Traumatic injuries to the nose and face are on the increase in the country, which is related to the gradual entry of the country into the automobile society and the increase in the absolute number of car accidents. Also violent injuries and industrial accidents are important causes. Some of the traumatic injuries to the nasal face belong to fractures of the nasal orbital sieve, which not only seriously affect the cosmetic appearance of the nasal face, but also injure important organs such as the skull and brain and eyes, causing significant injuries, and if effective revision surgery is not performed in time, it will have adverse effects on future life and work and significantly reduce the quality of life. In this paper, we review and summarize 40 cases of nasal orbital sieve compound fractures treated surgically from January 2008 to April 2011 with satisfactory results, and report them as follows.
1.Data and methods
(1) Clinical data
From January 2008 to April 2011, 40 patients were admitted to our department and the ophthalmology department and operated by our department, among them, 31 were male and 9 were female; their ages ranged from 15 to 66 years old, with an average of 37 years old; the time between trauma and operation ranged from 2 days to 60 days, among which 25 cases were operated within 2 weeks and 15 cases were operated after 2 weeks to 2 months; the classification of nasorbital sieve compound fracture was according to Markowitz classification, 2 cases were type III, 29 cases were type II, and 9 cases were type I out of 40 cases.
(2) Treatment methods
a. Surgical incision
The surgical field requires complete exposure of all fracture lines to facilitate the placement of titanium plates and fixation of titanium nails. If the trauma is open, the surgical area is first exposed by opening the original incision, supplemented by lower lid margin, nasal root, and labiogingival groove incisions if necessary. If the fracture is closed, a direct lower lid margin incision is made, supplemented by a transverse nasal root incision or a labiogingival sulcus incision. If there is a frontal fracture, a cranial coronal incision is made to expose the operative field.
b. Treatment of fractures
The anatomical position of the displaced bone tissue of the fracture is crucial for the restoration of nasal and ocular function, so the surgical repositioning of the displaced bone tissue is crucial. The surgical field exposes all fracture lines to be treated. fracture sites within 2 weeks of trauma generally do not have obvious bone scab formation, and there is little soft tissue embedded in the fracture break, so only the trauma of the fracture needs to be freed with a stripper, the bone tissue is retracted to the anatomical position with a towel clamp or tissue clamp, and it is fixed to the unfractured stable bone tissue with a titanium plate. for fractures over 2 weeks, there is often thicker and harder bone scab formation at the fracture site, and the displacement When the displacement is obvious, there is often a large amount of soft tissue embedded in the fracture site and even closely adhered to the deep soft tissue. In this case, a small bone chisel should be used to gently chisel away the scab along the fracture line, clean the embedded soft tissue with a stripper or small plastic scissors, gently shake the bone tissue after clamping it with a towel clamp, and gradually pull it to the normal anatomic position before fixation. For periorbital as well as frontal bone fractures, we choose 2.0 plates because of the hard bone tissue and large volume. For nasal bones, 1.3 plates are generally used because of the thin bone tissue.
c. Treatment of the nose and nasal septum
Nasal orbital sieve compound fractures are often accompanied by fractures of the nasal septum, causing nasal ventilation disorders. In cases where the trauma time is less than 2 weeks, the deviated septum can often be fixed by squeezing and pushing to the midline position with tonsil stripper after anatomical resetting of the nasal bone and nasal cavity filling. Longer septal deviations sometimes require submucosal corrective surgery with nasal filling and compression fixation. In cases of nasal lacrimal sac anastomosis, care needs to be taken to protect the mucosa around the fistula in the lateral wall of the nasal cavity to avoid local mucosal scar formation after excessive injury, which may affect the prognosis. For lacrimal reconstruction surgery with placement of a prosthetic tube from the lacrimal fossa to the nasal cavity, the length of the tube into the nasal cavity is observed, generally extending 2 mm into the mucosa of the lateral wall of the nasal cavity is appropriate. In one patient, the lacrimal duct was reopened only after a stage II surgery to correct the septal deviation. Postoperatively, the external nose was fixed with nasal clips and the nasal cavity was filled with an expanding sponge. At the same time, the nasal clip had the effect of reducing the local outward tension of the repositioned medial canthal ligament in patients who underwent medial canthal ligament repositioning, which facilitated the postoperative recovery.
