NOE FRACTURE PPT

A DETAILED PPT ON NOE FRACTURE AND ITS MANAGEMENT.

1.  Fractures of the middle third of the facial skeleton are known as maxillofacial skeletal injuries and they are associated with varying degrees of injuries of soft tissue.

2. The naso-orbito-ethmoidal region is si t uated in the central up p er mid face consists of a strong triangular frame.

3. Osteology Soft tissue anatomy

4. Nasal bones Ethmoid Frontal process of maxilla Medial orbital rim and wall Other bones involved: Perpendicular and cribriform plate of ethmoid Nasal process of frontal bone. Sphenoid bone.

5. 4 cavities involved: Cranium Orbits Nasal Maxilla STRENGTH Vertical buttress: frontal process of maxilla Horizontal buttress: superior/inferior orbital rims.

6. Superiorly, thin ethmoid bones form part of the floor of the anterior skull base, in this region dural injury and resultant CSF leakage is possible. The ethmoid bone is located posterior to the nasal bones,the ethmoid air cells are present at birth and enlarge to adult size by the age 12 years.

7. The overall growth and size of ethmoid complex is highly variable among individuals. The ethmoid labyrinth separates the orbits from the nasal cavity ,while the fovea ethmoidalis forms the roof of the ethmoid sinuses laterally.

8. Medial ca n thal ligament Lacrimal drainage apparatus Associated vessels.

9. The medial canthal ligament (MCT) is a crucial soft tissue component of NOE complex. It arises from the anterior and posterior lacrimal crest and frontal process of maxilla.

10. MCT surrounds the lacrimal sac and diverges to become the orbicularis occuli muscle., tarsal plate, and suspensory ligaments of eyelids .

11. The tendon splits around the lacrimal sac and attaches to the anterior and posterior lacrimal crests, as well as to the frontal process of maxilla. The canthal tendon diverges to become the pretarsal ,preseptal, and orbital orbicularis oculi muscle.

12. The action of the muscles and telecanthus al low for pumping action of the lacrimal sac and ducts allowing for propagation of tears through nasolacrimal system. In addition, the MCT acts as a suspensory sling for the globe, maintaining its support along with the lateral canthal tendon.

13. Has the potential to be disrupted on a NOE fracture especially a comminuted one . The system consists of a lacrimal glands situated in the superolateral anterior portion of the orbit and two lacrmial canaliculi that drain the eye via puncta that are situated in the medial aspect of each eye.

14. The sac drains into the inferior meatus via the nasolacrimal duct . The duct is around 20 mm in length half of which is bony . The portion of the nasolacrimal system that is most prone to damage is the bony nasolactimal duct.

15. The cribriform plate is loacted approximately 1 cm inferior to the fovea ethmoidalis and it formss the roof of the nasal cavity medially.

16. The horizontal buttress is divided into the superior horizontal buttress and the inferior horizontal buttress, which consists of the frontal bone, superior orbital rims and inferior orbital rims.

17. The medial vertical buttress consists of the internal angular process of the frontal bone and the bilateral frontal processes of the maxilla.

18. The blood supplying for the midface and nasal region comes from the branches of internal and the external carotid arteries . The anterior and posterior ethmoid arteries descend from the internal carotid artery . The maxillary artery from the external carotid artery and subsequent branches play a mainstay role for supporting the midface.

19. The NOE region is innervated by ophthalmic and maxillary nerves, which are derived from the Trigeminal nerve. T RI G EM I N A L NERVE OP T H A L MI C NERVE M A XIL L A RY NERVE

20. The nasal bones and underlying cartilage are susceptible to fractures because the nose maintains a prominent position and central location on the face and because it has a low breaking strength. Patterns of fractures are known to vary with momentum of the striking object and the density of the underlying bone . ( Murray,1994)

21.  As with other facial bones,younger patients tend to have larger nasoseptal fracture segments,whereas older patients are more likely to present with more- comminuted fracture patterns. (Cummings,1998)

22. RTA Sport injuries Fights Work related accidents Falls are the most common cause of nasal injury in children.

23. Violation of the primary buttresses of the NOE complex Comminution of the entire complex may occur Telecanthus,enophthalmos,diplopia, midface retrusion

24. The clinical symptoms associate wit the location and severity of the NOE fracture . Patients with naso-orbito-ethmoidal (NOE) fractures often have associated facial injuries or panfacial fractures.

