3. INTRODUCTION
• Isolated fractures of the nasal pyramid --About 40% of all facial fractures.
• Fractures of the nasal bones are often occured along with other fractures of the
facial skeleton.
• Delay in management --Significant cosmetic and functional deformity
4. EPIDEMIOLOGY AND ETIOLOGY
• Relatively little force is required to
fracture nasal bones (25-75lb/in)
• Young men– MC
• The peak incidence: 15-30 year age
group (assaults, contact sports and
adventurous leisure activities are
more common).
• Compound and comminuted
fractures are more common in the
elderly.
6. NATURE OF INJURY
• Laterally applied forces
(>66%)
• Frontal injuries (13%)-
grearter force is required
as the nasal cartilages
behave like shock
absorbers
7. EXTENT OF DEFORMITY
• Five-point grading system (developed for the extent of lateral
deviation of the nasal pyramid):
• Grade o: bones perfectly straight
• Grade 1: bones deviated less than half of the width of the bridge of
the nose
• Grade 2: bones deviated half to one full width of the bridge of the
nose
• Grade 3: bones deviated greater than one full width of the bridge of
the nose
• Grade 4: bones almost touching the cheek.
9. CLASS I FRACTURES (CHEVALLET)
• Result of low-moderate degrees of force.
• Extent of deformity is usually not marked.
• Simplest form of a Class 1 fracture is the depressed nasal bone.
• The fractured segment usually remains in position due to its inferior attachment
to the upper lateral cartilage which provides an element of recoil.
• The nasal septum is generally not involved.
10. • Severe variant--Both nasal bones and the
septum are fractured.
• The fracture line runs parallel to the naso-
maxillary suture ipsilateral to the side of the
applied force to a point approximately two-
thirds along the length of the nasal bone, where
the bone becomes much thicker.
• The fracture line then connects across to the
contralateral side and runs parallel and just
below the dorsum.
11. • The cartilaginous septum is
fractured approximately 0.5cm
below the dorsum and this
aspect of the injury may extend
posteriorly into the bony septum,
through the perpendicular plate
of the ethmoid and skull base.
12. CLASS 2 FRACTURE (JARJAVAY)
• Class 2 fractures are the result of
greater force .
• Associated with significant cosmetic
deformity.
• It involves the nasal bones, the frontal
process of the maxilla and septum.
• The ethmoid labyrinth and adjacent
orbital structures remain intact (seen in
Class 3).
13. • The pattern of deformity
• A frontal impact- results in comminuted nasal bone # and cause
gross flattening and widening of the dorsum
• Lateral impact- produces a high deviation of the nasal skeleton.
14. • It is a complex 'C-shaped' fracture*
• Extends from the quadrangular
cartilage beneath the nasal tip---
posteriorly through to the
perpendicular plate of the
ethmoid,--- to the anterior border
of the vomer— forward through the
lower part of the perpendicular
plate of the ethmoid into the
inferior part of the quadrilateral
cartilage.
15. CLASS 3 FRACTURES
• Most severe nasal injuries, result from
high velocity trauma.
• Naso-orbito-ethmoid fractures and
often associated fractures of the
maxillae.
• The external buttresses of the nose
give way and the ethmoid labyrinth
collapses on itself. This causes the
perpendicular plate of the ethmoid
to rotate and the quadrilateral
cartilage to fall backwards.
16. • It causes a foreshortened saddled nose and the nostrils facing
moreanteriorly, like the snout of a pig (pig-like' appearance)
• There is also telecanthus, which may be exaggerated further by disruption
of the medial canthal ligament from the crest of the lacrimal bone.
• Two categories of naso-orbito-ethmoid fractures by Raveh.
• Type I : -The anterior skull base, posterior wall of the frontal sinus and
optic canal remain intact.
• Type II:- disruption of the posterior frontal sinus wall, multiple fractures of
the roof of the ethmoid and orbit that may extend posteriorly to the
sphenoid and parasellar regions.
18. CLINICAL PRESENTATION
• HISTORY-
• MLC
• How and when the injury was sustained.
• Nasal obstruction, Pain.
• Change in appearance.
• Anosmia; hyposmia; Watery rhinorrhoea (skull base injury).
• Visual disturbance; diplopia; epiphora (Orbital trauma).
• Altered bite; loose teeth; trismus (Dental openion)
• Occupation.
19. • Complete nasal obstruction and persisting pain --R/Oseptal
haematoma.
• H/O previous injuries or past nasal surgery.
20. EXAMINATION
• Deviation, Depression, Step deformities.
• Mobility, Crepitus, Specific areas of point tenderness.
• Generalized swelling and specific bruising
• Skin and mucosal lacerations .
