification of NOE complex fractures How is NOE complex fracture classified? The status of the resulting central segment

of bone left by an NOE fracture is the basis of classification of fracture patterns for this type of injury.

Each fracture type is sub classified as either unilateral or bilateral.

Among many classifications of NOE fractures, the most widely accepted classification system was established by Markowitz et al.

.

Ayliff classification Type I: En bloc with minimum

displacement. Type II: En bloc displaced # with large

pneumatized sinus and minimum fragmentation.

Type III: Comminuted # with inatct MCT attached to large bone.

Type IV:comminuted # with free MCT attached to boe not large enough for plating.

Type V:Gross comminution needing grafting.

Yaremchuk classification Type I: Isolated bony NOE Type II: Bony NOE and central maxilla II A: Central maxilla only II B: Central and unilateral maxilla. II C:Central and bilateral maxilla. Type III: extended NOE III A ;with craniofacial injuries IIIB: with LF II and LF III Type IV: NOE with orbital displacement IV A: with cculo-orbital displacement IV B: with orbital dystopia Type V: NOE with bone loss

Stranc and Robertson classification(1979)

Plane I: Injuries do not extend beyond a line joining the lower end of the nasal bones to the anterior nasal spine.

Plane II:Injuries are limited to the external nose and do not trangress the orbital rim.

Plane III:Injuries are more serious involve orbital and possibly intracranial structures.

Rowe and Williams classification

Isolated NOE and frontal region # without other midface fractures

Unilateral Bilateral Isolated NOE and frontal region #

with other midface fractures. Unilateral bilateral

Markhowitz classification:

TYPE I: Involves single segment central fragment fractures.

TYPE II: Comminuted central fragment with fracture lines remaining peripheral to the MCT insertion.

TYPE III: Comminuted central fragment with fracture lines extending beneath the MCT insertion.

MARCHOWITZ CLASSIFICATION

TYPE I FRACTURE In this simplest form,NOE

fractures are isolated involving only the portion of the medial orbital rim that contains medial canthal tendon.

Type I pattern consists of single central fragment bearing the medial canthus.

These fractures maybe bilateral ,complete or displaced.

Uncommonly ,the medial canthal tendon is torn or avulsed completely from an intact medial bony wall.

In unilateral Markowitz type I fractures, there is a single large NOE fragment bearing the medial canthal tendon.

Involvement of the nasal bone: the nasal bone may also be involved and, in cases of comminution, may not provide

adequate dorsal support to the nasal bridge.

TYPE II FRACTURE Type II fractures are complete and

maybe unilateral or bilateral. They may be single segment or

communited external to the medial canthal insertion in the central segment.

MCT maintains continuity with large fractured segment of bone,which maybe used in the surgical reduction.

In unilateral type II fractures, there is often comminution of the NOE area, but the canthal tendon remains attached to a fragment of bone, allowing the canthus to be stabilized with wires or a small

plate on the fractured segment.

The nasal bone may also be involved and, in cases of comminution, may not provide adequate dorsal support to the nasal bridge.

Involvement of the nasal bone

The illustration shows a bilateral NOE type II fracture. In bilateral fractures the nasal bones are commonly involved. In some

instances, bone grafting of the nasal dorsum may be necessary.

Bilateral type II fracture with nasal bone involvement

TYPE III FRACTURE Communition within the central

fragment allows fracture to extend beneath the canthal insertion characterising the type III fracture pattern.

The canthus is rarely avulsed but it is to bone fragments that are too small to utilize in reconstruction.

In type III fractures, there is often comminution of the NOE area (as in type II fractures) and a detachment of the medial canthal tendon from the bone.

The nasal bones are usually involved and might not provide adequate dorsal support to the nasal bridge. In such cases bone

graft reconstruction often is indicated.

Involvement of nasal bone

The illustration shows a bilateral NOE type III fracture. The nasal bones are usually involved. Bone graft of the

nasal dorsum is usually necessary.

