PART II. HEAD AND TRUNK (Part 1)

PART II. HEAD AND TRUNK CHAPTER XXV. FRACTURES OF THE NOSE. Surgical Anatomy. — The bony framework of the nose comprises not only the two nasal bones, but also the nasal processes of the superior maxilla, the bony septum and the nasal spine of the frontal. The nasal bones consist of two small, oblong, quadri- lateral bones situated at the bridge of the nose. These bones articulate laterally with the processes of the superior maxillge, Fig. 456. Figs. 456 and 457. — Sagittal section through the nasal cavity. F. R., Vertical plate of frontal; N., Nasal bone: N. S., Nasal spine; N. P., nasal process of superior maxilla; G. G., Crista Galli; S.T., Superior turbinate; M. T., Middle turbinate; I. T., Inferior turbinate; S., Body of sphenoid; Pal., Palate bone; P.P., Palatal process of superior maxilla. above with the frontal (at the nasion) and in the median plane with each other. The two nasal bones meet in the median line and rest upon the spine of the frontal in much the same manner as the rafters of a roof rest upon the king-beam. This nasal spine is, in turn, backed up by the vertical plate of the ethmoid. This continuity of bony tissue, from the nasal bone to the christa galli, explains the possibility of a blow on the nose displacing the ver- 323 324 FRACTURES AND DISLOCATIONS tical plate of the ethmoid upward into the anterior fossa of the skull. In 3^oung subjects the articulations in the bony framework of the nose are distinct and contain more or less intersutural tis- sue, but in old age the sutures are ossified and the different bones become continuous. It is therefore evident that in the aged a greater amount of the trauma of the nose injuries is transmitted to the vertical plate of the ethmoid and septal complications are more common. The lower half of the nasal bone is thinner and more friable than the upper half ; the inferior border is sharp and has attached to it the upper lateral cartilages of the nose. In the less severe cases fracture is limited to the lower portion of the nasal bones because of the more exposed position and weaker construction. The deep surface of the nasal bones is covered by mucous mem- brane which is commonly lacerated in fracture with displacement, and hence fractures of the nasal bones, which are usually considered simple (and are simple as far as the skin is concerned) .are in reality rendered compound by laceration of the mucous lining on the deep surface. The bony septum is composed of the vertical plate of the eth- moid above and the vomer below (see Fig. 457). The angular interval between the ethmoid and the vomer is filled in by the cartilaginous septum. This cartilaginous septum ar- ticulates with the antero-inferior border of the vertical plate of the ethmoid and is continued into the vomer below. The junction of the cartilaginous septum with the anterior border of the vomer is peculiar because of the unusual manner in which the vomer is ossified. The ossification of the vomer begins in a single center and spreads in such a manner that two lateral plates of bone result, with a median layer of cartilage between them, which is continuous anteriorly with the quadrangular septal cartilage of the nose. Union between the two lateral plates of bone does not take place until after puberty. This peculiar arrangement results in the articulation between the vomer and the cartilage being stronger than the upper articulation between the ethmoid and the same cartilage. These anatomical points, together with the fact that the trauma is more directly transmitted to the upper part of the sep- tum, account for the more frequent displacement taking place between the ethmoid and the quadrangular cartilage in youth. Unless the interior of the nose is carefully inspected early in the FRACTURES OF THE NOSE 325 treatment, septal displacements may go unrecognized during the time that treatment would be most efficient. The angular artery and vein (continuations of the facial vessels) axe found running in a nearly vertical direction behind and lateral to the nasal bones, in which position they may give rise to troublesome hemorrhage when injured in severe compound frac- ture of the nose. The nasal nerve, a branch of the ophthalmic division of the trifacial, runs longitudinally on the internal surface of the nasal bone after having passed from the orbit to the nasal cavity by way of the anterior ethmoidal foramen and nasal slit. The upper portion of the vertical plate of the ethmoid is grooved for the passage of the ethmoidal nerves from the Schneiderian membrane to the olfactory bulb. The nasal nerve is, strictly speaking, a nerve of sensation, while the olfactory nerves have to do with the sense of smell ; the juxtaposition of these nerves with the bones involved accounts for the frequent disturbances of smell and sensation following fractures in this region. The mucous membrane of the nose is highly vascular, and in cases where a large vessel is lacerated we may experience consider- able difficulty in controlling hemorrhage. Etiology. — Fractures of the nasal bones and adjoining bony structures are the result of direct violence, such as blows on the face, falls and trauma sustained by various means. Fractures of the nasal bones constitute between four and five percent of all fractures. The injury is most commonly seen as the result of brawls. Symptoms. — The prominent symptoms of fracture of the nose are deformity, mobility and crepitus. Swelling of the soft parts rapidly follows the trauma and epistaxis is practically constant and appears immediately following the injury. There is more or less obstruction to nasal respiration, depending upon the inward displacement of the fragments, the swelling of the mucous mem- brane and the accumulation of clotted blood within the nasal cavities. The more extensive the region involved by fracture and the more pronounced the trauma, the greater the frequency of pronounced nasal obstruction. In