A METHOD OF INTERNAL SPLINTING FOR UNSTABLE NASAL FRACTURES. A. J. SEAR, M.B.,Ch.B., B.D.S., F.D.S.

Transcription

1 British Journal of Oral Surgery 14 (I 977) A METHOD OF INTERNAL SPLINTING FOR UNSTABLE NASAL FRACTURES A. J. SEAR, M.B.,Ch.B., B.D.S., F.D.S. Worcester Royal Injirmary Summary. A method of intra-nasal splinting has been outlined which revives principles and improves on methods established particularly well by two French Stomatologists at the beginning of this century. It uses a simple splint, carefully chosen from a range of sizes, that requires precise insertion, and has proved to have several advantages over more commonly employed techniques. Introduction The numerous methods, ancient and modern, of splinting a fractured nose can be divided into three main groups which are often combined to reduce their individual limitations. Internal packs of soft material, when inserted firmly enough to support the normally very narrow portion beneath the bridge, inevitably produce a widening effect, if it is fragmented. Obstruction of the nasal airway is unpleasant for the patient and it is often necessary to remove or replace these materials before stability has been achieved. External plasters, moulds and plates used to prevent widening and lateral deformity, unless adjustable (Oldfield & Roberts, 1947; Terracol, 1953), are rarely effective for more than a few days once oedema and haematoma are resolving. They obscure the parts to which they are applied and may produce pressure ulceration. Transnasal suspension wires attached to an external fixation apparatus, to be effective, must pass through reasonably sized fragments of bone in their correctly reduced position. Several wires may be required, supporting a rigid internal former, if a cheese-cutting effect on the soft tissues is to be avoided (Maliniac, 1947). A fourth group provides rigid internal support, for example by bent rods inserted through the anterior nares. As long ago as 1912, Molinits apparatus was in use, which supported the bridge from the floor of the nose. This was shortly after Claude and Francisque Martin, French pioneer maxillo-facial surgeons, had outlined the principles of accurate reduction and immobilisation of nasal fractures, using a range of ingenious adjustable splints based on this principle (Martin & Martin, 1910). These appliances have the disadvantage of protruding from the nose, but have the major advantage of supporting the bridge exactly where required and tenting the nasal soft tissues and septum to reduce any lateral displacement of fragments (Fig. 1). These advantages, plus the added requirements of minimal airway obstruction and tolerance until bone union is complete, led to the design and trial of an entirely internal rigid nasal splint. The i&a-nasal splint The splints are constructed from oval section, soft, stainless steel & (3.175 mm) x A ( mm). Identical pairs are bent in the form of a figure 7 with the widest (Received 26 April; accepted 2 June 1976)

2 204 BRITISH JOURNAL OF ORAL SURGERY External Suspension RIgId Bridge Internal Support Soft Internal Pat ks FIG. I. Methods of nasal splinting, showing the tenting effect of narrow internal bridge support. J J FIG. 2 (left). The figure 7 intra-nasal splint diagram and range of sizes found adequate in this series of cases. FIG. 3 (right). The complete range of paired splints, bending tools, 0.3 mm soft stainless steel wire and awl.

3 INTERNAL SPLINTING FOR UNSTABLE FRACTURES 205 FIG. 4 (left). Diagram of stages in splint insertion. FIG. 5 (right). Diagram of splints secured in position. Note the short-arm tip behind the ridge between vestibule and nasal cavity proper. diameter flat. The short arm is rounded and polished at its tip. The long arm is drilled and bevelled to a sharp point. The point must lie on a line dropped at right angles from the mid-point of the supporting arm to obtain maximum stability. A plan of the actual sizes of the range required facilitates accurate bending of the varying angles and matching of the pairs (Figs 2 and 3). Reduction and immobilisation of the maxillae and nasal floor is a prerequisite of definitive nasal treatment, when fractures of these parts co-exist. After reduction of the nose and prior to the insertion of splints, all soft tissue repair must be completed. Septal haematomata must be drained and partial submucous resection of the septum and septoplasty performed when appropriate. A true lateral radiograph of the nose and maxillae, exposed to show nasal bones and soft tissue outline without loss of hard palate definition, is used in selecting the appropriate splint size. The required length of bridge support is estimated first and the short limb of the splint chosen to err on the short side. When the splint is held at the estimated post-reduction angle the sharpened long limb should just reach the nasal floor. Approximately 30 cm lengths of 0.35 mm soft, stainless steel wire are secured through the eye of the splint by twisting on the inner side of its angle. The pointed limb is inserted into the nasal cavity, parallel to its floor, until the bend can be tucked into the vestibule (Fig. 4). The short supporting limb can then be raised into the vault of the nasal cavity (Fig. 5). Use of a short Killian s speculum and splint manipulation with polyp forceps has been found to allow the best visualisation while the short arm is being placed in position beneath the fractured nasal bones and, if dislocated, the upper nasal cartilages. It is important that the rounded tip of the short arm is always placed behind the limen nasi or ridge between the vestibule and nasal cavity