Bilateral type III fracture with nasal bone involvement

Initial evaluation Establish ABCs. Diagnose any associated injuries. Direct examination of NOE complex. A thorough head and neck

examination to reveal injuries to the brain,spine, orbit and facial skeleton is required.

A team approach involving the otolaryngologist,plastic surgeon, neurosurgeon and pohthalmologic consultation is mandatory.

Diagnosis: Direct examination Diagnostic imaging CT -2D CT -3D CT Dacrocystography

Radiographic imaging Plain radiographs have limited

usefulness in aiding in diagnosis of NOE #s.

Thin cut axial and coronal CT scans are the criterion standard for the diagnosis of NOE fractures.

Diagnostic imaging

Plain films are of almost no use in diagnosing NOE fractures because most

will be undetected.

CT Is of greatest value. HRCT adds to the existing value. What to ask for? -1-2 mm axial and coronal slices

with 3D recon. -top of skull –frontal-sinus –orbits-

maxilla - Bone window NOE bony

complex -soft tissue window

brain/ocular adnexia.

Axial cuts: Position and status

of frontal process of maxilla central fragment

Medial walls of orbit if they are “blown in” nasally.

Anterior and posterior tables of frontal bone.

Nasolacrimal system.

Coronal cuts: Cuts taken from nasal

bridge to orbital apex. Junction of floor to

medial wall assessed. Disruption of ant.

cranial fossa around cribriform plate.

CSF leak CT value. Localisation of CSF

leaks.

A surgeon can often distinguish between a type I NOE fracture versus a type II / III fracture by the degree of comminution noted on the CT.

It is generally very difficult to distinguish between a type II and a type III NOE fracture based on radiographic examination

3D CT

3D CT A 3D CT, as shown, can help

assessing the severity of the injury but the final diagnosis requires clinical findings and is usually made intraoperatively.

This 3D CT shows a bilateral NOE type II with involvement of the nasal bones.

Be aware that a 3D CT often underestimates the severity of the injury. 

Examine the nasal cavity for the presence of CSF.

Query all conscious patients about the presence of watery rhinorrhea or salty postnasal drainage.

Test bloody fluid that is suspicious for CSF rhinorrhea (see Lab Studies).

Examine facial lacerations under sterile conditions to assess depth of penetration or intracranial violation.

To evaluate the integrity of the medial canthal tendon.

Direct examination of NOE #

Measure and document telecanthus and enophthalmos.

Assess and document pupil responses and extraocular muscle mobility.

Palpate the nasal bones for crepitus and comminution.

Evaluate the septum for septal hematoma.

Evaluate the degree of nasal or midface retrusion. Preinjury photographs may be helpful.

Examine facial lacerations under sterile conditions to assess depth of penetration

or intracranial violation.

Evaluate the degree of nasal or midface retrusion

An intercanthal distance of > 35 mm is suggestive of traumatic

telecanthus ,measurement approaching 40mm are almost diagnostic.

The patient often has swelling in the medial canthal area and pain and crepitation with

palpation.

Examine the nasal cavity for the presence of CSF.

Query all the patients about the presence of watery rhinnorhea or salty postnasal drainage.

Test bloody fluid that is suspicious of CSF rhinnorhea.

With NOE fractures a CSF leak should be assumed to be present even if it is not clinically demonstrable and

appropriate chemoprophylaxis should be commenced.

The following diagnostic procedures can be performed if there is a suspected CSF leak (clinical sign: straw-colored or clear nasal drainage):

Tilt test with positive halo sign (as illustrated)

Comparison of the concentration of glucose between fluid and patient’s serum.

CT scan with thin coronal cuts (0.5 mm) of the cribriform plate.

Bloody rhinorrhea suspicious for CSF can be placed on filter paper and observed for a halo sign.

If CSF is present ,it diffuses faster than blood and results in a clear halo around the central stain.

Routine chemistry analysis of the rhinorrhea may reveal an elevated glucose content consistent with CSF.

Lab studies Beta 2 transferrin is the definitive

test for CSF rhinorrhoea.collect 1 ml of the suspected fluid in a red top tube.

Watery rhinorrhea that is positive for beta 2-transferrin is diagnostic for a CSF leak.

