Recent fractures of the nose

Recent fractures of the nose

RECENT FRACTURES JOSEPH SAPIAN, M.D. AND JOSEPH TAMERIN, Attending Plastic Surgeon, Beth David Jewish MemoriaI and Beth EI Hospitals NEW OF THE NO...

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RECENT FRACTURES JOSEPH SAPIAN,

M.D.

AND JOSEPH TAMERIN,

Attending Plastic Surgeon, Beth David Jewish MemoriaI and Beth EI Hospitals NEW

OF THE NOSE M.D.

Assistant Plastic Surgeon, Harlem Hospital

YORK

RACTURES of the nose are probably the most common fractures encounL tered in practice. UnfortunateIy, they do not receive the attention accorded fractures of other bones of the body. This negIigence is twofoId: (I) fractures of the nose are easiIy disguised by the sweIIing of the adjacent soft parts and hence remain undetected to the examining eye and finger; (2) fractures of the nose are considered onIy as minor injuries whose resuItant cosmetic disfigurements are too frequentIy disregarded. The cosmetic disfigurement may vary from a scarceIy detectabIe variation from the norma nose to grotesque maIformations. The frequency of ugIy and undesirabIe deformities becomes a matter of considerabIe psychoIogic and economic import in a day and age as fierceIy competitive and “appearance conscious” as this. A few years ago, doctors often rationaIized their negIect in caring for a fractured nose (when something couId stiI1 be done to prevent deformity) by saying that there was “IittIe if anything to do.” But since the deveropment of corrective rhinopIasty, there is a much better understanding of the principIes determining the nature and reasons for the disfigurement of the nose resuIting from various types of injuries. Hence many, if not the greater number of disfigurements previousIy dismissed as unavoidabIe are now recognized as definiteIy amenabIe to treatment. ParticuIarIy to be condemned is the negIect of a fractured nose in chiIdren, among whom it o&curs with great fre-

CITY

quency. Since pIastic procedures for the correction of nasa1 deformities are rareIy undertaken before the nose has reached its fuI1 growth (approximateIy the seventeenth year) any negIected deformity in chiIdren must await this fuI1 growth. The attending distress is rea1 and of serious consequence in the chiId’s outIook in life and his reIation to associates. Hence, a badIy treated nasa1 fracture in a chiId, resuhing in deformity, wiI1 stand as proof of the attending doctor’s negIect and incompetence.

F

ETIOLOGY

The most frequent cause of fracture of the nose is trauma. It is usuaIIy direct and varies from a very sIight degree capabIe of producing a fracture in the soft bones of chiIdren to the crushing and extensive bIows incident to motor accidents. INCIDENCE

Fractures of the nose occur in a11 ages. They are most common during the vioIent and are incident to athIetic periods, strenuous endeavors of a11 kinds. Hence they are more frequent in adoIescent maIes and in the earIy twenties. CLASSIFICATION I.

IO

OF

FRACTURES

SimpIe Fracture A. Fracture of bony bridge of nose I. Without deformity 2. With deformity a. Depression of bridge b. Deviation of bridge c. Widening of bridge

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B. Fractures of septum I. Without deformity 2. With deformity a. Depression of septum (I) SaddIe nose (2) Dropped tip (3) Obstruction of respiration b. Deviation of septum (I) Without externai deformity (2) With externa1 deformity (a) Protruding septum (b) Deviation of aIar cartiIages C. Combined fractures II. Compound Fractures. SYMPTOMS

AND

SIGNS

Epistaxis is a frequent sign. It is caused by the rupture of the deIicate nasa1 mucous membrane by the bony fragments. The epistaxis may be uniIatera1 if fracture has occurred on onIy one side; it may be slight and cease of its own accord, or it may be severe enough to exsanguinate the patient, unIess arrested. Ecchymosis is due to the subcutaneous extravasation of bIood. The ecchymosis may be uniIatera1 or biIatera1 and may differ, if biIatera1, in intensity on both sides. The ecchymosis is most marked in the eyeIids, and may be so severe as to shut the eye itseIf. The extravasation of bIood may spread to the cheek and down aIong the neck suggesting that an injury to the face may have taken pIace with the fracture. The ecchymosis and sweIIing in most cases appears within a few hours after the injury. At times it may be deferred for aImost twenty-four hours. The hemorrhage and sweIIing usuaIIy increase in intensity for forty-eight hours and then subside. Within ten days most of the discoIoration disappears. Swelting is due to the extravasation of bIood. The nose may become very bulbous if there has been much IocaI extravasation. In many instances there is IittIe swelling of the nose and a great dea1 in the eyelids.