25.  Gross facial edema may show firstly in the early stage of fracture, which will result in distortion of soft tissue landmarks.

26. Laceration in the nose and forehead. Intracranial involvement. Eye, forehead, and nose pain Forehead paraesthesias Traumatic hypertelorism Mongoloid slant.

27. Flattened nasal bridge with splaying of nasal complex. Saddle shaped deformity of nose from side. Epitaxis. Tenderness ,crepitus and mobility of nasal complex. Nasal injuries:

28. Epitaxis Reduced nasal projection and height. Septal deviation or dislocation. Anosmia caused by damage to the cribiform plate. Nasal congestion secondary to septal hematoma or bony/cartilaginous deformity.

29. Enopthalmus Diploplia Entrapment Vertical dystopia Loss of globe integrity Ass o ciated oc u lar injurie s :

30. Traumatic telecanthus Circumorbital oedema and ecchymosis S u b c o n juctiv a l haemorrhage. Possible supra- orbital/supra trochlear nerve parasthesia.

31. •  Oedema, e m phy s e m a, Echymosis Traumatic tel e c a nthus Orbital dysplasia Rounding of medial canthal angle Mongoloid slant

32. Traumatic telecanthus(IC/IP>1/2) Lack of eyelid tension- positive bowstring test. Rounding of the MCT. Shortened palpebral fissure. Medial canthal tendon displacement

33. For telecanthus to occur ,the fracture must involve at least 4 sites: Medial orbital wall Nasomaxillary butress/inferior orbital rim Nrontomaxillary junction Lateral nasal bone

34. Intracranial involvement :  Cerebrospinal fistula Pnemocephalus CSF rhinorrhoea

35. Fracture of floor of anterior canal fossa/base of skull. Escape of CSF through Ethmoidal sinus Sphenoidal sinus Cribriform plate Frontal sinus

36. Communication between Meninges Nose Paranasal sinuses Dural laceration Later becomes epithelised to Fistula Blood clot of brain tissue may obstruct fluid passage.

37. After lysis of clot or increased intracranial pressure leakage is seen. Mobile midface fractures often creates pumping action –because of increased CSF leakage.

38. How is NOE complex fracture classified? The status of the resulting central segment of bone left by an NOE fracture is the basis of classification of fracture patterns for this type of injury. Each fracture type is sub classified as either unilateral or bilateral. Among many classifications of NOE fractures, the most widely accepted classification system was established by Markowitz et al. .

39. Type I: En bloc with minimum displacement. Type II: En bloc displaced # with large pneumatized sinus and minimum fragmentation. Type III: Comminuted # with inatct MCT attached to large bone. Type IV:comminuted # with free MCT attached to bo n e not large enough for plating. Type V:Gross comminution needing grafting.

40. Isolated NOE and frontal region # without other midface fractures Unilateral Bilateral Isolated NOE and frontal region # with other midface fractures. Unilateral bilateral

41. In this simplest form,NOE fractures are isolated involving only the portion of the medial orbital rim that contains medial canthal tendon. Type I pattern consists of single central fragment bearing the medial canthus.

42. These fractures maybe bilateral ,complete or displaced . Uncommonly ,the medial canthal tendon is torn or avulsed completely from an intact medial bony wall.

43. In unilateral Markowitz type I fractures, there is a single large NOE fragment bearing the medial canthal tendon.

44. Involvement of the nasal bone: the nasal bone may also be involved and, in cases of comminution, may not provide adequate dorsal support to the nasal bridge.

