nasal bone fracture

1. FRACTURE OF NASAL BONE
&
FACIAL BONE AND ITS
MANGMENT
DR V SANKAR NAIK
ENT PG(2nd year)
NMCH

2. NASAL BONE FRACTURE
• Nasal bone fractures results delays in management can result result in
significant cosmetic and functional deformity.
• Compound and communicated fractures are more common in elderly
who are prone to fall.
• CLASSIFICATION:
• 1.Nature of injury
• 2.Extent of deformity
• 3.Pattern of fracture

3. NATURE OF INJURY:
• Most of fractures results from laterally applied forces greater than
66% .
• Frontal injury fractures for only 13%.

4. EXTENT OF DEFORMITY:
• A five points Grading system has been developed for the extent of
lateral deviation of the nasal pyramid.
Grade 1: Straight nasal bones
Grade 2: Nasal bone deviated less than half the width of the nasal
bridge
Grade 3: Nasal bone deviated half to full width of nasal bridge
Grade 4: Nasal bone deviated more than full width of nasal bridge
Grade 5: Nasal bone in contact with cheeks

5. PATTERN OF FRACTURE:
• Nasal fracture are divided into three classes
• Class 1:
• Frontal blow to nose leading to depression/ displacement of the distal
part of the nasal bone .
• This fracture was first described by CHEVALLET and BEARS.
• In children, these fractures may be of the greenstick variety and
significant nasal deformity

6. • Class 2:
• Lateral blow to nose leading to lateral deviation of bony nasal
pyramid .
• Involves nasal bones, septum , frontal process of maxilla .
• Displacement: Ethmoidal labyrinth and orbital.
• It is a C-shaped fracture .
• As a rule of thumb, if the nasal dorsum is deviated laterally greater
than half the width of the nose [grade 2].

7. • Class 3:
• High-energy injury to nose leading to complex fracture extending to
ethmoidal bone . Perpendicular plate of ethmoid may rotate
backward. Nasal tip may rotate upward.
• Accompanied saddle nose deformity gives “pig like” appearance.
• Medial canthal ligament may get disrupted and lead to telecanthus.

8. • Two categories of naso-orbital –ethmoidal fractures.
• Type 1: The anterior skull base, posterior wall of the frontal sinus and
optic canal remain intact.
• Type 2: There is disruption of posterior frontal sinus wall , multiple
fractures of the roof of ethmoid and orbit that may extend posteriorly
to the spenoid and parasellar regions.

9. TYPES OF NASAL BONE FRACTURES:
• Two types :
1: Depressed :they are due to frontal blow
lower part of nasal bones which is thinner ,easily gives
way,a severe blow will cause OPEN BOOK FRACTURE in which nasal
septum collapsed and nasal bones splayed out
Still greater forces cause communication of nasal bones and even the
frontal frocesses of maxilla with flattening and widening of nasal
dorsum

10. • 2: ANGULATED FRACTURES:
• A lateral blow cause may cause unilateral depression of nasal bone on
the same side or may fracture both the nasal bone and septum with
deviation nasal bridge
• Septal hematoma may form.

11. CLINICAL FEATURES
• Pain
• Swilling appears within hours and hides the defect
• Nasal obstruction
• Bleeding from nose and external wound
• Nasal deformity
• Periorbital ecchymosis
• External lacerations ,exposure of nasal bones and cartilage in coumpound
fractures
• Tenderness ,crepitus , and mobility of fractured fragments
• Sepatal deviation/hematoma

12. Diagnosis
Physical examination
X- ray –AP and PA VIEW

13. TREATMENT
• Depends on the duration of the injury.
• If the patient present immediately before the swelling over the nose
appears ,surgical intervention with reduction of the fracture can be
done immediately using a Asch’s and spencer well forceps after
disimpaction of the fractured bone followed by realignment by using
digital pressure [Walsham’s forceps].
• If swelling has already appeared over the nose, the fracture reduction
should be delayed until the swelling subside. After 7 to 14 days
fracture can be reduced .
• For delayed, neglected , manipulated fractures rhinoplasty is
required.

14. • The face can be divided into three regions :
• 1. upper third- above the level of supraorbital ridge.
• 2. middle third- between the supraorbital ridge and the upper teeth
• 3. lower third- mandible and the lower teeth .

15. FRACTURE OF THE FACE
• 1. UPPER THIRD:
Frontal sinus
supraorbital ridge
frontal bone

16. • 2.Middle third :
• nasal bones and septum
naso-orbital area
-zygoma
-zygomatic arch
-orbital floor
-Maxilla
Le fort I {transverse}
Le fort II {pyramidal}
Le fort III {craniofacial dysjunction}

17. • 3.Lower third :
Alveolar process
Symphysis
Body
Angle
Ascending ramus
Condyle
Temporomandibular joint.

18. LE FORT’S FRACTURES :
• 1.Le fort I [Guerin’s fracture]:
• This is a low transverse fracture of the maxilla involving the palate
only and is characterized by mobility or displacement of the maxillary
dental arch and palate , dental malocclusion is usually present .
• The fracture line involves lower part of the maxilla, which runs along
the lower edge of the pyriform aperture extending further to the
alveolar process of maxilla and finally to the lower part of the
pterygoid process of the spenoid bone .
•

19. • Le fortII [ pyramidal fracture]:
• This is the commonest type of le fort fracture.
• It involves fracture en block of the palate and middle third of the
nose, including the nose.
• The fracture line starts from at the mid-part of the nasal bone
extending to the lacrimal bone and orbital floor and the infraorbital
margin. It runs onto the zygomaticomaxillary suture line and extends
further laterally to the mid-portion of the pterygoid process.
• This commonly occurs following road traffic accidents and is often a
complex fracture, as a result of more severe trauma.

20. • Le fort III: [craniofacial dysjunction]
• This is a type fracture where the bony framework gets completely
separated from its cranial attachment[craniofacial dysjunction] and is
usually as a result of severe frontal violence and is often fatal.
• The fracture line starts from the root of the nose and extends along
the nasofrontal , maxillofrontal ,zygomaticofrontal and
ethmoidofrontal suture lines. It then extends to the upper part of the
pterygoid process of the sphenoid bone .
• The entire zygomaticomaxillary complex may be mobile and
displaced.

21. SYMPTOMS:
• Facial swelling
• Facial deformity
• Malocclusion
• Epistaxis
• Elongated face
• Nose block
• CSF rhinorrhea may be present in type three fractures
• Diplopia and other orbital symptoms may be present in type 2 and 3
fractures
• Infraorbital parasthesia especially in type 2 fractures.

22. SIGNS:
• Orbital ecchymosis, proptosis, limitation of extraocular movements may be
present in types 2 and 3.
• Malocclusion
• Periorbital edema
• Dish face deformity in types 2 and 3
• Step deformity
-At the orbital rim and nasal bones in type 2
-At the nasal bones in type 3
-pyriform aperture and palatal region in type 1.
.Crepitus on palpating/moving the fractured segments.
.Trismus may be present and more common in type 2 and 3 due to spasm of
pterygoid muscles.

23. INVESTIGATIONS:
• X- ray skull lateral views and x-ray PNS – occipito-mental and
occipitofrontal views. Submentovertical [base skull] view is valuable
but should be taken only after ruling out fracture of the cervical
spine.
• X-ray nasal bones.
• CT scan with 3D reconstruction
• Nasal endoscopy is usefull in the evaluation of CSF rhinorrhea.