4 206 BRITISH JOlJRNAL OF ORAL SURGERY FIG. 6. Radiograph of splints supporting fractured nasal bones and upper nasal cartilages. proper. This ridge corresponds to the margin of the lower nasal cartilage (Hamilton & Harrison, 1971). During fitting, minor adjustments to the shape of the short arm can be made with pliers or Levo-type bar benders. The splint is raised and brought forward under the nasal bridge using forceps and traction on the wire, until a satisfactory profile has been achieved and a definite resistance to further movement can be felt. If the splint size has been estimated correctly, the point should, in this position, just reach the nasal floor. Relaxation of traction will allow it to engage securely in the nasal floor. The second splint is placed in the opposite nasal cavity in exactly the same way, while gentle tension is maintained on the first splint s wire to prevent displacement. Tension is maintained on both wires by an assistant holding them at their mid-point. The upper lip is raised and a sharp mandibular awl is passed from one side of the fraenum, as close as possible to the anterior nasal spine, to emerge in the nasal cavity. The wire is threaded through the eye of the awl in the nasal cavity and drawn back into the labial sulcus without kinking. The awl is reinserted via the same mucosal puncture, but passed under the nasal spine to the opposite nasal

5 INTERNAL SPLINTING FOR UNSTABLE FRACTURES 207 cavity to draw back the other wire. They are twisted together for about 1 cm until tight beneath the spine. The trimmed twisted end is looped back and buried beneath the mucosa. A non-absorbable suture is passed through the wire loop while closing the puncture site to act as a marker. Radiographs will check the splints positions in relation to the support required (Fig. 6). When a fracture of the nasal spine precludes this method of securing the wires, eyelet wires, splints or per alveolar loops may be used. A pack can still be used after splinting to control haemorrhage if necessary. The splints may remain in place as long as deemed necessary. A short general anaesthetic using an oral endotracheal tube has been found most satisfactory for their removal. The twisted wire loop is presented by pulling on the marker suture and after untwisting can be cut off close to the mucosa. Each splint is disengaged by an upward and backward displacement of its long arm, which allows the tip of the short arm to appear in the vestibule and be delivered down and then forward. A short bleed should be anticipated and controlled with adrenaline gauze, before termination of the anaesthetic. A total of 74 patients have been treated by this method over five years. Their age range was 3 to 65 years and averaged 26 years. Fifty-seven were promptly treated fractures, five associated with fractures of the maxilla and one with an adjacent fracture of the orbital floor. Nineteen of these had a submucous resection type approach to the nasal septum. Three had external pressure applied initially adjacent to the inner canthi. Fourteen were fractures more than three weeks old, 12 of which required osteotomy or refracture combined with an SMR approach. One involved the support of an onlay bone graft. Three were growth deformities associated with airway obstruction, all these requiring osteotomy and submucous resection of the nasal septum. Antibiotics were used in all cases for the first week. The average duration of splinting was 46 days. One busy contractor chose 385 days, without any ill-effects, and supported the comments of many patients that they were not conscious of having splints in their nose. Complications are summarised in Table I and account for 15 per cent of the cases treated. In no case was penetration of the nasal floor evident or suspected. Table I Complications in 74 Cases Inflammation Of nasal bridge Resolved by antibiotic 4 Requiring splint removal 2 Stitch abscess -Resolved spontaneously 1 Epistaxis Pressure on turbinate? 1 Loose splints 2 Adhesions Complicating splint removal I Results In spite of pre-operative and final result photographs, objective assessment is difficult without good pre-injury profile and frontal face records. The end results satisfied or pleased all the patients and their relatives in this series. Figure 7 is a case of naso-ethmoidal collapse involving the frontal sinus treated

6 208 BRITISH FIGS 7a, b, c. d. Pre-operative involving JOURNAL OF ORAL SURGERY and end-result photographs of a case of naso-ethmoidal the frontal sinus treated by this method. collapse by this method and Fig. 8 is a case of nasal bone fracture with dislocation of the cartilages treated in a similar fashion. Two were considered to show some bridge sag and one bridge widening. These were cases where splints had either been loose or had been removed too early in relation to the extent of the injury. It is now suggested that six weeks is a reasonable period using this method in the absence of extensive soft tissue laceration. Three showed tip fall, attributed to excessive anterior septal cartilage resection and one old injury showed persisting lateral deviation thought due to inadequate soft tissue mobilisation.

7 INTERNAL SPLINTING FOR UNSTABLE FRACTURES 209 FIGS 8a, b, c, d. Pre-operative and end-result photographs of a case of nasal bone fracture with cartilagenous dislocation treated by this method. Acknowledgements 1 wish to thank Mr T. S. Stewart, my colleague in the E.N.T. Department, for his encouragement to me in developing this method and for his prior instruction in the techniques of nasal surgery. References Hamilton, W. J. & Harrison, R. J. (1971). Scott Brown s Diseases offhe Ear, Nose and Throat, 3rd Ed., pp London: Butterworths. Maliniac, J. W. (1947). Rhinoplasty and Restoration of Facial Contour. Philadelphia: F. A. Davis. Martin, C. & Martin, F. (1910). Lyon Chirurgical, 3, 1. Oldfield, M. C. & Roberts, W. R. (1947). British Medical Journal, 1, 886. Terracol, J. (1953). Les Maladies des Fosses Nasales, 2nd Ed., pp Paris: Masson et Cie. 14/3-B