A DETAILED PPT ON NOE FRACTURE AND ITS MANAGEMENT.

2. maxillofacial skeletal injuries

4. The naso-orbito-ethmoidal region is situated in the
central upper midface consists of a strong
triangular frame.

5. Osteology
Soft tissue anatomy

6. Nasal bones
Ethmoid
Frontal process of maxilla
Medial orbital rim and wall
Other bones involved:
Perpendicular and cribriform
plate of ethmoid
Nasal process of frontal
bone.
Sphenoid bone.

7. 4 cavities involved:
Cranium
Orbits
Nasal
Maxilla
STRENGTH
Vertical buttress: frontal process of
maxilla
Horizontal buttress: superior/inferior
orbital rims.

9. Superiorly, thin ethmoid
bones form part of the
floor of the anterior skull
base, in this region dural
injury and resultant CSF
leakage is possible.
The ethmoid bone is
located posterior to the
nasal bones,the ethmoid
air cells are present at birth
and enlarge to adult size by
the age 12 years.

10. The overall growth and size of ethmoid
complex is highly variable among
individuals.
The ethmoid labyrinth separates the orbits
from the nasal cavity ,while the fovea
ethmoidalis forms the roof of the ethmoid
sinuses laterally.

11. Medial canthal ligament
Lacrimal drainage apparatus
Associated vessels.

12. The medial canthal
ligament (MCT) is a
crucial soft tissue
component of NOE
complex.
It arises from the
anterior and posterior
lacrimal crest and
frontal process of
maxilla.

14. The tendon splits
around the lacrimal
sac and attaches to
the anterior and
posterior lacrimal
crests, as well as to
the frontal process
of maxilla.
The canthal tendon
diverges to become
the pretarsal
,preseptal, and
orbital orbicularis
oculi muscle.

15. The action of the muscles and telecanthus
allow for pumping action of the lacrimal sac
and ducts allowing for propagation of tears
through nasolacrimal system.
In addition, the MCT acts as a suspensory sling
for the globe, maintaining its support along
with the lateral canthal tendon.

17. Has the potential to be disrupted on a NOE
fracture especially a comminuted one.
The system consists of a lacrimal glands
situated in the superolateral anterior portion
of the orbit and two lacrmial canaliculi that
drain the eye via puncta that are situated in
the medial aspect of each eye.

19. The sac drains into the inferior meatus
via the nasolacrimal duct.
The duct is around 20 mm in length half
of which is bony.
The portion of the nasolacrimal system
that is most prone to damage is the bony
nasolactimal duct.

22. The horizontal
buttress is divided
into the superior
horizontal buttress
and the inferior
horizontal buttress,
which consists of
the frontal bone,
superior orbital
rims and inferior
orbital rims.

23. The medial vertical
buttress consists of
the internal angular
process of the
frontal bone and the
bilateral frontal
processes of the
maxilla.

24. The blood supplying for the midface and
nasal region comes from the branches of
internal and the external carotid arteries.
The anterior and posterior ethmoid arteries
descend from the internal carotid artery.
The maxillary artery from the external
carotid artery and subsequent branches
play a mainstay role for supporting the
midface.

25. The NOE region is innervated by ophthalmic
and maxillary nerves, which are derived from
the Trigeminal nerve.
TRIGEMINAL
NERVE
OPTHALMIC
NERVE
MAXILLARY
NERVE

26. The nasal bones and underlying cartilage are
susceptible to fractures because the nose
maintains a prominent position and central
location on the face and because it has a low
breaking strength.
Patterns of fractures are known to vary with
momentum of the striking object and the density
of the underlying bone. (Murray,1994)

27. As with other facial
bones,younger patients
tend to have larger
nasoseptal fracture
segments,whereas older
patients are more likely
to present with more-
comminuted fracture
patterns.
(Cummings,1998)

28. RTA
Sport injuries
Fights
Work related accidents
Falls are the most common cause ofnasal
injury in children.

29. Comminution of the
entire complex may
occur
Telecanthus,enophthalmos,diplopia,
midface retrusion

30. The clinical symptoms associate wit the
location and severity of the NOE fracture.
Patients with naso-orbito-ethmoidal
(NOE) fractures often have associated
facial injuries or panfacial fractures.