• Septal fracture/haematoma /abscess/perforation
• Other soft tissue injuries
• ENT, head & neck examination
22. TREATMENT
• Indications for surgery in the acute phase
• significant cosmetic deformity
• nasal obstruction caused by a septal haematoma.
• Most of the patients (up to 80%) do not require any active
treatment (undisplaced fracture).
• Soft-tissue swelling may mimic deformity —Reassurance.
• Topical vasoconstrictor drops --Alleviate congestion and
obstructive symptoms.
23. • Pts with pre-existing nasal deformity caused by a previous incident--
Septorhinoplasty when everything has settled down some months later.
• Pts --Occupational hazard, sport or leisure activity-- It is better to advise
definitive septorhinoplasty when the risk of further injury no longer exists.
• The optimal time for clinical assessment around 4 days-- oedema will subside
and any underlying deformity become apparent -( So R/A 4 days -Reduction with
in next 2-3 days)
• >7 day delay -- effective reduction difficult and sometimes will require
osteotomies.
• In children, healing occur more quickly and earlier intervention is indicated.
24. ANAESTHESIA
• LA/GA
• Local anaesthesia -- combination of external infiltration with internal application
of topical preparations. Lignocaine is injected along the nasomaxillary groove,
infraorbital nerve in its foramen and around the infratrochlear nerve.
• Topical EMLA (prilocaine and ligno-caine) cream orАМЕТО (amethocaine) gel to
the external nose instead of infiltration
• Within the nose, sprays, injections, pastes or packs coated with local anaesthetic
OR combinations of cocaine, lignocaine, adrenaline and phenylephrine.
• GA Indication-* Patients who are not suitable for reduction under LA,* Children,*
Patients with low pain thresholds or significant anxiety states,* Delay in
presentation
25.
26. METHODS OF REDUCTION
• Closed technique--The general principle is to mobilize the fragments first by
increasing and then decreasing the degree of deformity.
• Various elevators and forceps have been developed specifically for this purpose,
(Freer, Hills and Howarth elevators and Ashe and Walsham forceps.
• All Class 1 and most Class 2 fractures can be reduce with closed techniques.
• Some Class 2 fractures -Open reduction ( require Osteotomy- to release the fragments
before manipulation)
• A splint or plaster applied to the nasal bridge maintains the position of the nasal
bones and prevents accidental displacement.
• Splints kept in place for about 7 days.
• Refrain from contact sports for at least 6 weeks.
27. INDICATIONS OF OPEN REDUCTION
• Bilateral fractures with dislocation of the nasal dorsum and
significant (pre-existent or recent) septal deformity.
• Infraction of the nasal dorsum.
• Fractures of the cartilaginous pyramid, with or without dislocation
of the upper laterals. For depressed tip or flail lateral fractures
(unstable despite closed reduction techniques) --Kirschner (K) wires
can be used (Removed after 2 wks)
28. MANAGEMENT OF NASAL SEPTUM
• Septal reduction - performed with Ashe's forceps, often requires a Killian or
hemitransfixion incision, elevation of mucosal flaps to expose cartilage and bone
fragments, and replacement and/or removal of cartilaginous and bony fragments.
• Quilting sutures prevent haematoma formation.
29. COMPLICATIONS
• Poor cosmetic result :
• Factors include:
• 1 Extent of the injury.
• 2 Time delay in surgical reduction.
• 3 Poor surgical technique.
• 4 Unrecognized and untreated septal fracture.
• 5 Pre-existing nasal deformity.
• 6 Post-operative trauma (in recovery room or subsequently).
• 7 scarring and fibrosis
32. INTRODUCTION
• Maxillofacial trauma is extremely common.
• 10% of all accident and emergency attendances are related to facial
injuries.
• Immediate assessment of the airway is essential.
• Most facial fractures are managed by semi-rigid internal fixation through
extended subperiosteal exposure of the fracture.
• Wiring of the jaws is no longer the standard of care.
• Cerebrospinal fluid (CSF) rhinorrhoea and retrobulbar haematoma should
be excluded in all middle-third facial injuries.
33. AETIOLOGY
• RTA, Physical violence, falls,
attempted suicide, and
sporting injuries.
• Most injuries are low energy
and heals well.
• Higher-energy injuries cause
gross comminution of the
bones and do not heal as well
34. PRIMARY CARE
• ATLS PROTOCOL must be followed-
• 1.Airway: Evaluate and secure the airway, while maintaining alignment of the neck
in case there is an unstable cervical spine injury.
• 2.Breathing: Make sure that there is adequate ventilation.
• 3. Circulation: Control sources of blood loss.
