Treatment of nasal fracture by Paul of Aegina

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Jeffrey S. Fichera MS PA-C

The Ear, Nose, Throat and Plastic Surgery Assoc. Inc.

Facial Injuries in SportsFacial Injuries in Sports

The Athletic Trainer must be prepaired to manage facial injuries, including

ContusionsAbrasionsLaserationsNasal fractures

Facial Injuries in SportsFacial Injuries in Sports

Septal hematomasAuricular hematomsRuptured tympanic membranesFractures of the facial bones

Sports AcitiviesSports Acitivies

Account for 3% to 29% of all facial injuriesApprox. 10% to 42% of all facial fractures60% to 90% of injures occur in male

participants between 10 and 29 years old.

Mechanism of InjuryMechanism of Injury

Direct Impact – with another players body part (eg, head, fist, elbow)

Equipment (eg, ball, puck, goalpost, handlebars )

The Ground ( eg, wrestling mat, gym floor)Enviroment ( eg, tree, outfield wall )

Return-to-PlayReturn-to-Play

Treament requires knowledge of the injury

Type and serverity of injury

Physicial demands of the sport

Initial Exam and EvaluationInitial Exam and Evaluation

Pertinent History

Physicial Exam

Remember the “ WOW FACTOR ”

Soft-Tissue InjuriesSoft-Tissue Injuries

Contusions

Abrasions

Lacerations

ContusionsContusions

Most commonly encountered facial injury

Results from blunt trauma to the face

Treatment aimed at minimizing inflammatory response ( ice, nonsteroidals)

AbraisionsAbraisions

Partial-thickness disruptions of the epidermas

Commonly results from blunt trauma or sudden forcible friction

Always consider underlying injury40% of all Tetanus (1998-2000) resulted

from abrasions and lacerations

Nasal InjuriesNasal Injuries

Epistaxis

Septal Hematoma

Fracture

EpistaxisEpistaxis

80% of all nose bleeds are from the anterior source ( ie. Kiesselbach’s Plexus )

20% are posterior and usually a disease of the middle aged and elderly

Nasal Blood SupplyNasal Blood Supply

Why the WOW FACTOR?External Carotid

– Facial artery ( 2 branchs ant. Septum, ala )– Internal maxillary ( most important )

Terminal branch of EC gives rise to– Sphenopalatine

– Nasopaltine

– Greater palatine

Internal Carotid– Opthalmic artery

Anterior and Posterior ethmoid artery

EPISTAXISEPISTAXIS

Cosider nasal fracture as source of epistaxis.

Athlete may report having heard a “crunch” or “crack”.

Nasal fractures are diagnosed clinically.

Focus of Initial TreatmentFocus of Initial Treatment

HemostasisMinimizing swellingTreatment of Nasal Fracture

– Ice and Pain control– Aspirin contraindicated– Nasal decongestants for up to 3 days– Nasal fractures are reduced or refered to ENT

in 3 – 5 days.

Anterior EpistaxisAnterior Epistaxis

Best controlled by slightly reclining the patient and applying direct pressure to the nasal septum for 5 to 10 min.

Apply ice to the back of the neck may help by causing reflex vasoconstriction

Persistent EpistaxisPersistent Epistaxis

Occasionally requires nasal packing with:– Mericel Sponge

Topical Antibiotic Topical Coagulant

– FloSeal

– May use phenylephrine hydrochloride or oxymetazoline hydrochloride for vasoconstriction

Return to PlayReturn to Play

Can be immediate if bleeding is controlled.Custom face shields, helmets with face

masks, or protective devices should be worn for 4 weeks after injury.

Noncontact sports, return to play can be immediate if hemostasis controlled.

Nasal FractureNasal Fracture

Complications from Nasal Complications from Nasal FractureFracture

Chronic nasal obstructionDeviated septumSeptal hematoma

– Must Rule Out

Septal HematomaSeptal Hematoma

Bulging bluish mass Genarally form within

hours after injury Requires prompt I&D,

nasal pack and antibiotics

Must refer to ENT if present

Nasal FractureNasal Fracture

Septal DeviationSeptal Deviation

Ear InjuriesEar Injuries

Contusions caused by shearing forces applied to the external ear are common.

Most common in wrestling.Mechanism of injury is blunt trauma against

the wrestling mat.RESULT = AURICULAR HEMATOMA

The External EarThe External Ear

Auricular HematomaAuricular Hematoma

Diagnosis established by early– Ecchymosis– Erythema and pain– Palpable collection of

fluid– Swelling of external

ear with loss of anatomical landmarks

Early TreatmentEarly Treatment

Ice apllied eary with continued compression can minimize the risk of developing an auricular hematoma.

If hematoma present – prompt aspiration required

Treatment OptionsTreatment Options

Aspiration with 18 or 20-gauge needleIncision and Drainage using sterile

techniqueCompression applied for 7 to 14 days

– Dental roll with through & through sutures.– Antibiotics for 7 – 10 dayes recommended– Cephalosporins

I & D Evacuation of

hematoma

Dental Roll Application

Return to PlayReturn to Play

Noncontact sports may return to play immediately

Contact sports require ear protection and athletes may return to play 48 hours after dental rolls are removed.

ComplicationsComplications

Pressure necrosis of the underlying cartilage by seperating the perichondrial blood supply from the underlying cartilage, results in CAULIFLOWER EAR.

Cauliflower EarCauliflower Ear

Tympanic Membrane Tympanic Membrane PerforationPerforation

Most common Cause – pressure caused from OM

Blunt trauma – BarotraumaSwimming, diving, highaltitude changes,

direct contact to the ear

TM AnatomyTM Anatomy

Normal TMNormal TM

TM PerforationTM Perforation

TM Perforation SymptomsTM Perforation Symptoms

May be Asymptomatic orHearing lossVertigoBloody or serous dischargeDiscomfort worsened by wind or cold

DiagnosisDiagnosis

Always consider if mechanism of injury present.

Otoscopic evaluation

TreatmentTreatment

Keep ear canal dryENT evaluationAudiogramOtic drops may be requiredReturn to play will depend on sport and

symptoms

Facial FracturesFacial Fractures

75 % of facial fractures occur in the:– Mandable– Zygoma– Nose

All Facial Fractures Require Referal

DiagnosisDiagnosis

Type Mechanism of injury

Signs and Symptoms

Mandible Trauma to lower face

Malocclusion, abnormal mandibular movement

DiagnosisDiagnosisZygoma Blunt trauma to

the cheekPain, swelling; ecchymosis over fracture site; numbness along infraorbital nerve

Nasal Direct or glancing blow

Heard “crack”; ecchymosis; tearing; epistaxis; crepitus

DiagnosisDiagnosis

Zygomatic Arch Blunt trauma to cheek

Central depression or asymmetry of cheek bone; trismus

Maxilla or LeFort’s

High-velosity shearing force to midface

Elongated, distored face; mobile maxilla; maloccusion

DiagnosisDiagnosisOrbital Blowout Direct trauma to

globe (eg, from ball, elbow)

Periorbital edema; ecchymosis; subconjunctival hemorrhage; numbness along infraorbital nerve; diplopia;

Decreased upward gaze; sunken globe

Questions ?Questions ?

Treatment of nasal fracture by Paul of Aegina

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