Friday, November 05, 2010

Nasal Bone Fracture- Grey Zone

Young adult presented with lateral force injury and right nasal bone tenderness
pictures show possible  high fracture of right  side better appreciated as compared to the left, though  airzones and soft tissues are not  grossly abnormal. High freq USG(100% accurate )/CT scan (90%helpful)/ clinical exam  would help.


Case submitted by DR MGK Murthy.


Approximately 80% of fractures occur at the lower one third to one half of the nasal bones. This area represents a transition zone between the thicker proximal and thinner distal segments. Fractures of the nasal bones are frequently transverse. The lateral view obtained by using a soft-tissue technique is probably best for depicting old and new fractures of the nasal bones. Lateral view is not useful in this

The use of plain images and computed tomography (CT) scans for the diagnosis and management of nasal fractures has been controversial. Several small studies have shown that use of these modalities is neither cost-effective nor beneficial to the patient or physician. Nasal fractures are usually evident and can be elicited by means of careful history taking and physical examination. Rarely is the radiologic confirmation of these injuries needed

The misreads were found to be the result of the midline nasal suture, the nasomaxillary suture (low defect), and thinning of the nasal wall (high defect).  Short lucent lines that reach the anterior cortex of the nasal bone, with or without displacement, should be regarded as nasal fractures. Other lines, such as normal sutures or longitudinally oriented nasociliary grooves, can be mistaken for longitudinal fractures. However, a nasociliary groove should never cross the plane of the nasal bridge; if this is demonstrated, the line is a fracture. Fortunately, fractures usually demonstrate a sharpened delineation, with greater lucency than normal sutures and grooves.

The radiologist must look closely for marked deviation, displacement with sharp angulation, and soft-tissue swelling. It is important to remember that only approximately 15% of old fractures heal by ossification; as a result, old fractures are easily mistaken for new fractures, and this increases the rate of false-positive readings.

 Evaluation of air zones by profilogram can provide important information, because the air zones commonly are lost after trauma. Alterations of air-zone shapes may indicate cartilage volume increases or septal hematoma. Other injuries that are commonly associated with nasal fractures include midface injuries involving the frontal, ethmoid, and lacrimal bones; nasoorbital ethmoid fractures; orbital wall fractures; cribriform plate fractures; frontal sinus fractures; and maxillary Le Fort I, II, and III fractures

 Carry home msgs


How to do lat view(Profilogram)

The lateral view (profilogram) is obtained with the infraorbitomeatal line parallel to the transverse axis of the film and the intrapupillary line perpendicular to the plate.  Many prefer to include the full profile from the forehead to the chin

1. physical exam preferably under anaesthsia is good
2.High Resolution USG 100% accurate
3.Medicolegal  req may need Xray/CT- being questioned today
4. Lateral (profilogram) is preferred  along with waters view
5. lower fractures are  more common
6. soft  tissue swelling and Air zones abnormality very helpful for Radiologist
7. sutures  and grooves are our bugbear
8. old fractures do not  heal by ossification  and hence can be read as fresh fxs
9. non bony septal injuries very imp
10. we must look for associated fractures  like maxillary , orbital and  frontal bones

1 comment:

Lambert said...

I like your feed. This is very helpful. What should I understand under "Air zones"? Thank you.

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