Nasal and Nasal Complex Fractures Primary Management Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Introduction The upper midface area comprises mainly the nasoorbito- ethmoidal (NOE) region which plays a paramount role in facial expression. Fractures of this area often result in neglected bony defects in the fragile periorbital region with major secondary impairments such as traumatic telecanthus , orbital dystopia, and/or enophthalmos. Permanent cranial nerve deficits also can occur as the result ofMASUDI:BDS.HDD.FIBMS.post-traumatic/post-operative Dr.GALIB http://galibmas.blog.com squaele. Nasal fractures represent the third most commonly broken bone in the body and the most commonly facial bone to be fractured in association with other facial bone in multiple trauma of the face, high percentage of nasal fractures are subclinical or undiagnosed or treated at the time of injury, if it remains untreated or improperly treated a significant long term functional and cosmetic problems may result Aims of study •To review the primary evaluation and surgical intervention of these injuries . •To review the operative techniques used for NOE reconstruction of these injuries according to the etiology . •To review the complication encountered in the intermediate phase .Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com •To figure out a classification system that best serves the clinician for diagnosis and management NOE Fractures. •To evaluate trauma patients to the general attendance to the emergency dep. And out patients clinic in relation to Maxillo facial specialty because of the special type of conflict in our country. Meterial & Methods In this retrospective study which extended from January,2,2007 to January ,2,2008 ,including 721 patients referred as in patients to the Tenth Floor ,Specialized Surgeries Hospital ,patients referred from emergency Dep. Medical City and out patient clinic Specialized Surgeries Hospital of Maxillo _Facial Dep. ,age of the patients range Dr.GALIB MASUDI:BDS.HDD.FIBMS.from 6 months to 81 years ( male 498, female 223), from http://galibmas.blog.com these cases Nasal and Naso Orbito Ethmioldal injuries were 53 (42 male , 11 female ) ages ranging from 6 years to 68 years ,mean age was 30.9 years ,of these 6 patients pure Nasal injuries exclusively due to assaults* ( 4 male,2 female) because closed Nasal fractured are referred to ENT Dep. ,47 patients NOE fractures were treated in our dep. In accordance with early trauma repair protocol. Research Chart. Personal information : Name: Address: Date of admission: Age: Tel. No: Sex: Occupation: Date of discharge: Preoperative information: Medical history: Cause of injury: Radiographic investigations: Laboratory investigations: Operative information; Dr.GALIB 1;Type of NOE fracture or nasal fracture: 2;Surgical approach: 3;Type of graft used for reconstruction: a; Autogenous bone graft: b; Allograft: 4;Time of the operation: 5;Intraoperative complication; 6;Type of suture material: MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Postoperative information: Numerical rating scale: 0 1 2 3 No complications : Postoperative follow up : 4 5 6 7 8 9 10 Worst possible Complications: Criteria for early trauma repair Traditionally NOE fractures are associated with other facial bones fractures in term of multiple trauma of the head and neck, there are some to be put to clarify their relations to this types of injuries, surgical approaches to these injuries is Dr.GALIB MASUDI:BDS.HDD.FIBMS.staged repair involving early neurosurgical http://galibmas.blog.com procedures and debridement of bone fragments , dural repair and closure soft tissue laceration followed by delayed facial repair. Nasal injuries: Surgical anatomy: A: Osseous framework: External: Internal: B: Cartilaginous framework: External: Internal Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Classification of superficial appearance of the nose: Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Classification of nasal injuries Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Radiology & Ultra sonography Plain radiological view A:Waters viewDr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com B: Lateral view Computed Tomography (C.T. scan) Ultrasonography Isolated nasal injuries: Clinical evaluation & intervention: Lateral nasal injuries Anterior nasal injuries Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Naso ethmoidal fractures Surgical anatomy of NOE Clinical assessment Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Classification of naso ethmoidal injuries Isolated bilateral nasoethmoidal fractures Isolated unilateral nasoethmoidal injuries Combined naso ethmoidal injuries Combined unilateral nasoethmoidal injuries Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Radiological assessment of nasoethmoidal injuries Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Surgical approach Through an existing laceration H shaped approach Dr.GALIB MASUDI:BDS.HDD.FIBMS.Bilateral Z approach http://galibmas.blog.com Midline vertical approach W shaped approach Coronal approach Midface degloving Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Technique for repair The bony skeleton The frontal process of the maxillary bone Nasal cap Dr.GALIB MASUDI:BDS.HDD.FIBMS.The medial canthal ligament http://galibmas.blog.com Nasolacrimal system Management of orbital involvement associated with NOE fractures Orbital Bony Anatomy Midfacial Buttresses Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Orbital hemorrhage Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Cases Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Extensive NOE injury due to terrorist attack by explosive car Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Isolated NOE