Nasal fractures are common injuries that result from blunt force trauma to the nose. The nasal bones are the most frequently fractured part of the facial skeleton due to their prominent location and thin structure. Nasal fractures are often classified based on the direction and extent of displacement. Diagnosis involves history, physical exam, and imaging. Treatment ranges from closed reduction for non-displaced fractures to open reduction for severely displaced fractures. Closed reduction involves manipulating the bones back into position using nasal speculums and forceps followed by splinting.

1. NASAL FRACTURE
DR.PADMASREE PATOWARY
MDS II

2. CONTENTS
• Introduction
• Surgical anatomy
• Biomechanics
• Classifications
• Epidemiology
• Diagnosis and Evaluation
• Management
• Controversies
• Conclusion

3. INTRODUCTION
• Fractures of the maxilla, nose, zygomatic
complex and associated bones are commonly
referred to as fractures of the middle third of
the facial skeleton.

5. • Nose is a prominent facial structure and nasal
bone fractures are the most common facial
fractures.
• Compared to the any other facial bone, less
energy is required to fracture the nasal
complex.
• The frequency of nasal fractures is high and
often unnoticed by both maxillofacial
surgeons and patients.

6. SURGICAL ANATOMY

7. The nose
External nose
Bony part
Carilagenous
part
Nasal cavity
Floor Roof Lateral wall
Medial (septal)
wall

8. Skeleton of External Nose
Bony part :
Nasal bone
Frontal process of maxilla
Nasal part of frontal bone
Cartilaginous part :
Septal cartilage.
Lateral nasal cartilage.
Major alar cartilage.
Minor alar cartilage.

9. NASAL
SEPTUM
VOMAR
ETHMOID
Nasal septum

10. Vomar
• Roughly triangular
bone.
• Forms the inferior
and posterior part of
nasal septum.
• Superior border
articulates with
perpendicular plate
of ethmoid bone.

11. Ethmoid
• Perpendicular plate
forms the superior
portion of nasal septum
• Horizontal plate forms
the roof of nasal cavity
• Laterally; Scroll shaped
projections on either
side of the nasal septum
called the superior and
middle nasal conchae

12. Blood supply

13. Nerve supply
Innervation of the nasal cavityInnervation of the external nose

14. BIOMECHANICS OF NASAL FRACTURES
Nasal fractures occur in one of two main
patterns-
 From a lateral impact
 From a head-on impact

15. In lateral impact , the
nose is displaced away
from the midline on
the side of the injury.

16. In head-on impact , the
nasal bones are pushed
up and splayed so that
the upper nose (bridge)
appears broad, but the
height of the nose is
collapsed (saddle-nose
deformity).

17. • Approximately 80% of fractures occur at the
lower one third to one half of the nasal bones.
This area represents a transition zone between
the thicker proximal and thinner distal segments.
Surgical Treatment of Facial Injuries by Kazanjian and Converse,
1959.

18. • Rowe & Killey ‘s classification.
• Strance & Robertson’s classification.
• Harrison’s classification.
• Murray & Maran’s pathological classification.
• Rorich et al’s classification.
• AO classification.
CLASSIFICATIONS

19. Rowe and Killey (1968) described fractures of the
nasal bones and/or nasal septum according to the
pattern of disturbance and the degree of
displacement of the nasal structures found when the
nose fractures are dependent upon the direction
and degree of the forces applied.
I. Lateral nasal injuries
II. Anterior nasal injuries
Drawback- They only explained the impact factor
not about the force or involvement of the bone.

20. Strance & Robertson (1979) classified nasal
bone fractures based on direction of injury.
1. Lateral blow – frequently occurring.
2. Frontal impact – less frequently occurring.
Plane i.
Plane ii.
Plane iii.

21. Plane i

22. Plane ii
Plane iii

23. In 1979 , Harrison classified nasal fracture
which included subclasses to include fractures
of the nasal tip and anterior nasal spine,
fractures of the dorsum with or without septal
deflection, and comminuted nasal fractures
with management.

24. • Class 1: Chevallet
fractures
• Very little force is
sufficient to cause a
fracture of nasal bone.
• It has been estimated
to be as little as 25-75
pounds / sq inch.
• Class I fractures are
mostly depressed
fractures of nasal
bones.

25. • Clinically this fracture will present as a
depression over the nasal bone area. There
may be tenderness and crepitus over the
affected nasal bone.
• Radiological evidence may or may not be
present. In fact class I fracture of nasal bone is
purely a clinical diagnosis.

26. CLASS II FRACTURES
• These fractures cause a
significant amount of
cosmetic deformity.
• In this group not only the
nasal bones are fractured,
the underlying frontonasal
process of the maxilla is
also fractured. The fracture
line also involves the nasal
septum.