45. Type II fractures are complete and may be unilateral or bilateral . They may be single segment or communited external to the medial canthal insertion in the central segment . MCT maintains continuity with large fractured segment of bone,which maybe used in the surgical reduction.

46. In unilateral type II fractures, there is often comminution of the NOE area, but the canthal tendon remains attached to a fragment of bone, allowing the canthus to be stabilized with wires or a small plate on the fractured segment.

47. The nasal bone may also be involved and, in cases of comminution, may not provide adequate dorsal support to the nasal bridge. Involvement of the nasal bone

48. The illustration shows a bilateral NOE type II fracture. In bilateral fractures the nasal bones are commonly involved. In some instances, bone grafting of the nasal dorsum may be necessary. Bilateral type II fracture with nasal bone involvement

49. Communition within the central fragment allows fracture to extend beneath the canthal insertion characterising the type III fracture pattern . The canthus is rarely avulsed but it is to bone fragments that are too small to utilize in reconstruction.

50. In type III fractures, there is often comminution of the NOE area (as in type II fractures) and a detachment of the medial canthal tendon from the bone.

51. The nasal bones are usually involved and might not provide adequate dorsal support to the nasal bridge. In such cases bone graft reconstruction often is indicated. Involvement of nasal bone

52. The illustration shows a bilateral NOE type III fracture. The nasal bones are usually involved. Bone graft of the nasal dorsum is usually necessary. Bilateral type III fracture with nasal bone involvement

53. Establish ABCs. Diagnose any associated injuries. Direct examination of NOE complex. A thorough head and neck examination to reveal injuries to the brain,spine, orbit and facial skeleton is required. A team approach involving the otolaryngologist,plastic surgeon, neurosurgeon and pohthalmologic consultation is mandatory.

54. Direct examination Diagnostic imaging CT -2D CT -3D CT Dacrocystography

55. Plain radiographs have limited usefulness in aiding in diagnosis of NOE #s. Thin cut axial and coronal CT scans are the criterion standard for the diagnosis of NOE fractures.

56. Examine the nasal cavity for the presence of CSF. Query all conscious patients about the pr esence of watery rhinorrhea or salty postnasal drainage. Test bloody fluid that is suspicious for CSF rhinorrhea (see Lab Studies). Examine facial lacerations under sterile conditions to assess depth of penetration or intracranial violation. To evaluate the integrity of the medial canthal tendon.

57. Measure and document telecanthus and enophthalmos. Assess and document pupil responses and extraocular muscle mobility. Palpate the nasal bones for crepitus and comminution. Evaluate the septum for septal hematoma . Evaluate the degree of nasal or midface retrusion. Preinjury photographs may be helpful.

58. Examine facial lacerations under sterile conditions to assess depth of penetration or intracranial violation.

59. Evaluate the degree of nasal or midface retrusion

60. An intercanthal distance of > 35 mm is suggestive of traumatic telecanthus ,measurement approaching 40mm are almost diagnostic.

61. The patient often has swelling in the medial canthal area and pain and crepitation with palpation.

62. Examine the nasal cavity for the presence of CSF. Query all the patients about the presence of watery rhinnorhea or salty postnasal drainage. Test bloody fluid that is suspicious of CSF rhinnorhea. With NOE fractures a CSF leak should be assumed to be present even if it is not clinically demonstrable and appropriate chemoprophylaxis should be commenced.

63. The following diagnostic procedures can be performed if there is a suspected CSF leak (clinical sign: straw-colored or clear nasal drainage ): Tilt test with positive halo sign (as illustrated ) Comparison of the concentration of glucose between fluid and patient’s serum.

64. Bloody rhinorrhea suspicious for CSF can be placed on filter paper and observed for a halo sign . If CSF is present ,it diffuses faster than blood and results in a clear halo around the central stain . Routine chemistry analysis of the rhinorrhea may reveal an elevated glucose content consistent with CSF .