31. Gross facial edema may show
firstly in the early stage of
fracture, which will result in
distortion of soft tissue
landmarks.

32. Laceration in the nose and
forehead.
Intracranial involvement.
Eye, forehead, and nose pain
Forehead paraesthesias
Traumatic hypertelorism
Mongoloid slant.

33. Flattened nasal bridge
with splaying of nasal
complex.
Saddle shaped deformity of
nose from side.
Epitaxis.
Tenderness ,crepitus and
mobility of nasal complex.
Nasal injuries:

34. Epitaxis
Reduced nasal projection
and height.
Septal deviation or
dislocation.
Anosmia caused by
damage to the cribiform
plate.
Nasal congestion
secondary to septal
hematoma or
bony/cartilaginous
deformity.

35. Enopthalmus
Diploplia
Entrapment
Vertical dystopia
Loss of globe integrity
Associated ocular injuries:

36. Traumatic telecanthus
Circumorbital oedema
and ecchymosis
Subconjuctival
haemorrhage.
Possible supra-
orbital/supra trochlear
nerve parasthesia.

37. •
Echymosis
Traumatic
telecanthus
Orbital dysplasia
Rounding of medial
canthal angle
Mongoloid slant

38. Traumatic
telecanthus(IC/IP>1/2)
Lack of eyelid tension-
positive bowstring test.
Rounding of the MCT.
Shortened palpebral
fissure.
Medial canthal tendon displacement

39. For telecanthus to occur ,the fracture
must involve at least 4 sites:
Medial orbital wall
Nasomaxillary butress/inferior orbital rim
Nrontomaxillary junction
Lateral nasal bone

40. Intracranial involvement
Pnemocephalus
CSF rhinorrhoea

41. Fracture of floor of anterior canal
fossa/base of skull.
Escape of CSF through
Ethmoidal sinus
Sphenoidal sinus
Cribriform plate
Frontal sinus

42. Communication between
Meninges
Nose
Paranasal sinuses
Dural laceration
Later becomes
epithelised to Fistula
Blood clot of brain tissue
may obstruct fluid passage.

43. After lysis of clot or increased
intracranial pressure leakage is seen.
Mobile midface fractures often creates
pumping action –because of increased CSF
leakage.

44. How is NOE complex fracture classified?
The status of the resulting central segment of
bone left by an NOE fracture is the basis of
classification of fracture patterns for this type of
injury.
Each fracture type is sub classified as either
unilateral or bilateral.
Among many classifications of NOE fractures, the
most widely accepted classification system was
established by Markowitz et al.
.

45. Type I: En bloc with minimum displacement.
Type II: En bloc displaced # with large
pneumatized sinus and minimum fragmentation.
Type III: Comminuted # with inatct MCT attached
to large bone.
Type IV:comminuted # with free MCT attached to bone not
large enough for plating.
Type V:Gross comminution needing grafting.

46. Isolated NOE and frontal region # without
other midface fractures
Unilateral
Bilateral
Isolated NOE and frontal region # with
other midface fractures.
Unilateral
bilateral

47.  In this simplest form,NOE fractures are isolated
involving only the portion of the medial orbital rim
that contains medial canthal tendon.
Type I pattern consists of single central
fragment bearing the medial canthus.

48. These fractures maybe bilateral ,complete
or displaced.
Uncommonly ,the medial canthal tendon
is torn or avulsed completely from an
intact medial bony wall.

49. In unilateral Markowitz type I fractures, there is a single large NOE
fragment bearing the medial canthal tendon.

50. Involvement of the nasal bone: the nasal bone may also be involved
and, in cases of comminution, may not provide adequate dorsal
support to the nasal bridge.

51. Type II fractures are complete and may be
unilateral or bilateral.
They may be single segment or communited
external to the medial canthal insertion in
the central segment.
MCT maintains continuity with large
fractured segment of bone,which maybe
used in the surgical reduction.

