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An innovative approach to external fixation of severe nasal bone fractures with orthopedic plates.

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Severely comminuted and compound nasal fractures require careful acute management so that the need for subsequent rhinoplasty does not arise. In these cases, a simple reduction and application of an external cast or splint is inadequate because the corrected bony vault may tend to collapse again. In this article, I describe a simple technique for managing severe nasal bone injuries with good results. Although it is akin to placement of an external hammock nasal splint, this technique has been drastically simplified because it involves the use of commonly available operating room consumables.

A 16-year-old boy presented with a compound and severely depressed fracture of the nasal bones and frontal processes of the maxillae bilaterally after he had been struck with a cricket bat (figure 1). After orbital and intracranial trauma were ruled out, the patient was taken to the operating room and administered general anesthesia.

The fractured segments were disimpacted and realigned into their correct anatomic positions with a Walsham forceps. Two 18-gauge hypodermic needles were passed horizontally across the bony nasal vault, and they acted as conduits for the placement of two 26-gauge stainless-steel wires (figure 2, A). The wires were passed as close to the ethmoid sinuses as possible; care was taken not to damage the lacrimal sac. Because it is generally not possible to effectively palpate the anterior lacrimal crest in a case of severe nasal bone fracture, an estimate of its position was made, based on the position of the medial canthus. The superior wire was passed through the comminuted nasal bone fragments anterior and inferior to the medial canthus, and the inferior wire was passed through the frontal process of the maxillary bone. The needles were then withdrawn, and the wires were left in place.

Over an inner padding made of a folded, cut sheet fabricated from latex surgical gloves, another cut piece of fluoroplastic internal nasal splint was placed on both sides of the bony dorsum. The latter would help dissipate the pressure from the external fixator over a larger area. Cut segments (two holes) of a medium-sized orthopedic stainless-steel plate were used to fashion the external fixation device. This device was placed over the lateral aspect of the bony nasal vault on the fluoroplastic sheets and fixed into position with the previously placed stainless-steel wires (figure 2, B).

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The external fixator assembly was kept in place for 5 days. After it was removed, an external plaster cast was applied over the nose. The cast was removed 10 days later, and good results were seen, as the bony nasal vault regained its normal shape (figure 3).

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The patient experienced an initial loss of epithelium at the puncture site where the hypodermic needles had been inserted, and hyperpigmentation developed at these spots. To overcome this, he was asked to regularly apply Contractubex gel over the area for 2 months, beginning 2 weeks postoperatively. This helped in markedly reducing the hyperpigmentation both at the puncture sites and at the site of his original skin laceration over the nasal dorsum.

Surgeons generally prefer to splint fractured nasal bones internally with absorbable nasal or gauze packing along with a conventional external splint. While this strategy is adequate in cases of simple nasal fracture, it is not recommended in cases of severe and compound nasal fracture because displacement of the packing can cause significant deformity. Nasal packing may also predispose to wound infection. To circumvent this problem, many innovative techniques have been developed, such as a nasal bone clip fabricated from a K-wire, (1) halo external fixation, (2) and the use of bioabsorbable plates (3) and fibrin glue (4) for open fractures. All of these provide satisfactory outcomes. The technique described in this article serves to address the same problem in a simplified manner with the use of commonly available and inexpensive operating room consumables. However, certain key points must be kept in mind: (1) the wires should not be excessively tightened, or else they will push the bone fragments too much medially, and (2) the external fixator should not be kept in place for too long because it might cause pressure necrosis of the nasal dorsum skin.

References

(1.) Kosaka M, Sai K, Shiratake Y, Ohjimi H. Nasal bone clip: A novel approach to nasal bone fixation. J Craniofac Surg 2010;21 (2):552-4.

(2.) Wurman LH, Sack JG, Flannery JV Jr. Halo external fixation of nasal fractures. Laryngoscope 1983;93 (9):1212-16.

(3.) Kim MG, Kim BK, Park JL, et al. The use of bioabsorbable plate fixation for nasal fractures under local anaesthesia through open lacerations. J Plast Reconstr Aesthet Surg 2008;61 (6):696-9.

(4.) Jeong HS, Moon MS, Lee HK, Kim KS. Use of fibrin glue for open comminuted nasal bone fractures. J Craniofac Surg 2010;21(1): 75-8.

Harpreet Singh Kochar, MS

From the Department of ENT-Head Neck Surgery, Kailash Hospital, Greater Noida, Uttar Pradesh, India.
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Title Annotation:FACIAL PLASTIC SURGERY CLINIC
Author:Kochar, Harpreet Singh
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Geographic Code:9INDI
Date:Mar 1, 2011
Words:821
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