65. Beta 2 transferrin is the definitive test for CSF rhinorrhoea.collect 1 ml of the suspected fluid in a red top tube. Watery rhinorrhea that is positive for beta 2 -transferrin is diagnostic for a CSF leak.

66. Till test with positive halo sign

67. These two tests aids in the diagnosis of instability of the Medial canthus tendon. Bowstring test Bimanual palpation by placing an instrument into the nose to determine canthal bearing bone fragment displaced and mobile. .

68. In the bow string test ,the eyelid is pulled laterally while the tendon area is palpated to detect movement of fracture segments . A lack of resistance or movement of the underlying bone is indicative of a fracture . The surgeon may be able to grab the eyelid or use a forceps to grab the skin in the medial canthal area and pull it laterally (“bow-string” test).

69. It requires placing an instrument (kelly clamp) high into the nose,with its tip directly beneath the MCT . Gentle lifting with the contralateral finger palpates the canthal tendons and allows an assessment of instability of the tendon attachement and necessity for open reduction.

70. The lacrimal drainage system is intimately related to the NOE region and can be damaged during the trauma. The surgeon should assess the patency/continuity of the nasolacrimal system at the time of surgical treatment. If there is a discontinuity in the nasolacrimal system repair should be considered at the time of fracture treatment.

71. Dye disappearance test Jones test(primary and secondary tests) Lacrimal irrigation Scintigraphy Contrast dacryocystography CT scan

72. DDT is useful for assessing the presence or absence of adequate lacrimal outflow. 2% fluorescein dye solution or a moistened fluorescein strip instilled in conjuctival fornix. Persistence of significant dye indicates an obstruction. If the DDT result is normal, severe lacrimal drainage dysfunction is highly unlikely .

73. Obstruction of NLD

74.  The Jones tests have been used in the evaluation of epiphora. JONES I JONES II JONES TEST

75. Like DDT,this test investigates lacrimal outflow under normal physiologic conditions. 1 drop of 2% fluorescein dye placed into conjuctival sac. After about 5 mins ,cotton tipped applicator inserted under the inferior turbinate. If bud stained with dye ,test is positive. Test is negative If no dye is detected ,means there is partial or absolute obstruction or failure of lacrimal pump.

76. Radiographic visualization of the lacrimal sacs and associated structures after injection of a contrast medium . Contrast dacryocystography provides anatomical information with dye injection into the lacrimal system followed by computerized digital subtraction imaging.

77.  Better over treated than under treated . Why over treat? Inadequate treatment Secondary deformities Missing or displaced bone fragments, soft tissue scarring,malposition

78. Reconstitution of the skeletal framework of NOE region. Stabilization of the intercanthal width and MCT.. Orbital reconstruction. Establishment of nasal support. Reconstruction of other craniofacial injuries including frontal sinus. Soft tissue repair.

79. Early one stage repair Exposure of all fracture fragments Precise anatomic rigid fixation Immediate bone grafting as indicated for bony loss. Definitive soft tissue management.

80. Exposure Identify the MCL or the MCL bearing bone. Reduce/reconstruct medial orbital rims. Reconstruct medial orbital walls. Transnasal conthopexy Reduce septal displacement Soft tissue readaptation.

81. Unobstructed visualization of the articulations of all the bones in the region. One of the main reasons for treating NOE #s is esthetics ,hence incisions are made keeping in mind the esthetics. Remote incisions preferred.

82. Skin incisions -visible scars No external scars Existing lacerations Coronal incision Eyelid incisions Vertical//horizontal incisions Open sky approach H shape incision. W shape incision. Lynch incision. Transcaruncular incision Pre caruncular incision Transoral –degloving incision.  Midfacial degloving incision-great access/no scar .