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Impaired respiration may resuIt either from the accumuIation of bIood in the nasaI passages or from fracture-disIocation of the septum with swehing of the mucous membrane. A rarer cause of the impaired respiration is submucosa1 hemorwith separation of the mucorhage, periosteum from the quadriIatera1 cartilage; this is frequentIy foIIowed by infection and destruction of the cartiIage with saddle of the cartiIaginous bridge. Bony crepitus can ahnost aIways be elicited by manipuIation of the nose with the fingers. If the examination is deferred for a day or more, the fragments of bone wiI1 be more or Iess immobiIized by coaguIated bIood. This “Ioose immobiIization” can be reduced by gentIe pressure and at the same time the extent of the fracture can be determined. Pain is not severe in most instances. A severe crushing injury may be painless. ManipuIation of the bones, in an attempt to eIicit crepitus and to determine the nature and extent of the fracture, is aIso practicaIIy painIess. Deformity is not apparent unIess the nose has been deviated from the midline or has been crushed inward. Slight deformity is frequentIy masked by the sweIIing and ecchymosis and hence is overIooked. DIAGNOSIS

The diagnosis of a fractured nose may seem to be a very simple matter. It is amazing, however, how often the symptoms that wouId Iead to the identification of a fracture are ascribed to a simpIe contusion of the soft parts. The history of an injury in the region of the nose and the eye is significant. It is generaIIy beIieved that a black eye is due to a blow over the eye. In pIacing the first over the eye it wiI1 become obvious that the eye is protected by bony prominences. The lids cannot be directIy struck except by a more sIender instrument than the cIosed hand. The nose, as a bony prominence, is most easily fractured and hence receives the initial force directed at the eye. WhiIe

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it is true that ecchymosis of the eyeIid may be due to a contusion of the soft tissues over the aforementioned bony

nasal

bones

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PATHOLOGY

The pathoIogy of fractures of the nose can be best understood if one is famiIiar

lateral

car tilages yseptum

FIG. I. Bony bridge of nose.

prominences and a spread of bIood to the eyeIids, nevertheIess unsuspected fractures frequentIy accompany the ordinary black eye. Bloody nose, sweIIing of the nose, impaired respiration, and deformity shouId aIways Iead one to suspect a fracture. Examination for bony crepitus shouId aIways be attempted since fracture without some degree of deformity is uncommon,

FIG.

2.

Cartilaginous

bridge of nose.

with the norma anatomica reIationships. Normal Anatomy of the Nose. For purposes of interpretation of fractures the nose may be considered as composed of a bony and cartiIaginous bridge or arch. The bony bridge or arch is comprised of the two nasa1 bones and the fronta processes of the superior maxiIIae (Fig. I). The cartiIaginous bridge is composed of the two

FIG. 3. Depression of bony bridge of nose. A. Arrows indicate points of fracture. B. Depression of nasa1 bones with fracture and teIescoping of septum. c. RepIacement and retention with high intra-nasa1 packing.

and in the eIicitation of crepitus the fractured fragments can often be manipuIated painIessIy into a more desirabIe position. X-ray is frequentIy requested for diagnostic reasons. At best it is onIy an adjunct to the history and the physica findings. The pIates frequentIy fai1 to revea1 a fracture, or are confusing, as in the young, when the evidence from the physica findings is overwheIming in favor of a fracture. IntranasaI examination with a suitabIe nasa1 specuIum and strong Iight is aIways indicated to determine the condition of the septa1 cartiIage.

IateraI cartiIages and the two aIar cartiIages, supported by the septum (Fig. 2). The pathoIogy of the individua1 fractures wiI1 be considered under their specific treatment. GENERAL

TREATMENT

E&axis may be controIIed in a number of ways. It may be stopped either by intranasa1 packing Ieft in pIace for twenty-four hours or by the appIication of the Joseph spIint on the outside of the nose, in addition to the intranasa1 packing. These measures