27. CLASS III FRACTURES:
• These are the most severe nasal injuries
encountered. This is caused by high velocity
trauma.
• It is also known as naso orbital fracture / naso
ethmoidal fracture. (Naso orbito ethmoid
fracture)

28. • Murray and Maran (1986) described a
pathological classification of nasal fractures
following experiments on fifty cadavers. They
have devised a more complicated system
based on seven types of fractures; this system
emphasizes the deviation of the nasal pyramid
from the midline as being a clinical predictor
of treatment outcome.

29. • Rorich et al (2000) proposed a simple
classification that might guide treatment
Type Description
I Simple unilateral
2 Simple bilateral
3 Comminuted
a) Unilateral
b) Bilateral
c) Frontal process of maxilla
4 Complex
a) Associated with septal hematoma
b) Associated with open nasal laceration
5 Associated NOE fracture/midface fracture

30. AO (Arbeitsgemeinschaft fur Osteosynthese)
surgery provides a simple classification system
based on clinical findings (2009)
1. Laterally displaced.
2. Posteriorly depressed fractures
3. Disarticulation of upper lateral cartilage
4. Anterior nasal spine fracture
5. Involvement of nasal septum

31. Laterally displaced fractures
Posteriorly depressed fractures

32. Disarticulation of upper
lateral cartilage
Anterior nasal spine fracture

33. • The nasal septum is almost always involved in
nasal fractures and must be evaluated to determine if
treatment is necessary.
• If the impact force is weak, nasal bone
displacement is usually present without septal
fractures.
Involvement of nasal septum

34. Epidemiology
• Rowe and Killey (1968) analysed 629 middle third
fracture and the relative frequency of nasal
fracture was 6.99%.
• Fights and sports injuries are the most common
causes of nasal fractures in adults, followed by
falls and vehicle crashes.
• Physical abuse should be considered when
evaluating children and women with nasal
fractures.
• Nasal fractures may occur in isolation, but are
commonly associated with other facial injuries
and fractures.

35. Clinical Significance
• Most nasal fractures cause significant bleeding.
• Proper techniques for haemostasis should be
applied before any diagnostic procedure and any
definitive treatment.
• Prompt appropriate treatment to prevents
functional and cosmetic changes.
• Because of the nose's central location and
proximity to important structures, the clinician
should carefully search for other facial injuries in
the presence of nasal fractures.

36. • Diagnosis should be made with history of the
patient, physical examination and radiographic
investigation. The direction and strength of the
impact should be noted.
• Preexisting nasal or septal deformities should
also be considered.
• A history of nasal bleeding may indicate a
mucosal laceration. Skin laceration over the nasal
area may guide fracture diagnosis to the specific
anatomical area.
Diagnosis

37. Physical examination

38. A
B

39. Radiological investigation
The usual facial radiographs may not clearly
reveal a nasal fracture.
a. In 1957 Gillies and Millard recommended
Waters ( occipitomental ) view.
b. Lateral view
c. CT scans accurately demonstrate most nasal
fractures and their displacement.

40. • Management of nasal fracture can do in two
ways
1) Emergency management
2) Surgical management
Management

41. Emergency management
• Elevation of the head
• Use of cold compresses in the peri orbital
and nasal regions can be helpful for subside
the edema.
• Nasal packing is the most common method
of controlling bleeding within the nose. The
packing should be placed precisely at the
bleeding site(s) to provide uniform pressure
over the entire area.

42. • In most patients packing will control nasal
bleeding. After 2 to 5 days the packing can be
removed.
• Posterior nasal pack is needed when obstruction
of the airway because of hemorrhage into the
nasopharynx .

43. Anterior Nasal Packing
• This packing is done if localized
bleeding is profuse or bleeding
point is not localize.
• Use of a ribbon gauze soaked
with liquid paraffin(1 m gauze;
2.5 cm gauze in adult and 12 mm
in children).
• It can be done with vertical layer
and horizontal layer.
• It can be removed with 24 hour
and can be kept upto 2-3 days.
• Systemic antibiotic should be
given to prevent sinus infection
and toxic shock syndrome.

44. Posterior Nasal Packing
Epistaxin balloon.Smaller (10ml)
posterior ballon and bigger (30ml)
anterior balloon are inflated.
Channel of catheter provides airway
for nasal breathing.
•Foley catheter, and insert the device
into the nostril.
• Visualize the catheter tip in the back
of the throat. Inflate the balloon with
up to 10 mL of sterile water
• Withdraw the balloon gently until it
seats posteriorly.
•Pack the anterior nasal cavity with a
balloon device or layered ribbon gauze.
• Apply a padded umbilical clamp
across the catheter to prevent alar
necrosis and to keep the balloon from
dislodging.

