#nasal bone

29
NASAL BONE NASAL BONE FRACTURES FRACTURES GRAND ROUNDS GRAND ROUNDS DR. ASHISH GUPTA DR. ASHISH GUPTA

Upload: charan-kanwal

Post on 08-Apr-2015

421 views

Category:

Documents


3 download

TRANSCRIPT

Page 1: #Nasal Bone

NASAL BONE NASAL BONE FRACTURESFRACTURES

GRAND ROUNDSGRAND ROUNDS

DR. ASHISH GUPTADR. ASHISH GUPTA

Page 2: #Nasal Bone

HistoryHistory

Chote SinghChote Singh 37yr/ Male37yr/ Male ElectricianElectrician LudhianaLudhiana H/O Fall from height on 10H/O Fall from height on 10thth Aug’08 Aug’08 H/O Nasal & Oral bleedH/O Nasal & Oral bleed

Page 3: #Nasal Bone

On ExaminationOn Examination

Laceration Bridge of nose 1x1cmLaceration Bridge of nose 1x1cm Edema face mid thirdEdema face mid third Crepitus +Crepitus + Maxilla/ Mandible- NormalMaxilla/ Mandible- Normal Systemic Examination: Systemic Examination:

ChestChest CVSCVS P/AP/A Skull & SpineSkull & Spine Skeletal SystemSkeletal System

Page 4: #Nasal Bone

Nasal FracturesNasal Fractures

Most common of all facial Most common of all facial fractures.fractures.

Injuries may occur to other Injuries may occur to other surrounding bony structures.surrounding bony structures.

3 types:3 types: DepressedDepressed Laterally AngulatedLaterally Angulated ComminutedComminuted

Page 5: #Nasal Bone
Page 6: #Nasal Bone
Page 7: #Nasal Bone

Facial Bone FracturesFacial Bone Fractures

TYPETYPE Closed Closed OpenOpen GreenstickGreenstick ComminutedComminuted UndisplacedUndisplaced DisplacedDisplaced

LOCATION:LOCATION: Upper FaceUpper Face Middle thirdMiddle third Lower third Lower third

(Mandible)(Mandible)

Page 8: #Nasal Bone

LocationLocation

Upper FaceUpper Face Frontal Frontal Temporal Temporal Frontal sinusFrontal sinus Supraorbital Supraorbital

ridgeridge

Middle thirdMiddle third Nasal bone & Nasal bone &

septumseptum Maxillary sinusMaxillary sinus Orbital boneOrbital bone ZygomaZygoma Zygomatic archZygomatic arch Maxilla (Leforte Maxilla (Leforte

I, II, III)I, II, III) Alveolar Alveolar

ProcessProcess Maxillary Maxillary

DentitionDentition

Mandible

• Dentition

• Alveolar Process

• Symphysis

• Corpus/ body

• Angle

• Ascending ramus

• Condyle

• Coronoid process

Page 9: #Nasal Bone

CLASSIFICATION OF CLASSIFICATION OF FRACTURES ON AN FRACTURES ON AN

ANATOMICAL BASISANATOMICAL BASIS

CENTRAL REGIONCENTRAL REGION

1. Fractures of Nasal 1. Fractures of Nasal bones &/or nasal bones &/or nasal septum-a)Lateral nasal septum-a)Lateral nasal injury b)Anterior nasal injury b)Anterior nasal injuryinjury

2. Fractures of the frontal 2. Fractures of the frontal process of the maxillaprocess of the maxilla

3. Fractures of types 1 & 2 3. Fractures of types 1 & 2 which extend into which extend into ethmoid boneethmoid bone

4. Fractures of types 1, 2 4. Fractures of types 1, 2 & 3 which extend into & 3 which extend into the frontal bonethe frontal bone

LATERAL REGIONLATERAL REGION

1. Fractures involving 1. Fractures involving Zygomatic bone, arch & Zygomatic bone, arch & Maxilla, Excluding dento-Maxilla, Excluding dento-alveolar componentalveolar component

FRACTURES NOT INVOLVING THE OCCLUSION

Page 10: #Nasal Bone

FRACTURES INVOLVING THE FRACTURES INVOLVING THE OCCLUSIONOCCLUSION

Dento- Alveolar FracturesDento- Alveolar Fractures Supra-Zygomatic:Supra-Zygomatic:

Le Forte III (High level or Craniofacial Le Forte III (High level or Craniofacial dysjunction)dysjunction)

Sub-Zygomatic: Sub-Zygomatic: Le Forte I (low level or Guerin)Le Forte I (low level or Guerin) Le Forte II (Pyramidal) Le Forte II (Pyramidal)

Page 11: #Nasal Bone

a. a. Nasal bonesNasal bones Depressed #Depressed #

due to frontal blowdue to frontal blow

““open book #”open book #” Angulated #Angulated #

due to lateral blowdue to lateral blow

UL depression of BL UL depression of BL # with deviation of # with deviation of nasal bridgenasal bridge

b.b.SeptumSeptum

buckling, buckling, dislocation, #dislocation, #

Page 12: #Nasal Bone

Depressed -Unilateral or Depressed -Unilateral or bilateralbilateral

Open book- ChildrenOpen book- Children Fracture at jn. of thick Fracture at jn. of thick

upper & thin lower portionsupper & thin lower portions ComminutedComminuted Fracture dislocationFracture dislocation Comminuted fractures with Comminuted fractures with

fracture of frontal process fracture of frontal process of maxillaof maxilla

TYPES:TYPES:

Page 13: #Nasal Bone

Pathophysiology:Pathophysiology:

Blunt Trauma: Most CommonBlunt Trauma: Most Common Vehicular accidentsVehicular accidents AltercationsAltercations Sports-related traumaSports-related trauma Occupational injuriesOccupational injuries FallsFalls Animal BiteAnimal Bite

Penetrating Trauma:Penetrating Trauma: Gunshot woundsGunshot wounds StabbingsStabbings ExplosionsExplosions

Mass, density, and shape of the striking object, Mass, density, and shape of the striking object, as well as speed of impact, directly affect type as well as speed of impact, directly affect type and severity of facial injury.and severity of facial injury.