83. Correction of associated frontal sinus fracture. Harvesting of calvarial bone graft or primary reconstruction Harvesting of pericranial flap of sufficient length for sealing of defects in the ant.cranial fossa. Disadvantage: Cannot be used when the skull has been opened up previously for craniotomies by the neurosurgeons. ADV A NTAGES:

84. Curved incision over lateral nasal bones anterior to MCL attachment. Skin here is thin-allows easy exposure. Sufficient or limited reconstruction. Cannot be used in bilateral c a ntho p e x ie s ,bone grafting.

85. Skin incision approx. 3 cm in length made along the superior medial orbital rim from 1 cm medial to medial canthus to the lower border of the medial eyebrow. Angles of limbs of the W-110 to 120 degree Four limbs of the W can be placed parallel or oblique to the RTSL The lateral limb of the .W can be extended laterally long the lower border of the medial eyebrow, depending on the desired exposure.

86. Muscledissection,supratrochlea r nerve located and preserved. Periosteum is incised from upper half of the MCT to the medial portion of superior orbital rim-periorbita is laterally reflected.

87. Advantages: W has small segmented limbs parallel or oblique to the relaxed skin tenion lines. W limbs break up the scar into smaller components- minimal external scar. Pulling both ends of the W along its longitudinal axis provides the increase of its longitudinal length- allows implant up to 3 cm to be inserted. Superior access to medial orbital wall.

88. 1. Both MCL remain attached and the laterization of the complex is counteracted by the orbicularis oculi. Type I : b/l single segment NOE # 2. Tendon is still attached to the bone but the bone fragment is separate from complex : U/l single segment type I injury. 3. Avulsion of tendon from bony connection type III. 4. Bone into which the tendon inserts is missing

89. Biomechanics of midface made complicated by: – Nonuniform geometry of bones – Number and orientation of various attached ligaments and soft tissues. Treatment aimed to restrict three types of movements of a fractures segment in 6 directions Translatory movement essentially 2D restricted by wires as well as plates

90.  R o tatory mov e ments : 3 -D need plates restrictions at 3 separate points more effective.  Farther apart the fixation points better the stability wider plates thus preferred.  3 wires or several small plates oriented at different angles increase stability.

91. Adjunct to primary bone grafting. Avoids supplemental maxillomandibular or extraskeletal fixation . Better rigid support and immobilization. Prevents overriding of the fractured fragments.

92. Transnasal reduction of canthal bearing fragment most important step in preserving intercanthal distance. Loose nasal bones may be removed temporarily for better access. Fragment bearing the MCL identified. If fragment is large enough reduce and fix it to adjacent bone with miniplates

93. Importance : To regain anatomic morphology To regain lost orbital volume in blow out # To achieve normal eye position after injury.

94. Bone material of choice for reconstruction calvarial graft/rib graft. Long pieces of bone used should extend just behind the medial orbital rim. Fixed with lag screws or miniplates. If Bone pieces extend too posteriorly poor access. loss of stability

95. Canthal ligament was identified and tagged earlier. Followed by orbital wall and rim reconstruction. Steps demanded greatest traction. If canthopexy performed earlier : – Vigorous traction could pull through the MCL and further damage the ligament .

96. Transnasal wiring Ipsilateral/homolateral techniques: Nylon anchor suture, Stainless steel screw, Cantilevered miniplate (Y-shaped, five holes), Bone anchor systems.

97. Nasal bone forming medial orbital wall and the bridge of the nose fragile ? Withstand wire tightening. Glabellar portion of the frontal bone is solid and can withstand wire tightening. • The fixation is secure. Due to the relatively large amount of soft tissue covering the twisted wire, extrusion of the wire through the skin does not occur. No injury to delicate structures of the contralateral medial orbit such as the lacrimal sac or lacrimal duct.

98. Technically difficult. Necessitates wide exposure sufficient to allow transverse passage of a wire through a bony fenestration deep within the orbit. Weakening of the bones ( when central fragment is drilled twice), Dissection of the contralateral orbit.

99. A Kirschner wire with one of the tips hammered and shaped into a simple drill is passed from the left orbit toward the right thru central fragment. Plastic catheter is pushed forward over the Kirschner wire guide and through the transnasal hole.