Till test with positive halo sign

These two tests aids in the diagnosis of instability of the Medial canthus tendon.

Bowstring test

Bimanual palpation by placing an instrument into the nose to determine canthal bearing bone fragment displaced and mobile.

.

Bowstring test In the bow string test ,the eyelid is

pulled laterally while the tendon area is palpated to detect movement of fracture segments.

A lack of resistance or movement of the underlying bone is indicative of a fracture.

The surgeon may be able to grab the eyelid or use a forceps to grab the skin in the medial canthal area and pull it laterally (“bow-string” test).

Bimanual palpation

It requires placing an instrument (kelly clamp) high into the nose,with its tip directly beneath the MCT .

Gentle lifting with the contralateral finger palpates the canthal tendons and allows an assessment of instability of the tendon attachement and necessity for open reduction.

Evaluation of lacrimal apparatus

The lacrimal drainage system is intimately related to the NOE region and can be damaged during the trauma.

The surgeon should assess the patency/continuity of the nasolacrimal system at the time of surgical treatment.

If there is a discontinuity in the nasolacrimal system repair should be considered at the time of fracture treatment. 

Evaluation tests Dye disappearance test Jones test(primary and secondary

tests) Lacrimal irrigation Scintigraphy Contrast dacryocystography CT scan

Dye disappearance test:

DDT is useful for assessing the presence or absence of adequate lacrimal outflow.

2% fluorescein dye solution or a moistened fluorescein strip instilled in conjuctival fornix.

 Persistence of significant dye indicates an obstruction. 

 If the DDT result is normal, severe lacrimal drainage dysfunction is highly unlikely.

Obstruction of NLD

Instilling Fluorescein Dye in the Eye_low.flv

Jone’s test The Jones tests have been used in

the evaluation of epiphora.

JONES I JONES II

JONES TEST

Jones I test(primary dye test)

Like DDT,this test investigates lacrimal outflow under normal physiologic conditions.

1 drop of 2% fluorescein dye placed into conjuctival sac.

After about 5 mins ,cotton tipped applicator inserted under the inferior turbinate.

If bud stained with dye ,test is positive. Test is negative If no dye is detected ,means

there is partial or absolute obstruction or failure of lacrimal pump.

Jones II test:

Dacryocystography Radiographic visualization

of the lacrimal sacs and associated structures after injection of a contrast medium. 

Contrast dacryocystography provides anatomical information with dye injection into the lacrimal system followed by computerized digital subtraction imaging.

Management of NOE fracture: Better over treated than under treated

. Why over treat? Inadequate treatment

Secondary deformities

Missing or displaced bone fragments, soft tissue scarring,malposition

Goals of management of NOE #s

Reconstitution of the skeletal framework of NOE region.

Stabilization of the intercanthal width and MCT..

Orbital reconstruction. Establishment of nasal support. Reconstruction of other

craniofacial injuries including frontal sinus.

Soft tissue repair.

Basic principles: Early one stage repair Exposure of all fracture fragments Precise anatomic rigid fixation Immediate bone grafting as

indicated for bony loss. Definitive soft tissue management.

Sequencing surgical treatment:

Exposure Identify the MCL or the MCL

bearing bone. Reduce/reconstruct medial orbital

rims. Reconstruct medial orbital walls. Transnasal conthopexy Reduce septal displacement Soft tissue readaptation.

Exposure Unobstructed visualization of the

articulations of all the bones in the region.

One of the main reasons for treating NOE #s is esthetics ,hence incisions are made keeping in mind the esthetics.

Remote incisions preferred.

Surgical approaches to NOE complex

Existing lacerations Coronal incision Eyelid incisions Skin

incisions Vertical//horizontal incisions -visible scars Open sky approach H shape incision. W shape incision. Lynch incision. Transcaruncular incision No external Pre caruncular incision scars Transoral –degloving incision.

Midfacial degloving incision-great access/no scar.

Existing laceration

Coronal flap Advantages: Correction of associated frontal sinus

fracture. Harvesting of calvarial bone graft or primary

reconstruction Harvesting of pericranial flap of sufficient

length for sealing of defects in the ant.cranial fossa.