52. In unilateral type II fractures, there is often comminution of the NOE area, but the
canthal tendon remains attached to a fragment of bone, allowing the canthus to
be stabilized with wires or a small plate on the fractured segment.

53. The nasal bone may also be involved and, in cases of comminution, may not
provide adequate dorsal support to the nasal bridge.
Involvement of the nasal bone

54. The illustration shows a bilateral NOE type II fracture. In bilateral fractures the
nasal bones are commonly involved. In some instances, bone grafting of the
nasal dorsum may be necessary.
Bilateral type II fracture with nasal bone involvement

55. Communition within the central fragment
allows fracture to extend beneath the
canthal insertion characterising the type III
fracture pattern.
The canthus is rarely avulsed but it is tobone
fragments that are too small to utilize in
reconstruction.

56. In type III fractures, there is often comminution of the NOE area (as in type II
fractures) and a detachment of the medial canthal tendon from the bone.

57. The nasal bones are usually involved and might not provide adequate dorsal
support to the nasal bridge. In such cases bone graft reconstruction often is
indicated.
Involvement of nasal bone

58. The illustration shows a bilateral NOE type III fracture. The nasal
bones are usually involved. Bone graft of the nasal dorsum is
usually necessary.
Bilateral type III fracture with nasal bone involvement

59. Establish ABCs.
Diagnose any associated injuries.
Direct examination of NOE complex.
A thorough head and neck examination to
reveal injuries to the brain,spine, orbit and
facial skeleton is required.
A team approach involving the
otolaryngologist,plastic surgeon,
neurosurgeon and pohthalmologic
consultation is mandatory.

60. Direct examination
Diagnostic imaging CT
-2D CT
-3D CT
Dacrocystography

61. Plain radiographs have limited
usefulness in aiding in diagnosis of
NOE #s.
Thin cut axial and coronal CT scans are
the criterion standard for the diagnosis
of NOE fractures.

62. Examine the nasal cavity for the presence of CSF.
Query all conscious patients about the
presence of watery rhinorrhea or salty
postnasal drainage.
Test bloody fluid that is suspicious for CSF
rhinorrhea (see Lab Studies).
Examine facial lacerations under sterile
conditions to assess depth of penetration or
intracranial violation.
Toevaluate the integrity of the medial
canthal tendon.

63. Measure and document telecanthus and
enophthalmos.
Assess and document pupil responses and
extraocular muscle mobility.
Palpate the nasal bones for crepitus and
comminution.
Evaluate the septum for septal
hematoma.
Evaluate the degree of nasal or midface
retrusion. Preinjury photographs may be
helpful.

64. Examine facial lacerations under sterile conditions
to assess depth of penetration or intracranial
violation.

65. Evaluate the degree of nasal or midface retrusion

66. An intercanthal distance of > 35 mm is suggestive of
traumatic telecanthus ,measurement approaching
40mm are almost diagnostic.

67. The patient often has swelling in the medial canthal
area and pain and crepitation with palpation.

68. Examine the nasal cavity for
the presence of CSF.
Query all the patients about
the presence of watery
rhinnorhea or salty postnasal
drainage.
Test bloody fluid that is
suspicious of CSF rhinnorhea.
With NOE fractures a CSF leak should be assumed to be present even
if it is not clinically demonstrable and appropriate chemoprophylaxis
should be commenced.

69. The following diagnostic
procedures can be performed
if there is a suspected CSF leak
(clinical sign: straw-colored or
clear nasal drainage):
Tilt test with positive halo
sign (as illustrated)
Comparison of the
concentration of glucose
between fluid and patient’s
serum.

70. Bloody rhinorrhea
suspicious for CSF can be
placed on filter paper and
observed for a halo sign.
If CSF is present ,it diffuses
faster than blood and results
in a clear halo around the
central stain.
Routine chemistry analysis of
the rhinorrhea may reveal an
elevated glucose content
consistent with CSF.

71. Beta 2 transferrin is the definitive test forCSF
rhinorrhoea.collect 1 ml of the
suspected fluid in a red top tube.
Watery rhinorrhea that is positive for beta 2 -
transferrin is diagnostic for a CSF leak.