severe cases where the fracture extends well backward involving the nasal canal, in the nasal process of the superior maxilla, we may have obstruction of the nasal duct with consequent lachrj^mation of the affected side. Oc- 326 FRACTURES AND DISLOCATIONS casionally we have emphysema of the ej^elids and face as a result of air having been forced from the nasal passages into the sub- Fig. 459. Fig. 458. — Old fracture of nasal bones ^vith lateral displacement. Fig. 459. — Old fracture of nasal bones with lateral displacement. Fig. 460. Fig. 461. Fig. 460. — Separation and angular disylacemeiit of lateral and septal cartilages to patient's right. Fig. 461. — Fracture of nasal bones with displacement to right. Partial separation of lateral and septal cartilages with displacement to left. cutaneous cellular tissue. The nature of the late symptoms will vary according to the presence or absence of infection. The cir- FRACTURES OF THE NOSE 327 eulation is extremely free iu this region, the vitality and resistance of the tissues great, and accordingly we find recovery more prompt and complete than might otherwise be expected. Necrotic bone is seldom seen, and infections, except when virulent, are short-lived. Suppuration, however, when once established, may persist for weeks if there are particles of necrotic bone present. The dis- charge will keep up until these pieces have been removed or thrown off. Diagnosis. — Diagnosis of fracture of the nose is based upon the symptoms already enumerated ; deformity, mobility and crepitus. Figs. 462 and 463. — Two views of a case of destruction of the nasal bridge due to syphilis. Deformity resembles deformity following severe fracture. Deformity, as observed in these cases, is not as reliable from a diagnostic standpoint as it is in fractures of other regions. This fact is due to the variability of the normal nasal outline together with the frequent presence of old unreduced deformities following previous fractures. If the bridge of the nose is gripped between the thumb and the index finger the stability of the bones may be ascertained and crepitus elicited. The question of mobility is rather variable. During examination it is not infrequently possible to displace the fragments from side to side with but slight effort; but on the other hand, we often see cases in which the bones have been for- 328 FRACTURES AND DISLOCATIONS cibly displaced to one side and have apparently become wedged, requiring considerable force to return them to their normal rela- tions. A long slender instrument similar to the divider, when properly passed upward behind the seat of fracture, will enable Fig. 464. — Falling in of cartilages in old case of syphilis. Fig. 46.5. — Case of saddle nose due to hereditary syphilis. the surgeon to determine the internal contour of the nasal frag- ments. The diagnosis of fracture of the nose cannot be considered complete without ascertaining the condition of the osseous and cartilaginous nasal septum. This may be accomplished by direct inspection or by palpation with a probe. FRACTURES OF THE NOSE 329 Treatment. — In dealing with fractures in this region the treat- ment must var}- according to the severity of the injury. Severe compound comminuted fractures may, at times, become extremely difficult to manage. The indications must be considered in each and every individual case. Displacement, when present, must be corrected, and the fragments maintained in proper apposition. Ke- Fig. 466. Fig. 467. Fig. 466. — Raising the nasal bones by means of "divider" within the nasal cavity and moulding them into position vs^ith the thumb aiad index linger. Fig. 467. — Packing nasal cavities with strips of gauze soaked in adrenalin to control hemorrhage and support bridge of nose. duction is usually best accomplished by combined external and internal manipulation. A small slender instrument which will approximately fit the posterior surface of the nasal bone is passed upward into the nose, the fragment raised and pushed back into position, with the assistance, externally, of the thumb and index of the opposite hand. Fig. 468. — Asche nasal splints. (Different sizes.) Both sides should be adjusted in this manner, and the contour of the nose carefully inspected and palpated to produce as sym- metric a result as possible. At the same time we must be pre- pared to readjust the septum when it shows lateral displacement. The injuries seen in the septum are numerous, involving for the most part the quadrangular cartilage and the vertical plate of 330 FRACTURES AND DISLOCATIONS the ethmoid; the important point as far as treatment is concerned is the tendency toward displacement after the nasal bones have been replaced. Lateral bowing of the septum or overriding of the fragments should be reduced, and if there is tendency to re- currence of deformity some means of maintaining reduction must be employed. The tubular nasal splint will often accomplish all that is required but if some more secure method is needed pins may be introduced to hold the septum, as suggested by Roberts.