treatment of nasal fracture by paul of aegina
TRANSCRIPT
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Jeffrey S. Fichera MS PA-C
The Ear, Nose, Throat and Plastic Surgery Assoc. Inc.
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Facial Injuries in SportsFacial Injuries in Sports
The Athletic Trainer must be prepaired to manage facial injuries, including
ContusionsAbrasionsLaserationsNasal fractures
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Facial Injuries in SportsFacial Injuries in Sports
Septal hematomasAuricular hematomsRuptured tympanic membranesFractures of the facial bones
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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.
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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 )
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Return-to-PlayReturn-to-Play
Treament requires knowledge of the injury
Type and serverity of injury
Physicial demands of the sport
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Initial Exam and EvaluationInitial Exam and Evaluation
Pertinent History
Physicial Exam
Remember the “ WOW FACTOR ”
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Soft-Tissue InjuriesSoft-Tissue Injuries
Contusions
Abrasions
Lacerations
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ContusionsContusions
Most commonly encountered facial injury
Results from blunt trauma to the face
Treatment aimed at minimizing inflammatory response ( ice, nonsteroidals)
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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
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Nasal InjuriesNasal Injuries
Epistaxis
Septal Hematoma
Fracture
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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
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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
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Nasal Blood SupplyNasal Blood Supply
Internal Carotid– Opthalmic artery
Anterior and Posterior ethmoid artery
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Nasal Blood SupplyNasal Blood Supply
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EPISTAXISEPISTAXIS
Cosider nasal fracture as source of epistaxis.
Athlete may report having heard a “crunch” or “crack”.
Nasal fractures are diagnosed clinically.
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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.
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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
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Persistent EpistaxisPersistent Epistaxis
Occasionally requires nasal packing with:– Mericel Sponge
Topical Antibiotic Topical Coagulant
– FloSeal
– May use phenylephrine hydrochloride or oxymetazoline hydrochloride for vasoconstriction
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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.
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Nasal FractureNasal Fracture
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Complications from Nasal Complications from Nasal FractureFracture
Chronic nasal obstructionDeviated septumSeptal hematoma
– Must Rule Out
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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
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Nasal FractureNasal Fracture
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Septal DeviationSeptal Deviation
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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
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The External EarThe External Ear
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Auricular HematomaAuricular Hematoma
Diagnosis established by early– Ecchymosis– Erythema and pain– Palpable collection of
fluid– Swelling of external
ear with loss of anatomical landmarks
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Auricular HematomaAuricular Hematoma
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Early TreatmentEarly Treatment
Ice apllied eary with continued compression can minimize the risk of developing an auricular hematoma.
If hematoma present – prompt aspiration required
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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
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Auricular HematomaAuricular Hematoma
I & D Evacuation of
hematoma
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Auricular HematomaAuricular Hematoma
Dental Roll Application
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Auricular HematomaAuricular Hematoma
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Auricular HematomaAuricular Hematoma
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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.
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ComplicationsComplications
Pressure necrosis of the underlying cartilage by seperating the perichondrial blood supply from the underlying cartilage, results in CAULIFLOWER EAR.
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Cauliflower EarCauliflower Ear
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Tympanic Membrane Tympanic Membrane PerforationPerforation
Most common Cause – pressure caused from OM
Blunt trauma – BarotraumaSwimming, diving, highaltitude changes,
direct contact to the ear
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TM AnatomyTM Anatomy
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Normal TMNormal TM
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TM PerforationTM Perforation
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TM PerforationTM Perforation
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TM PerforationTM Perforation
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TM Perforation SymptomsTM Perforation Symptoms
May be Asymptomatic orHearing lossVertigoBloody or serous dischargeDiscomfort worsened by wind or cold
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DiagnosisDiagnosis
Always consider if mechanism of injury present.
Otoscopic evaluation
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TreatmentTreatment
Keep ear canal dryENT evaluationAudiogramOtic drops may be requiredReturn to play will depend on sport and
symptoms
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Facial FracturesFacial Fractures
75 % of facial fractures occur in the:– Mandable– Zygoma– Nose
All Facial Fractures Require Referal
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DiagnosisDiagnosis
Type Mechanism of injury
Signs and Symptoms
Mandible Trauma to lower face
Malocclusion, abnormal mandibular movement
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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
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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
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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
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Questions ?Questions ?