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are generaIIy unnecessary as the epistaxis is seIf-controIIed. Ecchymosis and sweIIing cannot easiIy be

subconjunctival hemorrhage of the eyebaI1, it may persist Iong after the other sweIIing and ecchymosis has subsided. There is no

aIleviated. The sweIIing generaIIy reaches its height in forty-eight hours and thereafter decIines, disappearing in about one week. On paIpation any resistance of the sweIIing shouId suggest hematoma or infec-

treatment to faciIitate the reabsorbtion of this cIot. Pain is generaIIy sIight and can be controIIed by codeine and aspirin. Fever does not occur unIess the fracture

FIG. 5. Deviation

of bony bridge of nose. A. Arrows indicate points of fracture (a,a). B. Deviation c. Reptacement and fixation without external splint.

tion. The ecchymosis and sweIIing are painIess. The onIy discomfort, aside from the cosmetic effect, may be the gIueing together of the eyeIids. This can be reIieved by boric acid compresses. The use of ice bags, coId instruments, etc., is without effect. If there is an accompanying

of entire arch.

has become infected. The intranasa1 bIood cIots and secretions can be easiIy removed with appIicators soaked in peroxide of hydrogen. The patient shouId be advised to refrain from bIowing his nose as it may permit the introduction of air between skin and nasa1 bones, causing an emphys-

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ema which is very stubborn to treatment and may persist for a few weeks. Infection shouId be treated, as infections

FIG. 6. Neglected fracture-deviation of bony bridge of nose with correction by excision of triangIe of bone from left fronta process. (From Safian.)

eIsewhere, by wet dressings and drainage. A convenient dressing for the nose can be shaped from a 4 inch square of gauze. PATHOLOGY

AND IMMEDIATE

VARIOUS

The cabIe weeks of the

NASAL

TREATMENT

OF

FRACTURES

treatment described beIow is appIito fractures Iess than two to three oId, i.e. before fibrous immobiIization fragments has occurred. I.

SIMPLE

FRACTURES

A. Fractures of Bony Bridge of Nose I. Without Deformity: Pathology: Linear fractures of the bony bridge may occur without any resuItant deformity. Extravasation of bIood into the subcutaneous tissues producing externa1

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sweIIing and ecchymosis and, internaIIy, congestion of the nasa1 mucous membrane and epistaxis, may be present in greater or Iesser degree. FortunateIy this type of fracture without deformity is the most frequent. Apparent deformity, such as widening of the bridge of the nose, is due to the sweIIing of the soft tissues or to a hematoma. Treatment: These fractures may be Ieft aIone except for the treatment of the accompanying symptoms. An apparent deformity of the nose may be due to sweIIing of the soft parts or to a hematoma. If the former, pressure on the bridge with the fingers or the appIication of a nasa1 spIint wiI1 demonstrate that the widening of the nose has not been caused by a spread of the fractured bones. The sweIIing wiI1 immediateIy recur once the pressure has been removed, it wiI1 increase up to forty-eight hours foIIowing the injury and then rapidIy subside. A hematoma produces a moderateIy hard sweIIing that cannot be reduced by externa1 pressure unIess some means is provided for the egress of coaguIated bIood. If there is a Iaceration of the skin in the vicinity of the cIot, the bIood shouId be expressed through this externa1 wound. If the cIot is of considerabIe size and is permitted to remain, it wiI1 require many weeks for resoIution. OccasionaIIy it may organize and form a fibrous thickening. Hence, if there is no externa1 avenue for the escape of bIood, one shouId be made, either from within the nares (after novocaine injections) and a tract made with a sharp knife, or from an externa1 incision. Pressure shouId be maintained over the region of the hematoma to prevent a recurrence; it can be maintained for approximateIy twenty-four hours by the use of a stent or soft meta spIint. 2. With Deformity: a. Depression of Bridge: Pathology: Depression of fragments may produce either unsightIy pIateaus or sharp ridges on the bridge, or if very severe, a saddIe of the bridge. When the bIow is direct and suficient to cause considerabIe

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depression of the bony fragments there is generaIIy a concomitant fracture and depression of the bony septum (perpendicuIar

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of the ethmoid teIescoped upon itseIf. The nasal chambers shouId be cocainized and the fragments eIevated with a bIunt instru-

Joseph b

FIG. 7, Widening

of bony bridge. A. Arrows indicate points of fracture. B. Spread of arch. c. RepIacement retention with Joseph or Safian brace.

pIate of the ethmoid) (Fig. 3). Treatment: Where fractured nasal fragments are driven inward, an attempt shouId be made to eIevate them into their former

and

ment. WhiIe manipuIating from within the nose, one shouId attempt to mobiIize the nasa1 fragments from without. With sIight depressions of the bridge it is occasionaIIy