Disadvantage: Cannot be used when the skull has been

opened up previously for craniotomies by the neurosurgeons.

Bicoronal Flap_low.flv

Lynch/medial canthal incision:

Curved incision over lateral nasal bones anterior to MCL attachment.

Skin here is thin-allows easy exposure.

Sufficient or limited reconstruction.

Cannot be used in bilateral canthopexies,bone grafting.

W shaped incision Skin incision approx. 3 cm in length

made along the superior medial orbital rim from 1 cm medial to medial canthus to the lower border of the medial eyebrow.

Angles of limbs of the W-110 to 120 degree

Four limbs of the W can be placed parallel or oblique to the RTSL

The lateral limb of the .W can be extended laterally long the lower border of the medial eyebrow, depending on the desired exposure.

Muscledissection,supratrochlear nerve located and preserved.

Periosteum is incised from upper half of the MCT to the medial portion of superior orbital rim-periorbita is laterally reflected.

Advantages: W has small segmented limbs parallel or

oblique to the relaxed skin tenion lines. W limbs break up the scar into smaller

components- minimal external scar. Pulling both ends of the W along its

longitudinal axis provides the increase of its longitudinal length - allows implant up to 3 cm to be inserted.

Superior access to medial orbital wall.

Midfacial degloving incision

Incisions utilized: Transoral degloving from 2nd molar. Intercartilaginous incision. Transfixion incision. PROCEDURE: Mucoperiosteal flap till piriform

aperture raised. Both intercartilaginous and tranfixion

incisions connected across the septal angle.

The osseocartilagenous nose is degloved over the upper lateral cartilage as for a septorhinoplasty.

The intranasal incisions connected with the oral incision by a nasal sill incison.

Midface can now be degloved.

Advantages: No external visible scars. Excellent visibility-as good as coronal

incision. Minimal risk to vital structures. No aesthetic sagging of tissues. Provides concurrent access to zygoma on

both sides.

Disadvantages: Suturing is vital-?stenosis of nasal

aperture. ?damage to infraorbital nerve.

Possible scenarios after exposure.

1. Both MCL remain attached and the laterization of the complex is counteracted by the orbicularis oculi. Type I : b/l single segment NOE #

2. Tendon is still attached to the bone but the bone fragment is separate from complex : U/l single segment type I injury.

3. Avulsion of tendon from bony connection type III.

4. Bone into which the tendon inserts is missing

Identifying MCL-capturing/tagging MCL

Reconstruction of medial orbital rim

Biomechanics in fixation of mid face #

Biomechanics of midface made complicated by:

– Nonuniform geometry of bones – Number and orientation of various

attached ligaments and soft tissues. Treatment aimed to restrict three

types of movements of a fractures segment in 6 directions

Translatory movement essentially 2D restricted by wires as well as plates

 Rotatory movements : 3-D need restrictions at 3 separate points plates more effective.

Farther apart the fixation points better the stability wider plates thus preferred.

3 wires or several small plates oriented at different angles increase stability. 

Advantages of rigid fixation

Adjunct to primary bone grafting.

Avoids supplemental maxillomandibular or extraskeletal fixation .

Better rigid support and immobilization.

Prevents overriding of the fractured fragments.

Reconstruction of medial orbital rim

Transnasal reduction of canthal bearing fragment most important step in preserving intercanthal distance.

Loose nasal bones may be removed temporarily for better access.

Fragment bearing the MCL identified.

If fragment is large enough reduce and fix it to adjacent bone with miniplates

Transnasal wiring for TYPE I and TYPE II#s

Imperative to drill one hole posterior to lacrimal fossa to prevent lateral splaying coronal section : horizontal mattress posteriorly and telecanthus.

Other wire passed superior and posterior to lacrimal fossa on Proper placement of transnasal wires posteriorly other side.

Wires tightened as much as possible to “overreduce” and narrow the base to gain the projection.