Page 14: #Nasal Bone
Page 15: #Nasal Bone

Mechanism of Septal InjuryMechanism of Septal Injury

Page 16: #Nasal Bone

Clinical FeaturesClinical Features

1.1. Depression/ angulationDepression/ angulation

2.2. Periorbital ecchymosisPeriorbital ecchymosis

3.3. EpistaxisEpistaxis

4.4. TendernessTenderness

5.5. CrepitusCrepitus

6.6. Loss of Pyramidal supportLoss of Pyramidal support

7.7. Septal deviation/ obstruction (hematoma)Septal deviation/ obstruction (hematoma)

8.8. Tenderness at base of columellaTenderness at base of columella

Page 17: #Nasal Bone

Nasal FracturesNasal Fractures

Ask the patient:Ask the patient: ““Have you ever broken your nose Have you ever broken your nose

before?”before?” ““How does your nose look to you?”How does your nose look to you?” ““Are you having trouble breathing?” Are you having trouble breathing?”

Page 18: #Nasal Bone

Conventional X-Ray Conventional X-Ray ExaminationExamination

Lateral view of Nasal bonesLateral view of Nasal bones Occlusal view of nasal bonesOcclusal view of nasal bones

Page 19: #Nasal Bone

OCCLUSAL VIEW LATERAL VIEW

Page 20: #Nasal Bone

# site# site Nasal BoneNasal Bone

SymptomsSymptoms Nose is crookedNose is crooked

Nose bleedNose bleed

Physical findingsPhysical findings DeformityDeformity

EpistaxisEpistaxis

EcchymosisEcchymosis

CrepitusCrepitus

X- RaysX- Rays Nasal bone- lateral & Occlusal viewsNasal bone- lateral & Occlusal views

DiagnosisDiagnosis

Page 21: #Nasal Bone

TreatmentTreatment

Closed reductionClosed reduction: : Unilateral or bilateral fracture of the nasal bones Unilateral or bilateral fracture of the nasal bones Fracture of the nasal septal complex that is Fracture of the nasal septal complex that is

deviated less than one half of the width of the nasal deviated less than one half of the width of the nasal bridgebridge

Open reduction:Open reduction: Extensive fractures Extensive fractures Deviation of the nasal pyramid greater than one Deviation of the nasal pyramid greater than one

half of the width of the nasal bridge half of the width of the nasal bridge Displaced fracture of the caudal septum Displaced fracture of the caudal septum Open septal fracture Open septal fracture

Page 22: #Nasal Bone

Manual ReductionManual Reduction

Page 23: #Nasal Bone

Closed reductionClosed reduction

Ice packs and head elevationIce packs and head elevation If the reduction is not to be performed If the reduction is not to be performed

immediately, then a period of 3-5 days immediately, then a period of 3-5 days precedes further evaluation. precedes further evaluation.

Fractures that are not displaced do not Fractures that are not displaced do not require treatment. require treatment.

30% of patients have a deviation that was 30% of patients have a deviation that was present prior to injury, in many cases, present prior to injury, in many cases, obtaining photographs for review is helpful obtaining photographs for review is helpful

Page 24: #Nasal Bone

Closed ReductionClosed Reduction

Page 25: #Nasal Bone
Page 26: #Nasal Bone
Page 27: #Nasal Bone

Open reduction: Plating/ Wire Open reduction: Plating/ Wire fixationfixation The septum is the key The septum is the key

structure that may prevent structure that may prevent the reduction of the nasal the reduction of the nasal pyramid. In patients in whom pyramid. In patients in whom the septal fragments are the septal fragments are interlocked, the inability to interlocked, the inability to reduce the septum results in reduce the septum results in the bony pyramid remaining the bony pyramid remaining deviated. deviated.

Approach: Approach: Hemitransfixion. Hemitransfixion. Raise mucoperichondrial flaps. Raise mucoperichondrial flaps. Access the dorsum by bilateral Access the dorsum by bilateral

intercartilaginous incisions. intercartilaginous incisions. Elevating the periosteum off Elevating the periosteum off

the nasal bones because the the nasal bones because the fractured segments may fractured segments may become unstable, devitalized, become unstable, devitalized, or lost or lost

Page 28: #Nasal Bone

COMPLICATIONS COMPLICATIONS

EARLYEARLY LATELATE

EdemaEdema Subperichondraial fibrosis Subperichondraial fibrosis

Ecchymosis Ecchymosis Thickening of septum Thickening of septum

EpistaxisEpistaxis Synechiae b/w septum & turbinates Synechiae b/w septum & turbinates

Partial nasal obstructionPartial nasal obstruction

Hematoma Hematoma Obstruction of nasal vestibuleObstruction of nasal vestibule

InfectionInfection OsteitisOsteitis

MalunionMalunion

Page 29: #Nasal Bone

To Operate or Not To????To Operate or Not To????