FIG. 8~. FIG. 8~. FIG. 8. Wide nasa1 bridge from neglected fracture with correction.

positions. The septum shouId be examined to ascertain whether it has been injured. If the injury is severe there may be an accompanying fracture of the perpendicuIar pIate

possibIe to restore the norma eIevation of the nose and the contour of the bridge. A high packing wiI1 heIp to maintain the parts in position unti1 fixation occurs, and any

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remaining sharp ridges may be Hed down Iater. If the depression is severe IittIe can be done to maintain the bones in their

nasal

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the bones by means of it. Other prostheses entaiI the introduction of bIunt eIevators into the nose which are attached ex-

bones

ColurrieiP r\*,' cartilage 7

FIG. g. Depression of septum with saddle of cartilaginous bridge. A. Norma1 anatomy of septum from side, a; from beIow. B. Fracture depression of septum with thickening. c. Saddle corrected by transpIant; thickened septum corrected by submucous resection.

norma position. A nasa1 packing may hoId the fractured fragments in an improved alignment. This packing shouId be changed daiIy and at best can be Ieft in pIace onIy for a short time. No externa1 dressing is necessary unIess there has been an injury to the skin. The Joseph nasal brace is of no vaIue in this condition. SpIints have been devised to maintain the fractured fragments in their norma aIignment. They are placed in various ways on heaIthy bony prominences and a support is pIaced within the nose in an attempt to raise the bony fragments. The splints are worn unti1 fibrous union has become sufficient to hoId the bones in their norma position. Such a spIint was devised by Carter. It is composed of a stee1 cradIe which rests on the fronta processes. A hammock is strung up of strong siIk from within the nose, externaIIy, through the skin and this hammock is tied to the cradIe and an attempt is made to eIevate

ternaIIy to an apparatus permitting the raising of these eIevators. We have not found these apparatuses of vaIue. The weight and eIasticity of the skin and the puI1 of gravity keep the depressed fragments from remaining in their norma position. The siIk used in the Carter spIint (aside from the objection that it permits an avenue of infection) wiI1, if puIIed tightIy enough, cause pressure necrosis of the mucous membrane. The same is true of the other prostheses. We have found that the immediate treatment of depressions of the bridge wiI1 not, in many instances, permit the restoration of the nose to its norma shape, no matter what treatment or spIints are empIoyed. PIastic correction shouId be undertaken on the subsidence of sweIIing and the saddIe of the bridge (if the depression is extremeIy obvious) can be overcome by the introduction of a properIy shaped transpIant (Fig. 4).

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b. Deviations of Bridge: Pathology: When the trauma there may be, in addition,

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is uniIatera1 a fracture-

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position. This simple procedure may not suffice, on occasion, in children because of fear and squirming and in ad&s because of

FIG. IOB. IOA. FIG. IO. Saddle nose corrected by removal of bony hump.

disIocation or deviation of either the fragment or the entire bridge of the nose to the opposite side. The points of fracture, when the entire bridge is deviated, are usuahy at the base of the fronta process of the superior maxiIIae. There is no widening of the arch if there has been no fracture at the apex of the bony vauIt, i.e., the nasa1 bones on both sides (Fig. 5). Treatment: No intranasa1 preparation for operation is necessary where the bridge of the nose is deviated in its entiretv from the mid-position. One can generaIIy reduce these fracture-dislocations without any In many instances no instrumentation. anesthesia is required. If the patient’s head is grasped secureIy between the hands and forearms, whiIe the thumb is pIaced over the convexity, a vigorous thrust in a downward and semi-circuIar direction wiI1 restore the nose to the mid-position. An audibIe cIick indicates that the bones have been moved and repIaced in their norma

some pain associated with the manipuIation. In these cases a Iight gas anesthesia or ethy1 chIoride inhaIation wiI1 faciIitate

Y

FIG.

I I.

Depression

of

septum with dropped * B. Dropped Up.

.-I anawmy. .__L_~~ A. 7.. LYO~IIELL

tip.

the restoration. If the bone has been properIy repIaced, no retention apparatus is required, ahhough a IightIy appIied nasa1 brace for a twenty-

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four to forty-eight hour period wilI ,prevent excessive soft tissue sweIIing. This type of deformity is probabIy the most

FIG.