Reconstruction of medial orbital wall

Importance: To regain anatomic morphology To regain lost orbital volume in

blow out # To achieve normal eye position

after injury.

Reconstruction of medial orbital wall.

Bone material of choice for reconstruction calvarial graft/rib graft.

Long pieces of bone used should extend just behind the medial orbital rim.

Fixed with lag screws or miniplates.

If Bone pieces extend too posteriorly poor access. loss of stability

?????2, Reconstruction of medial canthoplasty_low.flv

Is this the right time for canthopexy? Canthal ligament was identified

and tagged earlier. Followed by orbital wall and rim

reconstruction. Steps demanded greatest traction. If canthopexy performed earlier : – Vigorous traction could pull

through the MCL and further damage the ligament.

Options for medial canthopexy Transnasal wiring Ipsilateral/homolateral techniques: • Nylon anchor suture, • Stainless steel screw,

• Cantilevered miniplate (Y-shaped, five holes),

• Bone anchor systems.

Transnasal canthopexy – fundamental principles..

Holes: – medial orbital rim posterior and

superior to posterior lacrimal crest. – 2-4mm diameter. Direction of transnasal wire high to

low The essential biomechanical principle

is that although the tightening produces a vertical force, the MCT moves medially in its prepared area of attachment.

Basic Procedure for transnasal canthopexy

A contouring burr is used to create a depression in the frontal process of the maxilla just superior and posterior to the anterior lacrimal crest to inset the MCT.

On the contralateral fronto-glabellar area, a 1.5-mm hole is drilled and taken through to the depression created to receive the MCT. A second drill hole is made 5 mm below the first.

18-gauge syringe needle is passed through the first hole to the medial canthal area and the superior wire is fed through .

This is repeated through the second hole, and the wire is tightened until the canthus is firmly secured.

Why frontoglabellar region??

Nasal bone forming medial orbital wall and the bridge of the nose fragile ? Withstand wire tightening.

Glabellar portion of the frontal bone is solid and can withstand wire tightening. • The fixation is secure.

Due to the relatively large amount of soft tissue covering the twisted wire, extrusion of the wire through the skin does not occur.

No injury to delicate structures of the contralateral medial orbit such as the lacrimal sac or lacrimal duct.

Transnasal: Technically difficult. Necessitates wide exposure

sufficient to allow transverse passage of a wire through a bony fenestration deep within the orbit.

Weakening of the bones ( when central fragment is drilled twice),

Dissection of the contralateral orbit. 

A NEW METHOD FOR TRANSNASAL CANTHOPEXY AND FRACTURE

FIXATION   A Kirschner wire with

one of the tips hammered and shaped into a simple drill is passed from the left orbit toward the right thru central fragment.

Plastic catheter is pushed forward over the Kirschner wire guide and through the transnasal hole.

A bent, looped wire is introduced from left to right through the plastic tube left in the transnasal hole after the Kirschner wire is removed.

 A titanium microplate is placed in the loop at the second penetration site.

Second microplate is placed between the exiting wires at the first penetration site,

Ends of the wires are twisted together

The free tips of the wire at the site of first penetration can be used for canthopexy without microplate placement, if desired.

After passing thru ligament;The 30G wire is passed through the posterior hole of the miniplate and loosely twisted.

The plate is positioned, with the medial canthal tendon pushed deep, near the posterior lacrimal crest. The drill hole is made in the area of the anterior hole of the plate and fixed with a stainless steel screw (2 × 6 mm).

The stainless steel wire is then tightened. The frontal process of the maxilla in the region

of the lacrimal crest is utilized for fixing the two-hole plate transversely .

MCL reconstruction with miniplates and wire

A simple method for medical canthal wiring reconstruction.

A homolaterally fixed osteosynthesis plate and a metal wire is used.

Avoids transnasal wiring and gives superior control when correcting the position of the lacerated medial canthus.

 20 metal wire is fixated to the ligament by a double stitch.

One end of the metal wire is brought through the last hole of the plate and the plate is then fixed at the nasal bone in such a way that the end of the plate is at least some millimetres posterior and superior to the lacrymal fossa.

