Nasal and facial fractures

1. Dr Mohammed Nishad N

2. NASAL FRACTURES
 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 .
Introduction

3. EPIDEMIOLOGY AND ETIOLOGY
 Relatively little force is required
to fracture the 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) .
 In childhood, Toddler also
common (grean stick )
 Compound and comminuted
fractures are more common in
the elderly

4. Classification and pathophysiology
 Nature of injury .
 Extent of deformity .
 Pattern of the fracture.

5. Nature of injury
 Laterally applied forces (> 66%)
 Frontal injuries ( 13%).
Greater force is required as the nasal cartilages behave
like shock absorbers.

6. Extent of deformity .
 Five-point grading system (developed for the extent of
lateral deviation of the nasal pyramid):
 Grade 0: 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.

7. Pattern of the fracture.
Three broad categories :-
 Class I
 Class II
 Class III

8. Class 1 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.

9.  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.

10.  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.

11. Class 2 fractures
(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).

12. 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 devia-tion of the
nasal skeleton.

13. 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.

16.  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.

17.  It causes a foreshortened
saddled nose and the
nostrils facing more
anteriorly, 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.

18. 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.
Complication :-
 Multiple dural tears,
 fluid leaks (CSF),
 pneumocranium
 cerebral herniation .

19. 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.

20.  Complete nasal obstruction and persisting pain --R/O
septal haematoma.
 H/O previous injuries or past nasal surgery .

21. 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 &naeck examination

22. Investigation
 Nasal X-rays
 CT SCAN
 CSF analysis ,beta 2 transferrin

23. 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.

24.  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.

25.  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.

26. 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 or
AMETOP (amethocaine) gel to the external nose
instead of infiltration

27.  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

28. 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 .

30.  All Class 1 and most Class 2 fractures can be reduced
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.

31. indications for 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)

32.  Septal reduction -- performed with Ashe’s forceps, but
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.
Management of the nasal septum

33. 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

34. Nasal obstruction :
Causes:
 1• Valve obstruction .
 2• Collapse of upper lateral cartilages and depressed
nasal bones.
 3• Septal deviation.
 4• Widened septum (haematoma).
 5• Tip ptosis.

35. Epistaxis
 Fractures involving the nasoethmoidal complex can
cause laceration to the anterior ethmoidal artery--
Result in repeated, brisk and significant haemorrhage
--Stops once the fracture has been reduced.
 Rarely prolonged packing or ligation of the artery is
required.
 Bleeding can also occur at the time of reduction( if
instruments are used.)
 Preparation of the nose with vasoconstrictive agents
helps to minimize this blood loss.

36. Septal complications
 submucoperichondrial bleed .
 Septal haematomas ,Septal abcess
 Cartilage necrosis ,Septal perforation
 Nasal deformity –saddle nose,columellar retraction,broadened
septum
Septal haematomas :
 Acute unilateral or bilateral nasal obstruction .
 On inspection --Reddish-purple, fluctuant swelling of the caudal
septum.
 A deviated septum can be confused with a septal haematoma.
Gentle pressure on the bulging area -- fluctuant if a collection is
present.
 Untreated, -- Abscess ( fluctuating fever and severe facial and
cranial pain).
 Rarely, cavernous sinus thrombosis or other forms of intra-
cranial sepsis .

37.  The haematoma or abscess - drained under LA/GA,
using needle aspiration or
. Preferably an incision.
 Quilting sutures - to eliminate the dead space.
 Packs or splints - to provide pressure on the septum.
 Appropriate antibiotic therapy

38. Facial fractures
 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 hae-matoma should
be excluded in all middle-third facial
injuries.

39.  RTA,Physical violence,
falls, attempted suicide,
and sporting injuries.
 Most injuries are low
energy and heals well.
 Higher-energy injuries
cause grosscomminution
of the bones and do not
heal as well
Aetiology

40. Primary care
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.
ATLS Protocols must be followed

42. 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 .

43.  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 .

44. 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

45. BEST CLINICAL PRACTICE
 ✓Maxillofacial fractures can endanger the airway.
 ✓Be aware of associated cervical spine injuries.
 ✓Consider tracheostomy at the outset in patients with
extensive trauma.
 ✓Close soft tissues injuries as soon as possible.
 ✓CT scans of the head and facial bones help to define
the extent of both facial and cerebral injuries.
 ✓Do not forget to give tetanus prophylaxis.
 ✓Exclude cervical spine injuries.
 ✓Check visual acuity in all patients with middle-third
facial injuries.

46. Mandibular fracturs

47. 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

48. Surgical anatomy
 Direct and indirect force.
 Fractures happen at points of
potential weakness where the bone is relatively thin.
 The angles of the mandible -weakened by unerupted
wisdom teeth,
the para-symphysis- by the long root of the lower
canine
condylar neck -by its slender anatomy.
 Multiple site # also common
 Displacement of the fracture depends --Pull of
attached muscles.

49. 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 dis-
traction of the fractured segments .
 Haematomas in the buccal sulcus or floor of the
mouth.
 Blood-stained saliva ,
 Anaesthesia of the lower lip

50. Fractures of the condylar neck
 Tenderness over the TMJ.
 Trismus.
 Deviation of the jaw towards the injured side on open-
ing 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.

51. 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.