injury Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com NOE injury associated with foreign body Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Extensive NOE injury Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Results It is difficult to obtain acceptable classification of NOE fractures based on clinical or radiological presentation because of intermingling between the thin bony frame work and the covering soft tissues(Manson1985) . C N S deficit mostly associated with RTA injuries while eye ball involvement mostly associated with injuries caused by assaults (graph 3.4) high percentage of trauma patients in relation to general attendant reflecting the special type of conflict in our country(Trauma patient to general attendance 58%). Primary management of well selected patients depend on criteria of Dr.GALIB MASUDI:BDS.HDD.FIBMS.early trauma repair lead to good cosmetic and functional results ,no http://galibmas.blog.com age groups are spared from the conflict and assaults,the preponderance of male to female ratio because of responsibility of the male to his family in our society ,an overview of the causality indicate mixed type of injuries and multi directional forces that caused most of the injuries due to combination of war ,crime, civil unrest and terrorist attacks . Most complication resulted from extensive injuries associated with CNS deficit which need delay in treatment more than 10 days allowing time for the thin fragile fragments of bone to undergo resorbsion and start fibrosis which interfere with realignment of the pieces to obtain good cosmetic and functional results . Statistical Analyses Time 2\1\2007-2\1\2008 Total number of patients 721(Male 498 ,Female 223) Age 9 months – 81 years N + NOE 53(Male 42,Female 11) Age 6-68 years(mean age 30.9 years ) Trauma patients 422(Male 314,Female 108) N +NOE : total no. 7.3% N+NOE :trauma patient 12.5% Dr.GALIB MASUDI:BDS.HDD.FIBMS.Trauma patients : total no. of patients 58.5% http://galibmas.blog.com Male : Female (of referred patients ) 2.23:1 Male : Female(of N+NOE fractures) 2.9:1 Pure Nasal injuries 6 (male 4, female 2) NOE total 47 RTA 17(male 11,female 6)ratio M: F (1.8 : 1) Assaults 36 (male 26 , female 10) ratio M:F (2.6 : 1) Eye ball involvement 20 Spared eye ball 16 Unilateral involvement of the eye ball 14 Bilateral involvement of the eye ball 6 0 General Maxillo facial attendence 299 0 Trauma Patients 422 Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Trauma Patients General Maxillo - facial attendence ,0 Nasal & NOE injuries, 53 Total No. of the patients, 721 Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Total No. of the patients Nasal & NOE injuries Nasal & NOE injuries, 53 ,0 Trauma patiens, 422 Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com Trauma patiens Nasal & NOE injuries Bilateral eye ball envolvment 6 Unilateral envolvment 14 Eye ball enolvment 20 Dr.GALIB MASUDI:BDS.HDD.FIBMS.Spared eye http://galibmas.blog.com ball 16 800 700 Male 600 Female Total no. 500 Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com 400 300 200 100 0 Total no. of patients Trauma patients Nasal & NOE injuries Nasal 40 35 30 25 20 Dr.GALIB MASUDI:BDS.HDD.FIBMS.http://galibmas.blog.com 15 Total No. Female 10 Male 5 0 RTA Assaults Discussion From simple nasal fractures to minimal ethmoid involvement through grossly comminuted fractures with displacement ,all should be considered compound.(Michael, G. ,Stewart 1993). Gold standard of care for patients with NOE injuries begins with careful clinical evaluation ,detailed radiological examination ,careful ophthalmic examination and Dr.GALIB MASUDI:BDS.HDD.FIBMS.secondary special examination ,particularly to verify the http://galibmas.blog.com function of the lacrimal apparatus ,clinical examination may be difficult due to edema or emphesima ,the traumatic telecanthus and traumatic hypertolerism ,it may be helpful if the surgeon can correlate intercanthal distance to the interpupiliry distance ,distraction test ,CSF leak and the integrity of commonly damaged structures like cornea ,lens ,retina ,EOM movement ,optic nerve function ,ocular reflexes ,swinging light test ,examination of lacrimal apparatus, globe position. Conclusions Fracture healing is a dynamic affair that coordinate a host of complex interacting mechanisms then remarkable repair processes highlight the powerfull regenerative abilities of fracture bone which can culminate in restoration of the damage partDr.GALIB to a MASUDI:BDS.HDD.FIBMS.near anatomical state . http://galibmas.blog.com •Macroscopic aspects of fracture repair. •Fracture healing and bone graft repair. •Histological aspects of fracture repair. • Biochemical and molecular aspects of bone healing . Suggestions •Although the treatment of facial injuries has made dramatic advances of the last decade due to improvement in the knowledge of wound healing , anatomy diagnostic testing and bio- material ,the optimal management of patients who have sustained multiple facial trauma associated with nasal complex fractures need collaborative interdisciplinary approach that incorporates the clinical expertise of number relative specialties . Dr.GALIB MASUDI:BDS.HDD.FIBMS.- •the growth of tertiary trauma centers had two important consequences, http://galibmas.blog.com severely injured patient are now able to survive there initial physical insult and will require reconstruction of devastating facial injuries and interdisciplinary team can acquired greater experience with managing complex facial trauma because it is challenging to repair, reflecting the interacted nature of the relevant anatomy and the nessacerity of exquisite attention to the detailed required for surgical intervention to restore preinjured appearance and post traumatic deformities which are profound and problematic.