• 4. Disability: Assess the level of consciousness and neurological dysfunction.
• 5. Exposure: Ensure that all other injuries are identified
35. PRINCIPLES OF PRIMARY MANAGEMENT
• Once the primary survey of the injury completed, a secondary survey is carried out to
exclude other injuries and to categorize the extent of the facial injury.
• The soft tissues of the face - Any lacerations or cuts near relevant anatomical
structures -- eyebrows, conjunctival margins, nasal aperture and the vermillion border
of the lips.
• Facial nerve function.
• Integrity of the parotid duct.
• Visual acuity and ocular movements. (retrobulbar haemorrhage and retinal
detachment--both are preventable and treatable causes of permanent blindness.).
• Palpating the orbital margins, zygomatic projection, nasal skeleton and mandibular
outline.
• A full dental examination is necessary.
• Dental occlusion and maxillary or mandibular instability
36. RADIOGRAPHIC EVALUATION
• X-rays of the facial skeleton, chest, cervical spine and pelvic.
• computerized tomography (CT) scan - Head &Facial skeleton.
• The timing of any maxillofacial intervention is contro-versial.
• With modern-day techniques-- trend is to fix facial fractures earlier. ( avoids
double insult of accidental and surgical trauma).
• Swelling can be reduced by head-up position with ice packs, together with a
single dose of dexamethasone.
• Facial wounds should be cleaned and lacerations closed as soon as possible.
• parenteral prophylactic anti-biotics
37. MANDIBULAR FRACTURES
• INTRODUCTION
• Parabolic-shaped bone with a complex
articulation that consists of paired
synovial joints - the
temporomandibular joint.
• Rehabilitation requires accurate
reduction, adequate fixation and
mobilization.
• The traditional method of treatment
was immobilization of the fracture with
intermaxillary fixation (IMF) .
• Nowadays -Miniplates fixation
38. SIGNS AND SYMPTOMS
• Depends on site of the fracture-
• Fractures of the body, angle and symphysis :
• Step deformity palpable either externally or intraorally
• Asymmetry of the lower dental arch and derangement of the
occlusion.
• Pain and paradoxical movement and crepitus on distraction of the
fractured segments.
• Haematomas in the buccal sulcus or floor of the mouth.
• Blood-stained saliva
• Anaesthesia of the lower lip
39. • Fractures of the condylar neck
• Tenderness over the TM).
• Trismus.
• Deviation of the jaw towards the injured side on opening the mouth.
• Inability to move the mandible to the side opposite the fracture.
• Deviation of the jaw to the fractured side at rest with an anterior open
bite secondary to gagging of the molar teeth in fracture dislocation.
• Symmetrical anterior open bite in bilateral fractures of the necks of the
condyles.
40. CLOSED REDUCTION TECHNIQUES
• Inter Maxillary Fixation (IMF) :-Much smaller role in modern
maxillofacial surgery. Role in two groups of patients.
• First :- undisplaced fractures and no neural deficits who want
to avoid more complex surgery
• second, :- unilateral condylar fractures.
• In casuality IMF :-A simple tie wire placed around the teeth
either side of a displaced fracture can reduce pain, bleeding
from bone ends and make nursing easier in the initial hours
and days before a planned open reduction and internal
fixation.
41.
42.
43. FRACTURES OF MAXILLA
INTRODUCTION
• subdivided :-lateral (zygomatic)
• central (maxillary, nasal, nasorbito-ethmoid)
Symptoms and signs -depend on the level of the fracture
The classical features of a midfacial fracture
• circum-orbital ecchymosis (panda facies) —
• facial oedema
• emphysema,
• lengthening of the face
• infra-orbital nerve sensory deficit
• bruising at the junction of the hard and soft palate
44. SURGICAL ANATOMY
• The bone of the midfacial region - very thin and offers little resistance to anterior
and lateral forces.
• Le Fort described three levels of midfacial fracture
45. LE FORT 1 (GUERIN #)
• This fracture runs above the floor of the nasal cavity, through the nasal septum,
maxillary sinuses and inferior parts of the medial and lateral pterygoid plates.
LE FORT 11 (PYRAMIDAL FRACTURE)
• Fracture line runs from the floor of the maxillary sinuses superiorly to the
infraorbital margin and through the zygomaticomaxillary suture.*
• orbit --it passes across the lacrimal bone to the nasion. The infraorbital nerve is
often damaged by involvement in this fracture.
46. LE FORT 111
• Disconnection of the facial skeleton from the cranial base.
• The fracture traverses the medial wall of the orbit to the superior orbital fissure
and exits across the greater wing of the sphenoid and zygomatic bone to the
zygomaticofrontal suture.
