2. Trauma to face:
the face can be divided into three regions:
Upper third: above the level of supraorbital ridge.
Middle third: between the supraorbital ridge and the upper teeth.
Lower third: mandible and the lower teeth.
3. Nasal fractures
Introduction:
Treatment of nasal fractures was first recorded 5000 years ago by ancient Egypt.
The Edwin smith describes repositioning of deviated nasal bones with the fingers or
elevators, the insertion of splints and the application of external dressing.
Isolated fractures of the nasal pyramid account for about 40% of all facial fractures.
Fractures of nasal bones are often sustained along with other fractures of the facial
skeleton.
Delays in management can result in significant cosmetic and functional deformity.
4. Epidemiology and aetiology:
Relatively little force is required to fracture the nasal bones.
The peak incidence is in the 15--30-year age group when assaults, contact sports and
adventurous leisure activities are more common.
In childhood, fractures are often of a greenstick nature.
Compound and comminuted fractures are more common in the elderly who are prone to
falls.
6. Nature of injury:
Most fractures result from laterally applied forces (>66%).
Fractures following frontal injuries account for only 13%.
Greater force is required to fracture the nose with a blow directed from the front as the nasal
cartilages behave like shock absorbers.
7. Extent of deformity:
A five-point grading system has been developed for the extent of lateral deviation of 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 the 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.
8. Pattern of fracture:
subdivided into three broad categories.
This classification has some practical utility as each category of fracture requires a
different method of treatment.
Class 1 fractures:
results from low-moderate degrees of force.
In low degree force, the fractured segment usually remains in position due to its inferior
attachment to the upper lateral cartilage.
In moderate variant, both nasal bones and the septum are fractured
Class 1 fractures does not cause gross lateral displacement of the nasal bones.
9. Class 2 fracture:
Are the result of greater force and are often associated with significant cosmetic deformity.
In addition to fracturing the nasal bones, the frontal process of maxilla and septal structures
are also involved.
A frontal impact comminutes the nasal bones and causes gross flattening and widening of
the dorsum.
Characterized by:
The septum and nasal bones will need to be reduced to obtain a cosmetically acceptable
result.
The ethmoid labyrinth and adjacent orbital structures should be intact.
A lateral impact produces a high deviation of nasal skeleton.
10. Class 3 fracture:
The most severe nasal injuries encountered and result from high velocity trauma.
The external buttresses of the nose give way and the ethmoid labryninth collapse on itself. This causes
the perpendicular plate of the ethmoid to rotate and the quadrilateral cartilage to fall backward.
Causing a classic, *pig-like* appearance to the patient.
Two categories of naso-orbito-ethmoid fractures:
1. The anterior skull base, posterior wall of the frontal sinus and optic canal remain intact.
2. There is disruption of the posterior frontal sinus wall, multiple fractures of the base of the skull.
Nasofrontal-ethmoidal fracture may be accompanied by telecanthus that result from injury to
supporting structures of eye.
11. Clinical presentation:
History
► details of how the injury was sustained.
► nasal obstruction.
► change in appearance, a crooked or bent appearance.
► epistaxis.
► hyposmia.
► watery rhinorrhea.
► visual disturbance.
► diplopia.
► epiphora.
► altered bite.
► loose teeth.
► trismus.
13. Investigation:
◦ Unlike other fractures, nasal X-rays are not required to make diagnosis or aid subsequent
reduction.
◦Clinical evidence of a more serious facial injury (CT) scan should be acquired.
◦Samples of any watery rhinorrhea must be collected in those with suspected CSF leak and
tested for beta2 transferrin.
14. Management:
● 80% do not require any active treatment.
● A reexamination about five days later:
when there is uncertainty about the need for reduction because of oedema development.
● Surgical intervention in the acute phase are done when there is:
1.Significant cosmetic deformity.
2.Nasal obstruction caused by a septal fracture and deviation or haematoma.
15. Procedures:
● Closed reduction.
● Open reduction and internal fixation.
● Indications for open reduction:
1- bilateral fractures with dislocation of the nasal dorsum and significant (preexistent or
recent) septal deformity.
2- infraction of the nasal dorsum.
3- fractures of the cartilaginous pyramid, with or without dislocation of the upper laterals.