Reach the desired position the wire can be twisted and the wound closed. 

 Bone anchor systems  Have provided for effective

longterm biomechanical stability in extremity tendon reattachment to bone in orthopedics

Prethreaded bone anchor system Mitek mini bone anchor system used. 

The key to replicating the delicate three dimensional contour of the medial canthus lies in addressing all three vectors of attachment”.

 Optimal position for bone anchor placement is determined.

The hole for screw placement is positioned within the central portion of the lacrimal fossa.

If bone loss present no lacrimal fossa, the screw hole is placed within a rigidly fixated medial orbital wall bone graft at a point corresponding to the contralateral central lacrimal fossa position. 

Reduce Septal fractures/displacement:

NOE # are associated with fractures of perpendicular plate of ethmoid, septal deviation, septal hematomas.

Goal should be to – assure midline positioning of

septum to prevent airway compromise.

– Reduce septal fractures

Nasal dorsal augmentation

Collapse of the bony architecture broadening of base.

Weakening of nasal septal structures.

Damage to upper lateral cartilages.

Complete loss of dorsal nasal projection and loss of support.

Aim for overprojection of the dorsum and not underprojection

Bone grafts Reinforcement of thin bones Prevention of overriding and

displacement of fragments Maintenance of vertical dimension Provides substrate for osseous

union Prevention of soft tissue scarring

 Bone graft sites: calvarial excellent choice.

Shape it like a surf board gently tapering it at the end.

Length should extend from frontonasal junction to nasal tip.

Colummelar strut if needed. Fixation: - Single lag screw into the nasal

pyramid. -Microplate to cantilever off the

frontal bone.

Soft tissue readaptation: Post surgical soft tissue thickening

can hamper esthetics. Soft tissue thickening appearance

of telecanthus. Solution: Soft tissue thermoplastic

stents. Splint is contoured and overextended

into nasorbital valley. into junction of nose and medial orbit. reinforced with elastic tapes.

NOE fracture emergencies

Persistent Cerebrospinal fluid leakage.

Unconsciousness Skull fractures Increasing intracranial pressure Meningitis

Complications following surgery: Temporary or permanent parasthesia. CSF leak. Meningitis. Sinus infection or mucocoele. Anosmia. Infection of implants. Postoperative telecanthus is a

relatively common complication of nasoorbitoethmoid (NOE) fracture repair.

Pseudotelecanthus. Enophthalmos results from

inadequate repair of the medial orbital wall or orbital floor. 

Midface retrusion may occur. Extraocular dysfunction. Blindness. Possible need for additional

surgery.

Postoperative details: Postoperative ophthalmologic examination is

recommended, as well as gross visual acuity checks every 6 hours for a 24-hour period.

The Penrose drains are removed from the scalp at 24 hours, and the pressure dressing is discontinued after 3 days. The lead bolsters and scalp sutures are removed at 10 days postoperatively.

The patient should be examined and queried again, looking for any evidence of a CSF leak. Patients should be asked to perform standard nasal hygiene (nasal saline irrigations and no nose blowing).

Outcome and prognosis: Disruption of the delicate ethmoid

complex and comminution of the nasal bones can make the repair of nasoorbitoethmoid (NOE) complex fractures extremely difficult.

These injuries often test the capabilities of even the most experienced surgeons.

To obtain an aesthetic surgical result, the surgeon must meticulously identify, accurately reduce, and rigidly fixate the medial canthal tendon and central fragment.

Special attention also must be focused on the overlying soft tissue to avoid hematoma, chronic induration, and pseudotelecanthus.

Aesthetic reconstruction of the nasal root and medial canthal region continues to be a significant surgical challenge. Future advances may address this issue with the use of surgical navigation systems and/or intraoperative imaging, which returns the bony architecture to its premorbid state more accurately.

Conclusion: NOE injuries can be difficult to

manage. Proper assessment and early surgical management of the NOE and concomitant injuries are key to optimal outcomes. Overcorrection of the bony position and compression of the soft tissue overlying the MCT are critical. Residual telecanthus tends to be recalcitrant despite the best efforts.