JANUARY, ‘936

tion of the patient, instumentarium or anesthesia is necessary. The bones shouId be mobiIized externaIIy by the fingers and

FIG.

12A.

FIG. 12. Dropped

Fractures

tip corrected

easiIy treated, since the diagnosis is obvious and the treatment in many cases simpIe and satisfactory. If the deviated bones are not immediateIy restored and heaIing takes pIace in an abnorma1 position, the attending deformity is very unsightIy and requires a pIastic correction (Fig. 6). This invoIves the remova1 of a wedge of bone on the concave side of the deviation. c. Widening of Bridge: Pathology: The widening of the nasa1 bony bridge is due to a fracture of the apex of the bony arch, so that the bones are no Ionger contained within their narrow Iimits, but are permitted to spread (Fig. 7). In the young, separation of the fronta processes from the nasa1 bones may occur without fracture and produce a simiIar widening of the bridge. Treatment: In this condition, as in deviations of the bridge, no intranasa1 prepara-

12B.

by shortening nose.

then a Joseph or Safian nasa1 brace appIied and tightened so that the bridge is made narrower. The brace shouId be appIied for twentyfour hours and thereafter shouId be worn for an hour daiIy unti1 the bridge remains narrow. In appIying the nasa1 brace it is important to be certain that the fragments of bone have been properIy mobiIized. If they have not, the pressure of the brace wiI1 cause necrosis of the skin with attending sIough and scar formation. This condition is frequentIy overIooked and Ieaves an unsightIy bridge. If the bones are not mobihzed whiIe the fracture is stiI1 fresh, and are not maintained in a norma esthetic aIignment by the nasa1 brace then no attempt wiI1 avai1 to narrow the bridge short of a plastic correction with artificiaIIy and their produced Iines of fracture maintenance by the nasa1 brace (Fig. 8).

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B. Fractures of Septum I. Without

Pathology:

Deformity: These may

occur

Fractures

the septum. avoided. but

2.

are

Anlericnn

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It must therefore

ocation

FIG. 14. Deviation deviation

of septum with externa1 deformity. of CartiIaginous bridge. c. DisIocation

Hence, fractures of the septum, without deformity, frequentIy go on to actua1 deformity, sometimes at a considerabIy Iater date than the origina injury. Contracture of the scar is another factor in the production of a secondary deformity. Treatment: The treatmen?of fractures of the septum without deformity is dependent upon the symptoms. The epistaxis shouId be controIIed, where necessary by the use of intranasa1 packing. Where a hematoma of the septum forms causing a separation of the mucoperichondrium it is advisabIe to drain the hematoma under steriIe conditions after having cocainized the nasa1 mucous membrane. The mucousmembrane ffaps shouId then be maintained flat against the septum by the use of intranasa1 packs. A compIete coIIapse of the end of the nose often occurs in abscess of

be zeaIousIy

With Deformity:

superior paIata1 ridge. c. Fracture-deviation

uncommon. CartiIage does not reunite to cartiIage in a manner simiIar to bone repair. Fibrous union between the fragments occurs. This offers IittIe resistance to the weight of the overIying IateraI cartiIages and skin, the puI1 of gravity, and the customary more or Iess vigorous handIing which the nose receives in daiIy Iife.

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of septum

from

of septum.

a. Depression of Septum: SaddIe nose, dropped tip or obstruction of respiration may resuIt from fractures with depression of the septum. (I) SaddIe Nose : Pathology: If the septum has been fractured at the junction of the quadriIateraI cartiIage and the tips of the nasa1

Normal anatomy. B. Fracture-deviation of septum with of septum with deviation of carti1aginou.s bridge.

A.

with depression of the septa1 bones, cartiIage, a saddIe of the Iower haIf of the nose wiI1 resuIt. This may vary from a scarceIy noticeabIe depression to a marked and unsightIy hoIIow. Treatment is of IittIe avai1 in the immediate correction of a recent fracture of the septum with an accompanying saddIe of the cartiIaginous bridge. It is best to advise the patient that not much can be accompIished unti1 the sweIIing has disappeared when the saddIe can be effaced by the introduction of a suitabIy shaped transpIant (Fig. 9) or by the reduction of the bony hump (Fig. IO). (2) Dropped Tip : Pathology: If the septum has been fractured and depressed in its anterior margin, the tip which it supports wiII come to occupy the new IeveI of the septum

