NASAL FRACTURES

NASAL FRACTURES

Relatively little force is required to fracture the nasal bones


Most fractures result from laterally applied forces (over 66%),fractures following frontal injuries accounted for 13%,greater force is is required to fracture the nose with a blow directed from the front as the nasal cartilages behave like shock absorber
Nasal fractures can be divided into three broad categories
Class 1 fractures
Result from low-moderate degrees of force and hence the extent of deformity is usually not marked,the simplest form of class 1 is depressed nasal bone
The fracture segment usually remains in position due to its inferior attachment to the upper lateral cartilages which provides an element of coil,the nasal septum is generally not involved.(except in more severe variant),the fracture line run parallel to the nasomaxillary suture ipsilateral to the side of applied force to a point of about 2/3 along the length of the nasal bone as the bone become more thicker
The cartilaginous septum is fractured approximately 0.5 cm below the dorsum and may extend to posteriorly to the boney septum tthis fracture is called Chevallet fracture.
Class 1 fracture tend not to cause gross lateral displacement of the nasal bones and may not even be perceptible
Class 2 fractures
Are the result of greater force and are often associated with significant cosmetic deformity .In addition to fracturing the nasal bones the frontal process of maxilla and septal structures are also involved,the ethmoid labyrinth and adjacent orbital structure remain intact.
It involve the thicker proximal portion of the nasal bone it result in true deviation and also fracture of perpendicular plate of ethmoid and quadrilateral cartilage,this called Jarjavay fracture
Class 3 fracture
Are the most severe nasal injuries result high velocity trauma,also called naso-orbital-ethmoid fractureand often have associated fracture of maxilla.the external buttresses of the nose give way and ethmoid labrynth collapse on it self,this cause the perpendicular plate of ethmoid to rotate and quadrilateral cartilage to fall backwards cause classic pig-like appearance ,telecanthus,which may be exaggerated further by disruption of medal canthal ligament
Clinical presentation
History
Details of how injury was sustained
Nasal obstruction
Change in appearance
Epistaxis
Watery rhinorrhe
Visual disturbance
Diplopia
Epiphora
Altered bite
Loose teeth
Trismus
Examination
Deviation,depression,step deformity
Mobility,cripitus,tenderness
Generalized swelling
Skin laceration
Septal fracture,haematoma,abscess,perforation
Mucosal laceration
Investigation
Plane x ray is controversial,not required to make the diagnosis
Treatment
Soft tissue swelling can produce the misleading appearance of a deformity which disappears as the swelling subside
Topical vasoconstrictors drops are helpful
Reexamination about five days later is helpful
Many patients have preexisting nasal trauma so manipulation of the nose will only return it to its most recent appearance
Immediate surgical intervention in acute phase are cosmetic deformity and nasal obstruction caused by septal haematoma
Reduction is no longer done in a period more than 2 weeks
Reduction can be done ULA or under general anaesthesia
Local can be done by inernal application of lignocaine with external infiltration
Recently use of topical EMLA (prilocaine and lignocain) cream or AMETOP (amethocain) gel externally instead of infiltration,within the nose,sprays,injections,paste,packs coated with local anesthesia are all acceptable
Sometime use of vasoconstriction reduce bleeding associated with mucosal tear during instrumentation so lignocain and adrenaline andcocain and phenylpherine is used
Various elevator and forceps are required like Ashe s for septum and Walsham s for nasal bones
50% of class 2 fracture need open reduction because of overlapping segment of fractured perpendicular plate of ethmoid or septal cartilage
Splints or packs is necessary and kept in position for 7 days,and necessary to refrain sports for at least 6 weeks