100.  A bent, looped wire is introduced from left to right through the plastic tube left in the transnasal hole after t Kirschne r wire removed.

101. A titanium microplate is placed in the loop at the second penetration site. Second microplate is placed between the exiting wires at the first penetration site, Ends of the wires are twisted together The free tips of the wire at the site of first penetration can be used for canthopexy without microplate placement, if desir ed

102. After passing thru ligament;The 30G wire is passed through the posterior hole of the miniplate and loosely twisted. The plate is positioned, with the medial canthal tendon pushed deep, near the posterior lacrimal crest. The drill hole is made in the area of the anterior hole of the plate and fixed with a stainless steel screw (2 × 6 mm). The stainless steel wire is then tightened. The frontal process of the maxilla in the region of the lacrimal crest is utilized for fixing the two- hole plate transversely .

103.  The key to replicating the delicate three dimensional contour of the medial canthus lies in addressing all three vectors of attachment”.

104. NOE # are associated with fractures of perpendicular plate of ethmoid, septal deviation, septal hematomas . Goal should be to assure midline positioning of septum to prevent airway compromise. Reduce septal fractures

105. ng Collapse of the bony architec t ure broade ni ng of base. Weakening of nasal septal structures. Damage to upper lateral cartilages. Complete loss of dorsal nasal projection and loss of support.

106. Reinforcement of thin bones Prevention of overriding and displacement of fragments Maintenance of vertical dimension Provides substrate for osseous union Prevention of soft tissue scarring

107. e x c e ll e nt gently tapering it Bone graft sites: calvarial choice. Shape it like a surf boat at the end. Length should extend from frontonasal junction to nasal tip. Colummelar strut if needed. Fixation: - Single lag screw into the nasal pyramid. -Microplate to cantilever off the frontal bone.

108. Persistent Cerebrospinal fluid leakage. Unconsciousness Skull fractures Increasing intracranial pressure Meningitis

109. Temporary or permanent parasthesia. CSF leak. Meningitis. Sinus infection or mucocoele. Anosmia. Infection of implants. Postoperative telecanthus is a relatively common complication of nasoorbitoethmoid (NOE) fracture repair.

110. Pseudotelecanthus. Enophthalmos results from inadequate repair of the medial orbital wall or orbital floor. Midface retrusion may occur. Extraocular dysfunction. Blindness. Possible need for additional surgery.

111. Postoperative ophthalmologic is examination recommended, as well as gross visual acuity checks every 6 hours for a 24-hour period . The Penrose drains are removed from the scalp at 24 hours, and the pressure dressing is discontinued after 3 days. The lead bolsters and scalp sutures are removed at 10 days postoperatively . The patient should be examined and queried again, looking for any evidence of a CSF leak. Patients should be asked to perform standard nasal hygiene (nasal saline irrigations and no nose blowing).

112. Disruption of the delicate ethmoid complex and comminution of the nasal bones can make the repair of nasoorbitoethmoid (NOE) complex fractures extremely difficult. These injuries often test the capabilities of even the most experienced surgeons.

113. To obtain an aesthetic surgical result, the surgeon must meticulously identify, accurately reduce, and rigidly fixate the medial canthal tendon and central fragment. Special attention also must be focused on the overlying soft tissue to avoid hematoma, chronic induration, and pseudotelecanthus.

114. Aesthetic reconstruction of the nasal bone an d medial canthal region continues to be a significant surgical challenge. Future advances may address this issue with the use of surgical navigation systems and/or intraoperative imaging, which returns the bony architecture to its premorbid state more accurately.

115. NOE injuries can be difficult to manage. Proper assessment and early surgical management of the NOE and concomitant injuries are key to optimal outcomes. Overcorrection of the bony position and compression of the soft tissue overlying the MCT are critical. Residual telecanthus tends to be recalcitrant despite the best efforts.