• Posteriorly-It runs inferior to the optic foramen, across the lesser wing of the
sphenoid to the pterygomaxillary fissure and sphenopalatine foramen.
• The arch of the zygoma is also broken.
47. SIGNS AND SYMPTOMS
• •epistaxis .
• •circumorbital ecchymosis.
• •facial oedema.
• •surgical emphysema.
• •lengthening of the face.
• •infraorbital anaesthesia.
48. MANAGEMENT
• Emergency Treatment
• It can compromise the airway with torrential epistaxis and posterior
impaction of the maxilla.
• The bleeding can be arrested by using anterior and posterior nasal
packs.
• If retroposition of the maxilla -- it can be pulled forwards using the
index and middle finger placed behind the patient's soft palate
49. • REDUCTION
• The maxilla is mobilized by a combination of digital pressure and
traction on arch bars or interdental wires.
• FIXATION
• Internal fixation with 1.3 or 1.5mm, low-profile miniplates placed along
along the buttresses.
• Subperiosteal elevation with preservation of the infraorbital nerve
allows reconstruction of the paranasal and zygomatic buttresses
50. ZYGOMATIC COMPLEX FRACTURE
Surgical anatomy
• The body and processes of the zygomatic bone forms lateral middle
third of the facial skeleton.
Blows to this part cause -
• Depressed fracture of the entire zygomatic bone
• Fracture of the zygomatic arch
51. 'Tripod fracture' because of the
disruption of the three commonly
recognized articulations
• 1.fronto-zygomatic
• 2.infraorbital rim
• 3.zygomaticomaxillary buttress.
Accurate anatomical reduction is
important for facial appearance,
optimum function of the eye, and
because of its close proximity to the
coronoid process, for opening and
closing the mandible.
52. SIGNS AND SYMPTOMS
• The lateral aspect of the face will be swollen and bruised.
• subconjunctival haemorrhage .
• Periorbital edema .
• Eye movements restricted, particularly in upward gaze if
there is an orbital floor dehiscence and blowout of the
orbital contents .
• Step deformity of the infraorbital margin.
• frontozygomatic suture - tender .
• In arch fractures -palpable depression and limited mouth
opening.
• Altered sensation of the cheek.
53. IMAGING
• fractures are visible on 15 and 30° occipi-tomental X-rays.
• CT scanning -if there are signs of diminished ocular motility.
• Hess charting should done in all cases with subjective diplopia.
MANAGEMENT
• Minimally displaced fractures -
• Conservative with a full explanation to the patient and instruc-tions not to
blow their nose for a period of 2-3 weeks.
• Review after 10 days to make sure that no active intervention is required.
• Displaced fractures -Reduction with or without fixation.
54. ORBITAL FLOOR FRACTURE
• Blunt trauma to the globe or adjacent bone can lead to fracture of the orbital
floor.
• Signs and symptoms :-
• cardinal signs :-- Enophthalmos
--Hypoglobus (depressed pupillarylevel).
• Other signs :-
• Supratarsal hollowing,
• Hooding of the eye,
• Narrowing of the palpebral fissure width
• infraorbital nerve deficit.
• Diplopia on upward gaze
55. • IMAGING:-
• CT imaging with axial, coronal and sagittal plane
• Management:-
• exploration and repair.
• soft-tissue components should be mobilized and supported by a
graft.
• Various grafts and materials --Polydimethylsiloxane(PDS) ,
Titanium alloplasts are used
56. NASO ORBITO ETHMOID FRACTURES
Definition and classification
• It involve the anatomical confluence of the nose, orbits and ethmoids.
• Markowitz et al classified NOE in terms of their attachment to the medial canthal
ligaments
CLASSIFICATION
TYPE 1 Single large central fragment bearing the canthal
ligaments
TYPE 11 Fragmentation of the central fragment, medial canthal
ligaments attached to bone
TYPE
111
Comminution of the central fragment with no bone
attached to canthal ligaments
57. SIGNS AND SYMPTOMS
• Loss of nasal projection
• Tipping up of the end of the nose
• Splaying of the nasal root and telecanthus -- Gross comminution.
• Blunting of the canthal angle and movement of the medial canthus can be
elicited by displacement of the lateral palpebral ligament.
Common features
58. MANAGEMENT
Type I fractures :
• stabilized using miniplates.
• Surgical access is through a coronal flap, intra-orally and lower eyelid incisions
may be required.
Type Il and III fractures:
• repaired with miniplates.
• Require transnasal canthopexy to reduce the telecanthus and hold the position of
the medial canthal ligaments. This is done by plates and/or a wire.
• The lacrimal integrity should be assessed pre- or peri-operatively and stented if
damaged