52. THE INTACT DENTAL ARCH
Methods of applying wire to an intact dental
arch to provide IMF .
Eyelet wires:-
Can be applied if two adjacent teeth in
contact.
Disadvantage :-
 Difficult to combine eyelet wires with
elastic traction
 Difficult to thread wire through tight
interdental contact points.
Modification is the Leonard button , an
eyelet wire with a small metal disc instead
of a loop.

53. THE INCOMPLETE DENTAL
ARCH
Arch bars :-
 It is a strip of metal that is wired to each jaw using
several individual teeth.
 The bar is prefabricated using a dental impression
(intra op/pre op).
 It can span short gaps within each jaw, but not with
large gaps or when there is no posterior tooth.
 Advantage -
stabilize more complex fractures
provide indirect fixation

54. Intermaxillary bone pins
 A mono-cortical screw is placed through the mucosa
between the canine and first premolar on each side
and jaw.
 The screws are then wired together with elastic bands.
 The path of the screw should enter the bone and avoid
the roots of teeth.
 These screws are brittle and care must be taken while
inserting them .

55. External fixation
Indication:-
 patients with gross tissue loss ( seen in war and for
those with pathological fractures,)
 patient is too unwell to undergo extensive surgery.
Method –
Placement of corti-cal screws and then connecting
them with an external bar made of acrylic.

56. Internal fixation
 ACCESS:-
Intra-oral incisions
 bone plates are placed through an intra-oral
approach.
 Mucogingival incisions are made – flap includes the
periosteum
 Care must be taken- damage to mental nerve.

57. Extra-oral incisions
 External incisions
 use - for the lower border of the mandible and
condylar neck.
 Lower border plates are ideal when there is gross
comminution or tissue loss.
 Incision - made two finger-breadths below the lower
border of the mandible in order to avoid damage to the
mandibular branch of the facial nerve.
 Condylar neck fractures are approached through a
retro-mandibular incision .
 Higher condylar neck fractures are better exposed
through a pre-auricular incision .

58. 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
 anterior open bite.
 infra-orbital nerve sensory deficit
 bruising at the junction of the hard and
soft palate

59. 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

60. 1.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.

61.  Le Fort 2 (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.

62.  Le Fort 3 :-
 Disconnection of the facial skeleton from the cranial
base.
 The fracture traverses the medial wall of the orbit to
the superior orbital fis-sure 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.

63.  Le Fort classification is attractive and accu-rate for
low-energy injuries, in high-energy injuries there are
very few instances of pure Le Fort fractures and most
configurations involve multiple Le Fort
levels,33together with zygomatic and
nasal/nasoethmoid com-ponents.

64. Signs and symptoms
 •epistaxis .
 •circumorbital ecchymosis.
 •facial oedema.
 •surgical emphysema.
 •lengthening of the face.
 •infraorbital anaesthesia.

65. Management
 Emergency Treatment
 It can compromise the airway with torrential epistaxes
and posterior impaction of the maxilla.
 The bleeding can be arrested by using epistats or
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

66. REDUCTION
 The maxilla is mobilized by a combination of digital
pres-sure and traction on arch bars or interdental
wires.
FIXATION
 Internal fixation with 1.3 or 1.5mm, low-profile
miniplates placed along the buttresses .
 Subperiosteal elevation with preser-vation of the
infraorbital nerve allows reconstruction of the
paranasal and zygomatic buttresses

67.  .
The infraorbital rim needs to be reduced and fixed in Le
Fort 2 maxillary fractures, nasomaxillary fractures,
zygomatic injuries and orbital floor repairs.

68. 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 .

69. ‘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.

70. 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.
 frontozy-gomatic suture - tender .
 In arch fractures -palpable depression
and limited mouth opening.
 Altered sensation of the cheek.

71. 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.

72. 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.

74.  GILLIES TEMPORAL APPROACH:-
 Small incision is made down to the superficial
temporal fascia.
 The fascia is then incised and an elevator is passed
down on the temporalis muscle so that its tip lies just
under the fracture.
 The bone is then elevated.

75.  POSWILLO HOOK:-
 The point of application of the hook is the
intersection of a line drawn vertically from the lateral
orbital margin and a horizontal line drawn from the
inferior margin of the nose.
 The hook is inserted through a stab incision and the
zygoma lifted back into position

76. INTRA-ORAL OR KEEN APPROACH
 mucogingival incision is made in the buccal sulcus in
the molar/premolar region.
 An elevator may be passed behind the zygomatic body
to elevate the fracture.

77. Post-operative care
 The patient is instructed not to blow their nose ,
 For the first 12 hours, they should be closely observed for
signs or symptoms of a retrobulbar haemorrhage.
 Increasing pain,
 Proptosis,
 Ophthalmoplegia,
 Diminishing visual acuity
 Loss of light reflex
 Dilated pupil
 Palpable increase in ocular pressure indicate the need for
urgent exploration and evacuation of any haematoma.
 long-term complications - malunited fractures.

78. 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

79. 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

80. Naso orbito ethmoid fractures
 Definition and classification
 It involve the ana-tomical confluence of the nose,
orbits and ethmoids.
 Markowitz et al classified NOE in terms of their
attachment to the medial canthal ligaments

81. 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

82. Management
Type I fractures :
 stabilized using miniplates.
 Surgical access is through a coronal flap, intra-orally and
lower eyelid incisions may be required.
 Type II 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

83. THANK YOU