d. Treatment of the eye
In collaboration with the ophthalmologist, orbital wall reconstruction is required for periorbital septal sinus paper plate fractures and maxillary sinus parietal wall fractures in the orbital floor, when the orbital contents are embedded in the septum or fall into the maxillary sinus, resulting in spherical invagination or diplopia. Titanium mesh and Medpor materials are generally used. In 40 patients with tear overflow, the cause of tear overflow was determined preoperatively. 25 patients had tear overflow, 3 cases were affected by the displacement of the medial canthal ligament, and the medial canthal ligament was restored to normal after repositioning; 2 cases had tear duct rupture, and the tear duct was placed into the nasal cavity at the lacrimal caruncle, and lacrimal reconstruction surgery was performed; 5 cases were caused by the compression of the nasolacrimal duct by the displaced bone tissue of the fracture, and the bone tissue was restored to normal after repositioning; 15 cases had nasolacrimal duct rupture, and the nasal lacrimal sac anastomosis was performed The nasolacrimal duct was ruptured in 15 cases, and a nasal tear sac anastomosis was performed. For type I fractures, the bone tissue attached to the medial canthal ligament was repositioned to its normal anatomic position and fixed; for type II fractures, the bone tissue attached to the medial canthal ligament was pulled to its anatomic position and fixed to the stable bone tissue with a longer titanium plate because of the instability of the surrounding bone; for type III fractures, the medial canthal ligament was ligated with 2.0 nylon braided suture “8 ” suture to the medial canthal ligament and then retracted to the normal anatomic position. A hole is drilled in the stable bone tissue and then sutured there. If there is no stable bone tissue available for fixation in the anatomic position, it can be fixed to a titanium plate that spans this area.
2. Results
The nasal facial appearance improved significantly in 40 patients, and 27 patients with nasal congestion had normal postoperative ventilation. 25 cases of tear overflow, including 1 case of lacrimal caruncle disposed of prosthetic tube lacrimal reconstruction, were obstructed by the prosthetic tube topping the deviated septum, and all of them had lacrimal passage after stage II septal deviation correction. All 15 cases with significant medial canthus displacement were successfully repositioned, and the medial canthus was symmetrical after surgery.
3. Discussion
In some patients with compound fractures of the nasal orbital sieve, the sieve bone and periorbital fracture are visible on CT examination, but there is no bone tissue displacement, and only the displaced nasal bone is collapsed. In such patients, the traditional closed repositioning surgery of the nasal bone is feasible to reset the collapsed and displaced nasal bone, which can generally achieve better results and avoid the more invasive internal fixation surgery. The nasal orbital sieve compound fracture with obvious displacement of bone tissue is also not all eligible for internal fixation surgery in one phase. Titanium plate internal fixation is only applicable to patients without obvious infection foci at the trauma site, therefore, those who suffer from purulent sinusitis, purulent dacryocystitis and more serious contamination of trauma tissue are not suitable for titanium plate internal fixation surgery.
Choice of incision: Opening into the surgical area from the original incision generally does not cause new trauma, but the problem of new trauma caused by the incision should be considered when choosing an auxiliary incision. The small incision at the root of the nose is usually made to facilitate the fixation of the titanium plate in the frontal area, and the incision is small, consistent with the direction of the skin grain, and traumatic, and generally without sequelae. The biggest problem with the lid margin incision is the possibility of lid ectropion; we have had one case of partial loss of lower lid skin due to trauma and slight ectropion after suturing. We appreciate the importance of suturing technique as well as sharp separation to avoid lower lid ectropion. A coronal incision of the forehead can cause numbness of the forehead skin. The labioglossal incision can also cause the possibility of numbness in the cheek and upper lip. These trauma issues need to be fully communicated with the patient and family preoperatively.
The force of trauma causing a compound fracture of the nasal orbital sieve is often greater; therefore, patients diagnosed with a compound fracture of the nasal orbital sieve should not undergo immediate revision surgery and should be observed for 1 to 2 days to rule out the presence of fatal cranial trauma. Use this time to contact the ophthalmologist and brain surgeon to make an assessment of the existing injury caused by the fracture, as well as to inform the patient of the problems that can be solved with this surgery and those that will require a phase II procedure. All of the cases in this group are within 2 months of trauma. Our experience is that for trauma longer than 2 months, it is difficult to anatomically reset the displaced bone tissue surgically, which may be related to the formation of a new stabilization system by the bone scab. The surface scab can be chiseled away with a bone chisel, but the deeper scab cannot be loosened, and forcible retraction may cause brain and eye damage, which is not worth the loss. Therefore, patients over 2 months old can only be treated symptomatically by performing external rhinoplasty with corresponding osteotomy. The repositioning surgery of the medial canthus and the reconstruction surgery of the lacrimal duct are poorer than those patients operated within 2 months because the anatomical repositioning of the bone tissue cannot be achieved.
To sum up our clinical experience, the indications for titanium plate internal fixation surgery of nasal orbital sieve compound fracture should include, (1) poor results of closed compound or displacement of bone tissues causing re-deformation of nasal appearance for a short time after extraction of nasal filling; (2) soft tissues or fragmented bone fragments embedded in the fracture end by CT examination, which cannot be resolved by closed repositioning, and no septic lesions in the traumatized tissues or surrounding tissues or no serious contamination in the wound The time interval between trauma and surgery is less than 2 months.