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(Fig. I I). This dropping of the tip may become so severe that it may aImost touch the upper Iip and (even in the absence of

FIG. IjjA. FIG. 15. Fracture-dislocation

with deviation

an obstruction to respiration due to the fracture or the septum) seriousIy impair the norma inffow of air into the nares. Treatment: The treatment of fracturedepressions of the septum with dropping

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treatment is dubious and informed that a future pIastic correction may be necessary. This can be performed when the sweIIing

of lower two-thirds

FIG. 15B. of septum. Correction.

has subsided. The pIastic correction consists in either the shortening of the septum and the attachment of the tip at a higher IeveI (Fig. IZ), or the introduction of a strut in the coIumeIIa to support the tip. pr0trdin.g

FIG. 16. Deviation

of septum with external deformity. A. Normal anatomy. alar cartiIages.

of the tip is Iikewise attended by few satisfactory resuIts. Attempts may be made to eIevate the fractured septum by means of a smooth Asch forceps, but the puI1 of gravity and the weight of the skin and IateraI cartiIages a11 tend to cause a recurrence of the deformity. The patient shouId be advised that the success of immediate

B. Protruding

seitum.

c. Deviation

of

(3) Obstruction of Respiration : Obstruction of respiration is a frequent concomitant of fracture-depression of the septum since the depressed fragments increase the thickness of the septum. Fre-

quently three or four fragments of bone and cartiIage

may be sheIIed out from such

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a thickened septum at subsequent tive correction. 6. Deviation of Septum:

opera-

FIG. 17A. Frc. 17. Protrusion

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permanent. Where the disIocation has been accompanied by fracture of the cartiIage or of its attachment to the perpendicuIar

FIG. 17~. of septum. RepIacement.

Fracture-deviations of the septum may occur with interna deformity, with external deformity, or with both. (I) Without ExternaI Deformity: Pathology: Fracture-deviation of the septum without externa1 deformity is frequent. The quadriIatera1 cartiIage may be fractured and bent, producing obstructed respiration without any externa1 evidence of the injury (Fig. 13). Treatment: The immediate treatment of deviations of the septum with or without externa1 deformity is more or Iess the same. The septum shouId be anesthetized by the intranasa1 appIication of cocaine and then grasped with either a smooth pair of forceps or with the fingers, one in each nostri1, and the septum repIaced in the midposition. IntranasaI packing maintains the septum untiI it heaIs by fibrous union. Where the septum has been disIodged in its entirety from the superior paIata1 ridge without fracture of the cartiIage, its replacement is generaIIy successfu1 and

pIate, the replacement may be temporarily satisfactory but the deformity tends to recur. Where the fracture-deviation has occurred without externa1 deformity, poor repIacement or the recurrence of the dispIacement wiII be attended by obstructed respiration. The patient shouId be advised that in spite of treatment this obstructive deviation may resuIt and require future excision. When a sufficient Iength of time demonstrates beyond question that the deviation is not amenabIe to the treatment aforementioned (the maintenance of an intranasa1 spIint) then the patient shouId be subjected to a submucous resection which wiI1 again provide free nasa1 passages. (2) With ExternaI Deformity: (a) Deformity of CartiIaginous Bridge: Fracture-deviation of the Pathology: septum with deviation externaIIy of the CartiIaginous bridge of the nose frequentIy accompanies fracture-deviation of the bony portion. The quadriIatera1 cartilage in such instances is frequentIy deviated in its

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entirety, and torn Ioose from its attachment in the mid-position to the superior paIata1 ridge (Fig. 14).

FIG.

Fractures

Patkology: Fracture-deviation of the septum with its anterior edge presenting at the nares may exist without deviation

18A.

FIG. 18. DispIacement

of aIar cartiIages

Treatment: When the deviation of the septum causes a twist of the Iower end of the nose, attempts shouId be made to repIace the septum (and thereby the nose) in the mid-position. The intranasa1 manipuIation is the same as that for deviation of the nose without externa1 deformity. It is occasionaIIy usefu1 to over-correct the nose to the opposite side and to maintain the Iower end of the septum in the overcorrected position by means of either adhesive or a IateraI nasaI spIint. The patient shouId be advised that here aIso a perfect resuIt is not aIways possibIe. A pIastic operation shouId be advised when a nose obviousIy remains disIocated despite efforts at manuaI or instrumenta correction (Fig. IS). (b) Deformity at Tip. (a) Protruding Septum :

