Definition of NOE fracture?

o Must involved the portion of bone where the medial canthal tendon attaches;

the frontal process of the maxilla provides the main structural support

Classic physical exam findings?

o Flattened nasal dorsum, telecanthus (pseudohypertelorism), periorbital

swelling, bowstring sign, epistaxis (bleeding from ethmoid a.) +/- epiphora.

Must look for a CSF leak.

What is the difference between hypertelorism and telecanthus?

o Telecanthus is a widenting of the distance between the medial canthal

tendons while hypertelerism denotes a wider inter-globe distance.

Normal intercanthal distance in adult? Rough rules of thumb to remember?

o 30-35mm. The distance should be approximately half the interpupillary

distance; the distance between the medial and lateral canthal tendon on one

side should approximate the intercanthal distance.

What is the bowstring sign?

o Used to determine the integrity of the medial canthal tendon

attachment. After grasping the medical canthal tendon and pulling laterally,

the tendon should normally "snap back". Increased laxity may mean

traumatic discontinuity.

Relationship of the medial canthal tendon and the lacrimal sac?

o The lacrimal sac rests in the lacrimal fossa and sits between the attachments

of the medial canthal tendon

How do you evaluate for associated injury to the nasolarcrimal apparatus?

o Use the Jones I (direct dye) & II (indirect dye) Test. Jones 1: Place dye (or

fluroscene) drops to the eye and a white cotton nasal pledget under the

inferior turbinate. Watch for 5 minutes and if dye conducts to the pledget than

no obstruction exists. If no dye passes, then go on to a Jones II Test. Jones

II: The punctum is antesthetized and dilated and an irrigating catheter is used

to wash normal saline through the system. If dye and saline is collected on

the pledget, then a partial or incomplete obstruction is seen. If no irrigant is

trasmitted, then a total obstruction should be documented.

Gold standard imaging in evaluation of NOE fractures?

o Thin cut (1.5mm) CT of midface

Treatment of persistent epiphora?

o DCR. About 1/5 of patients eventually require DCR.

Describe the classification system of NOE fractures described by Markowitz

and Manson.

o Classification revolves around the integrity of the medial canthal tendon and

its attachment ("central fragment"). Type I: single noncomminuted central

fragment without medial canthal tendon disruption. Type II: involves

comminution of the central fragment, but the medial canthal tendon remains

firmly attached to a definable segment of bone Type III: uncommon and result

in severe central fragment comminution with disruption of the medial canthal

tendon insertion.

Goals of surgery.

Protection of orbital and intracranial contents, prevention of epiphora, and restoration of

normal intercanthal distance. The success of the surgery hinges on the insertion of the

medial canthal tendon onto the bony central fragment.