^ Hemorrhage from the torn mucous membrane may be severe, but even when moderate at the time of examination there is no assur- ance that it will not be profuse a few hours later; it is therefore Fig. 469. Fig. 470. Fig. 469. — Author's moulded, dental composition, nasal splint. Fig. 470. — The Cobb nasal splint. wise to pack the upper anterior portion of the nasal cavity at the first treatment. This will maintain the fragments in proper posi- tion and also serve as a pack to control hemorrhage from the lacerated portion of the mucous membrane. It is usually not necessary to pack the parts tightly enough to bulge the bridge of the nose ; the strip of gauze however should be carried well up under the nasal bones before the packing is begun. ,If these strips of gauze are previously saturated with a 1 to 1,000 adrenalin chlorid solution we have an additional preventive against hem- orrhage. When the case is first seen hemorrhage is, as a rule, the most important element to be dealt with, and for this reason it is best to employ the pack rather than the nasal splint, which 1 "Surgery of Fractures and Dislocations of the Nose," in Stirg., Gynec. and Obstet. June, 1911. John B. Roberts, M.D, FRACTURES OF THE NOSE 331 finds a more appropriate place iu the after-treatment of the case. AVe should attempt to reduce deformity immediately following injury, yet, if the hemorrhage is pronounced, it should be con- trolled even at the expense of perfect reduction. Later on when the danger of hemorrhage has passed, more accurate adjustment of the fragments may be made, and one of the various forms of nasal splint, commonly in use, emploj^ed. The same trauma which produces the fracture not infrequently lacerates the skin over the nose. "When this is the case, we have the wound to treat as well as the fracture. Wounds when present should be thoroughly cleansed and the edges approximated. If the margins of the wound show much laceration the ragged edges should be trimmed away with a sharp scalpel before the sutures are placed. Either local or general anesthesia is advisable except in the most mild type of case. If the nose is gently packed for a few minutes with strips of gauze saturated in a four percent solution of co- caine, subsequent manipulations will be rendered almost free from pain and the surgeon's work is made much easier. Operative Treatment. — There is little in the way of operative treatment in these cases aside from that already described. There are exceptional cases, however, in which it may be necessary to reconstruct the bridge of the nose or to correct old deflections of the septum or nasal bones which have resulted from old unre- duced fractures. Pronounced depression may result either from the original trauma or from subsequent infection and sloughing. Syphilis is still another cause of falling of the bridge or cartilages and the resultant deformity should not be confused with the trau- matic condition. Syphilitics often misrepresent their case and unless the surgeon recognizes the luetic nature of the condition, he may perform a plastic operation on the nose of an active syphilitic, while the specific processes are still destructive. In correcting deflections and depressions of the bridge an at- tempt is made to bring the displaced portions of bone back into position after having refractured them as near as possible to the original seat of fracture. Much can be accomplished in the lower portion of the bone by incisions through the mucous membrane on the deep surface of the bones. When the deflection begins high up near the frontal refracture may be accomplished by a small subcutaneous incision and narrow chisel. After the displaced fragments have been refractured they are brought back into posi- 332 FRACTURES AND DISLOCATIONS tioii and treated the same as a recent fracture. The septum re- quires attention and when deflected it may become necessary to do a submucous resection, as is done for deflections resulting from causes other than fracture. In some cases of saddle nose there is not sufficient bony tissue from which to reconstruct the bridge and the problem then becomes one not only of plastic surgery but also of bone transplantation. A bone transplant ol appropriate size and shape is taken from the crest of the tibia, introduced within the tissues of the nose and the soft parts closed over it according to the plastic method best suited to the case in hand. When the bone transplant is used it should be shaped and placed to flt the needs of the particular case, and the denuded osseous material of the transplant should be brought firmly in contact with the de- nuded surface of the living bone, so that the reformative osteo- genetic elements may find their way from the living bone into the transplant during the process of repair. The injection of paraffin to correct nasal depression has often been followed by satisfactory results, but on the whole cannot be recommended except in rare cases. The most satisfactory suture, except where there is considerable tension of the parts, is horse-hair. After-Treatment. — The gauze packs should not be allowed to remain in place more than forty-eight hours at the most and we should exercise the greatest gentleness in their removal in order that we may avoid the recurrence of hemorrhage. If the packs are allowed to remain longer they become foul, thus favoring in- fection and suppuration. We occasionally meet with cases in which both primary and secondary hemorrhage are difficult to control. If hemorrhage follows the removal of the packs, the inside of the nose is to be inspected to determine whether we have a general oozing or a hemorrhage from a single vessel. In cases where loss of blood from a single vessel is persistent it may become advisable to touch the bleeding end with a small electro-cautery. When the dangers of hemorrhage and infection are past the re- maining desideratum consists in maintaining the fragments in position until union has taken place. In most cases the simple nasal splint (Asche splint) fitted into the upper nares will suffice. A slight degree of pressure may be maintained from the outside by strips of adhesive plaster applied across the bridge of the nose. Various types of complicated external nasal splints (such FRACTURES OF THE NOSE 333 as the Cobb, Eisendratli, Neres, etc.) have been devised and nsed with success, but it is only in rare instances that they are of real service. "When external pressure is necessary to maintain the fragments in proper position we may employ the following method which is quite efficient and simple. A piece of dental composition, hav- ing been rendered pliable by immersing it in hot water, is applied to the nose and a mould of the parts taken Avith such pressure as may be necessar}^ to maintain proper reduction. Cold water is then poured over the composition