4. General information
• Most common facial bone fracture .
• More tan 50% of facial bone fracture
• Due to its anatomical position in the face
• Male > female.
• Pyramidal shape(nasal bones, nasal septum, nasal process of frontal bone,
frontal process of maxilla, the ethmoid bone, the vomer, cartilaginous
structures)
5. Anatomy
• The nasal bones articulate superiorly with the nasal part of frontal bone and lateraly
with the frontal process of maxilla .the two nasal bones articulate with each other in
the midline.
• The nasal bones are thicker above the intercanthal line and gradually decrease in
thickness as we go down to articulate with lateral nasal cartilage.
• The transition of nasal bones from thicker to thinner is the most common site of
nasal fracture.
• Nasal septum is qudrelateral in shape .its cartillagenous anteriorly and formed of
vomer inferiorly and perpendicular ethmoidal plate posteriorly and superiorly.
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7. Nasal anatomy
• Soft tissues and hard tissues .
• Hard tissues
• lateral nasal bones(nasal process of maxilla, frontal bone ,ethmoidal bone)
• Nasal dorsum(nasal spine)
• nasal septum(cartillagenous and bony septum(perpinduclar palatine,vomer,
maxillary and ethmoid)
• nasal floor (palatine bone ,vomer ,palatine process of maxillary bone)
11. Diagnosis
• Diagnosis mainly from clinical picture.
• Laceration ,contusion and haematoma + epistaxis
• Septal haematoma an emergency case.
• Nasal obstruction.
• Saddle nose, deviated nasal septum
• Uneven nostrils and broad nasal tip
• Step deformity and nasal crepitation
12. • Septal haematoma is an emergency should be evacuated as soon as possible
to avoid septal perforation and permanent nasal deformity.
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14. Radiographic evaluation
• X-ray has alittle role in nasal fracture diagnosis.
• CT scan in ER can show deviated nasal septum and fracture nasal spine
• Recently US has arole in diagnosis of bony fracture in general including nasal
fracture.
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34. Management
• According to clinical evaluation and degree of signs and symptoms
• Wait for edema to subside to get optimal esthetic results.
• Simple to moderate cases can be managed with closed reduction using Ash
and Walsham.
• In more sever complicated cases ORIF with or without bone augmentation.
• Prosthetic nose augmentation can be used to restore esthetic and function.
38. NOE#
• Anatomy: 1. NOE anatomy
• 1.1. Bony structure
• The NOE complex consists of the nasal bones, frontal process of
the maxilla, nasal process of the frontal bone, lacrimal bone, lamina
papyracea, ethmoid bone, sphenoid bone and nasal septum, which separate
the nasal and orbital cavities from cranial cavity.1, 2 The medial orbital wall
is made up of the lacrimal bone and the lamina papyracea of the ethmoid
where blowout fracture is easy to occur (Fig. 1).1
39. Blood supply
• The blood supplying for the midface and nasal region comes from the
branches of internal and the external carotid artery. 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.2
40. Nerve supply
• The NOE region is innervated by ophthalmic and maxillary nerve, which are
derived from the trigeminal nerve.
41. Markwiz classification
• Type I( tedon attached to bone, one fracture line not displaced)
• Type II(the bone fractured and displaced but the tendon still attached to it)
• Type III(the fracture is commonuted and the tendon separated from the
bone)
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43. Clinical picture
• The clinic symptoms associate with the location and severity of the NOE fracture.
Gross facial edema may show firstly in the early stage of fracture, which will result
in distortion of soft tissue landmarks.2 It might be followed by the symptoms in the
eyes and nose. opthalmic symptoms include diplopia
, telecanthus>35mm, enopthalmus, epiphora and shortened palpebral fissure, which
result from orbit wall or medal canthal tendon malformation. Moreover, the nasal
symptoms include retrusion of the nasal bridge, anosmia caused by damage to the
cribiform plate, and nasal congestion secondary to septal hematoma or
bony/cartilaginous deformity. Cerebrospinal fluid (CSF) may also present, which
needs to be highly valued
47. Diagnosis and treatment
• From the history and clinical examination together with CT scan.
• Treatment differ according to type of fracture.
48. • Type I fracture can be managed conservatively(waiting edema to subside and follow
up until symptoms disappear) in some cases open reduction and fixation needed.
• typeII the bony segment displaced and need open reduction and fixation with plates
and screws.
• In type I&II no need for canthopexy the canthal tendon still attached to the bony
segment.
• Type III: reconstruction of the medial orbital wall needed with titanium mesh with
medial canthopexy.
• In case of naso-lacrimal duct injury repair of the duct is mandatory with stent .
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50. Surgical approaches
• Translaceration and direct approach.
• H- incision
• Infra-orbital ,subciliary ,subtarsal and transconjunctival incision.
• Coronal and hemicoronal incision .