45. Surgical management
Nasal trauma algorium
History : physical and radiographically
Fracture No Fracture
Discharge
Classify fracture

46. Classify fracture
Type I simple
Type II simple
Type III comminuted
Type IV complex
(associated septal
Hematoma)
Type V
Significant edema Evaculate /pack septal
hematoma irrigate/close
wound
No Yes

47. No Yes
Significant edema
Elevation /ice
Reassess in 3-5
days after swelling
subsides
Fracture reduction
•Meticulous septal
examination
with or without
endoscope
•Closed reduction

48. Fracture reduction
•Meticulous septal examination
with or without endoscope
•Closed reduction
Type I II III
•Antibiotics /steroids
•Splints
Type IV
•Reduce septal fracture/
dislocaton
•Consider limited inferior septal
reconstruction

49. Closed reduction is usually
reserved for simple, non
comminuted nasal fractures,
although exceptions can be
made .
Closed reduction

50. The indications for closed reduction are:
• Unilateral or bilateral fractures of the nasal
bone with displacement.
• Fractures of the nasal septal complex causing
nasal airway compromise.
• Closed reduction should be performed as soon
as possible, preferably 10-14 days post injury,
but may be possible up to 21 days.

51. Few instruments are needed for fracture reduction.
These include
I. Asch nasal septal forceps.
II. Walsham nasal forceps.
III. Boies or Ballengers elevator.
IV. Internasal specula.
Fracture reduction instruments

52. Fracture reduction instruments for acute nasal fracture management. From
left: Walsham forceps, Asch forceps, Boies elevator, nasal speculum.

53. In laterally displaced fractures

54. In centrally depressed fractures

55. Reduction of the nasal septum

56. Nasal bones-
After reduction, adhesive strips
are placed over the skin of the
nasal dorsum and the nasal
bones are splinted using an
external splint that conforms
to the patients nose. If the
nasal bones are comminuted
or loose, they should be
supported with an intranasal
packing, which should be
placed before placing the
external splint.
Splinting

57. Nasal septum
The nasal septum can
be stabilized with
splints or packs.
Removal of packings and splints
Hemostatic packs are removed after 24 hours. Packs that are
supporting the nasal bones are left in place as long as the
external splint is in place.
The patient should be prescribed antibiotic treatment for as
long as the nasal packs are in place.

58. Open reduction
Essentially in two conditions , open reduction are
performed.
• 1st early correction of nasal fractures that could
not be properly reduced in a closed fashion.
• Secondly correct a previously existing nasal
deformity.
The latter should be more properly classified as
septorhinoplasty to correct an internal and
external deformity.

59. Indications for open reduction are:
• Extensive fracture dislocation of the nasal
bone and septum.
• Fracture dislocation of the lower septum.
• Open septal fractures.
• Deformity after closed reduction.
• Inadequate bony reduction due to deformity.
• Combined deformities of septal and alar
cartilages

60. Surgical Approach
1. Through existing laceration.
2. Bicoronal approach.
3. Endonasal
a. Transcartilaginous (Intracartilaginous, Cartilage splitting)
b. Retrograde
c. Bipedicled chondrocutaneous flap (delivery)
4. External (open)

61. • Use of existing
lacerations
Nasal fractures are often
associated with
lacerations. These
existing soft-tissue
injuries can be used to
access directly the nasal
bones for management
of the fractures.

62. • Bicoronal approach
The bicoronal or
bitemporal incision
is used to approach
the anterior cranial
vault, the forehead,
and the upper and
middle regions of
the facial skeleton.

63. For endonasal and external techniques are accomplished
through various incisions strategically placed to allow for
careful anatomic dissection of the underlying nasal skeleton.
The following incisions can be used:
1. Alar cartilage incisions
a.transcartilaginous(intracartilaginous,cartilage
splitting)
b. intercartilaginous
c. marginal
2. Septal incisions
a. complete transfixion
b. partial transfi xion
c. hemitransfixion
3. Transcolumellar incision

64. 1.Endonasal
a. Transcartilaginous
Approach- Intracartilaginous
incision extending up to and
around anterior septal angle
into a partial transfixion
incision with dissection of
vestibular skin off
undersurface of lower lateral
cartilage.

65. b. Retrograde Approach-
For this approach
intercartilagious incision is
used. This incision is placed
between the caudal end of
the upper lateral cartilage and
the cephalic margin of the
lower lateral cartilage and
then carried into the
appropriate septal incision.

66. This edge is brought into
full view by retracting the
ala with the double
ended nasal hook while
simultaneously providing
gentle pressure with the
middle finger over the
upper lateral cartilage.