JANUARY,1936

by deviation

FIG. 18~. of lower end of septum.

of the tip or IateraI cartiIages. This type of deformity is generaIIy due to fracturedeviation of the extreme anterior edge of the quadriIatera1 cartiIage (Fig. I 6). Treatment: Immediate treatment consists in repIacing the septum and maintaining it in position as we11 as possibIe. Recurrence of the disIocation in spite of treatment wiI1 necessitate pIastic correction both for cosmetic reasons and to nasa1 respiration. The plastic improve correction consists in repIacing the septum when it is of norma Iength, and resecting the Iower end where it is found advisabIe to shorten the nose. Attempts have been made to correct this type of deviation by a submucous resection begun at the Iower end of the septum Ieaving no Iower support for the nose. This procedure shouId never be carried out (in spite of its popularity

~~~ sERrEs var. XXXI,

NO. I

Safian

& Tamerin-NasaI

with Ieading rhinoIogists) for the foIIowing reasons: (I) it changes the reIationship of the coIumeIIa and the Iip and occasionaIIy retracts the coIumeIIa. This Iengthens the Iip where a change is estheticaIIy undesirabIe; (2) by depriving the tip of its support it weakens the dorsum of the nose and permits it to sink under the sIightest externa1 trauma. These protrusions of the septum should be approached by undermining the skin of the nose (as for shortening of the nose), thus giving a free approach to the deff ected septum. If the deflection is found to be an integra1 part of the framework of the nose it shouId be repIaced and the aforementioned consequences of its remova wiI1 not occur (Fig. I 7). If it is found advisabIe to shorten the nose the patient shouId be informed to that effect, and a trianguIar portion of the septum, with the overIying mucosa, removed. This step wiI1 occasionaIIy excise both the compIete deffection and the protrusion and aIso provide, at one and the same time, both a norma respiratory passage and an improved externa1 configuration of the nose. The patient shouId be treated as though he had had a shortening of his nose for cosmetic reasons onIy. No intranasa1 packing is necessary, the coIumeIIa shouId be attached to the resected or repIaced septum by two braided siIk sutures which may be Ieft in pIace for five days. (b) Deviation of AIar CartiIages: Pathology: The aIar cartiIages are frequentIy dispIaced aIong with the deviation of the Iower end of the septum (Fig. 18). Treatment: Correction consists in the repIacement of the deviated septum, thus permitting the aIar cartiIages to return to their norma position. C. Combined Fractures Pathology: Fractures of the various parts of the nose in toto show the combined pathoIogy characteristic of the separate deformities. Treatment: The treatment of fractures of the nose where both the bony framework and the CartiIaginous support have been deranged consists in the combination of

Fractures

American Journd

the various techniques the individua1 case. II.

COMPOUND

of

described

surgery 23 to suit

FRACTURES

Pathology: Lacerations of the skin, with retraction of the skin borders producing defects of various shapes and sizes, may accompany fractures of the nose. Where the destruction of tissue is of extreme degree, uIceration of the skin of the nasa1 bridge may resuIt which in itseIf may Iead to infection of the fractured bones, necrosis and Ioss of periosteum, bone and Iining mucous membrane. The resuIt is a perforation. Treatment: The cIeansing of skin Iacerations and the debridement of destroyed tissues is of great importance in the treatment of compound fractures of the nose. Lacerations of the skin shouId be sutured or heId in apposition by strips of adhesive. A dirt or oi1 tattoo of the nasa1 skin may occur, which can be excised on a subsequent occasion. Skin infection may spread to the periosteum and bone with necrosis resuIting in a perforation into the nasa1 cavity. This deformity requires careful pIastic correction and may necessitate a series of operations which shouId not be undertaken unti1 compIete cicatrization has taken pIace. CONCLUSIONS I. The nose is composed of six individua1 structures and a simpIe diagnosis of fracture of the nose is of no vaIue without a detaiIed anaIysis of the structures invoIved in the injury. 2. Any combination of the six structures may be invoIved in the fracture which accounts for the Iarge variety of deformities foIIowing such an injury. 3. Deformities of the nose resuIting from fracture are often disguised by an edema of the soft tissues. 4. Not a11 acute fractures can be successfuIIy treated by immediate manipuIation. 5. The necessity for a possible subsequent submucous resection and pIastic operation shouId be impressed upon the patient.