67. c. Bipedicled
chondrocutaneous flap
(delivery) -
The delivery approach to the tip
and lower two thirds of the
nose allows for direct view of
the lower lateral cartilages,
both of which may be viewed
simultaneously.
Two incisions are required for
this technique.
i. Intercartilaginous incision
ii. Marginal incision

68. A sharp, angled tip (Converse)
scissors are used to dissect the
soft tissue plane just above the
perichondrium of the lateral
crura and dome. Single hook
retraction in the dome are aids
in dissection here.
The lower lateral cartilage with
attached, intact vestibular skin is
the “delivered” out of the nose
as a bipedicled
chondrocutaneous
flap, with exceptional exposure
of the majority of the lower
lateral cartilage.

69. 2. External (open)-
Marginal and inverted
“V” transcolumellar
incision used for
external approach.
Exposure obtained of
lower two thirds of
the nose using the
external approach

70. Associated fractures
Grafting

71. Midline repositioning of
quadrangular cartilage of the
septum and the vomer
The septum is repositioned in
its original midline position
together with the
quadrangular cartilage and
vomer. As small suture may
be placed from the anterior
nasal spine to the anterior
portion of the septum to
maintain its reduction.

72. Closure
A quilting stitch using
absorbable suture material is
passed back and forth through
the septum to stabilize the
mucosal flap and prevent
septal hematoma formation.
A few interrupted
absorbable sutures
are used to re
approximate the
mucosal incisions.

73. Post operative care
• Postoperative positioning : Keeping the patient’s
head in a raised position both preoperatively and
postoperatively may significantly improve edema
and pain.
• Nose-blowing : To prevent orbital emphysema,
nose-blowing should be avoided.
• Ice packs for reduce the nasal edema.

74. Complications
a) Early complications
b) Late complications

75. • Early complication
a. Septal hematoma.
b. Edema , ecchymosis and epistaxis .
c. Infection.
d. Emphysema.

76. •Late complication
a.Untreated hematomas of the nasal septum may
become organized, resulting in subperichondial
fibrosis and thickening with partial nasal airway
obstruction.
b.Synechiae may form between the septal and the
turbinate in area where soft tissue lacerations
occur and the tissues are in contact.

77. c. Residual osteitis is seen occasionally in compound
fractures of the nose or in fracture associated with
infected hematomas. Dacryocystorhinostomy may
be needed for its correction.

78. CONTROVERSIES
i. Closed Versus Open Reduction.
ii. Timing Of The Treatment.
iii. Anesthesia.

79. Closed Versus Open Reduction
• Nasal bone fractures can be treated by either
closed or open techniques.
• Before choosing a method of reduction, the status
of the septum must be established.
• If the septum is fractured and displaced, attempts
at closed reduction often result in unsatisfactory
results.
• Closed treatment should be reserved for simple
unilaterally displaced nasal fractures without any
significantly displaced septal fractures.

80. • Results following closed reduction have been
examined in some past reports.
• Crowther et al reported the result of closed
reduction of nasal fractures with 85% of the
patients satisfied with their nasal appearance.
• A Danish study reported similar favorable long-
term results at 3 years following closed reduction
of nasal fractures .
• These past reports suggest that in the appropriate
patient closed reduction can be an extremely
useful modality to treat simple nasal fractures
with significant septal pathology.

81. • There are differences of opinion regarding
timing of the treatment of nasal fractures.
• If a patient is seen shortly after trauma, before
significant edema develops, immediate treatment
may be indicated.
• Other indications for immediate treatment
include the presence of lacerations with exposure
of the underlying skeletal or cartilaginous elements
or the presence of a septal hematoma that requires
immediate drainage.
Timing Of The Treatment

82. • However, many surgeons said to re-evaluate
the patient in a number of days before
performing definitive treatment.
• By re-evaluating a patient a number of days
after the trauma, factors that may contribute to
postoperative nasal deformity, such as acute
edema, unrecognized pre-existing nasal deformity
and undetected septal fractures, can better be
assessed before surgical intervention (Rohrich RJ
et all in 2000).

83. LOCAL VERSUS GENERAL ANESTHESIA
• Reduction of nasal fractures may be performed
under local anesthesia supplemented with
intravenous sedation or under general
anesthesia.
• Fracture reduction under local anesthesia is an
attractive alternative to general anesthesia
because hospitalization and operating room
utilization are not required and it is a safe and
efficient method to deal with these injuries.
• Studies comparing both techniques have
determined there are no differences in clinical
outcome as far as patient satisfaction.

84. Conclusion
• Skilled management of nasal and septal fractures
requires a detail understanding of facial anatomy,
causes of injuries, function and aesthetics of the
nose, modern operative techniques, timing for
reconstruction, setting and anesthesia choices, and
possible complications.

85. • Although most operative repairs have good
results, secondary reconstructions are
surprisingly common.
• Accordingly, long-term follow-up may be
helpful in select patients, but most patients
should be informed of the possible long-term
aesthetic and functional consequences of
their injuries.