72. Till test with positive halo
sign

73. These two tests aids in the diagnosis of
instability of the Medial canthus tendon.
Bowstring test
Bimanual palpation by placing an
instrument into the nose to determine
canthal bearing bone fragment displaced
and mobile.
.

74. In the bow string test ,the eyelid is pulled
laterally while the tendon area is palpated to
detect movement of fracture segments.
A lack of resistance or movement of the
underlying bone is indicative of a fracture.
The surgeon may be able to grab the eyelid or
use a forceps to grab the skin in the medial
canthal area and pull it
laterally (“bow-string” test).

76. It requires placing an instrument (kelly
clamp) high into the nose,with its tip
directly beneath the MCT .
Gentle lifting with the contralateral finger
palpates the canthal tendons and allows an
assessment of instability of the tendon
attachement and necessity for open
reduction.

78. The lacrimal drainage system is intimately
related to the NOE region and can be
damaged during the trauma.
The surgeon should assess the
patency/continuity of the nasolacrimal
system at the time of surgical treatment.
If there is a discontinuity in the
nasolacrimal system repair should be
considered at the time of fracture
treatment.

79. Dye disappearance test
Jones test(primary and secondary tests)
Lacrimal irrigation
Scintigraphy
Contrast dacryocystography
CT scan

80. DDT is useful for assessing the presence or
absence of adequate lacrimal outflow.
2% fluorescein dye solution or a moistened
fluorescein strip instilled in conjuctival fornix.
Persistence of significant dye indicates an
obstruction.
If the DDT result is normal, severe lacrimal
drainage dysfunction is highly unlikely.

81. Obstruction of NLD

82. JONES I JONES II
JONES TEST

83. Like DDT,this test investigates lacrimal outflow
under normal physiologic conditions.
1 drop of 2% fluorescein dye placed into
conjuctival sac.
After about 5 mins ,cotton tipped applicator
inserted under the inferior turbinate.
If bud stained with dye ,test is positive.
Test is negative If no dye is detected ,means
there is partial or absolute obstruction or failure
of lacrimal pump.

86. Radiographic visualization of the
lacrimal sacs and associated
structures after injection of a
contrast medium.
Contrast dacryocystography
provides anatomical information
with dye injection into the
lacrimal system followed by
computerized digital subtraction
imaging.

87. Better over treated than under treated .
Why over treat?
Inadequate treatment
Secondary deformities
Missing or displaced bone fragments,
soft tissue scarring,malposition

88. Reconstitution of the skeletal framework of
NOE region.
Stabilization of the intercanthal width andMCT..
Orbital reconstruction.
Establishment of nasal support.
Reconstruction of other craniofacial
injuries including frontal sinus.
Soft tissue repair.

89. Early one stage repair
Exposure of all fracture fragments
Precise anatomic rigid fixation
Immediate bone grafting as indicated forbony
loss.
Definitive soft tissue management.

90. Exposure
Identify the MCL or the MCL bearing
bone.
Reduce/reconstruct medial orbital rims.
Reconstruct medial orbital walls.
Transnasal conthopexy
Reduce septal displacement
Soft tissue readaptation.

91. Unobstructed visualization of the articulations
of all the bones in the region.
One of the main reasons for treating NOE #s is
esthetics ,hence incisions are made keeping
in mind the esthetics.
Remote incisions preferred.

92. Skin incisions
-visible scars
No external
scars
Existing lacerations
Coronal incision
Eyelid incisions
Vertical//horizontal incisions
Open sky approach H shape incision.
W shape incision.
Lynch incision.
Transcaruncular incision
Pre caruncular incision
Transoral –degloving incision.
Midfacial degloving incision-great access/no scar.

95. Correction of associated frontal sinus fracture.
Harvesting of calvarial bone graft or primary
reconstruction
Harvesting of pericranial flap of sufficient length
for sealing of defects in the ant.cranial fossa.
Disadvantage:
Cannot be used when the skull has been opened
up previously for craniotomies by the
neurosurgeons.
ADVANTAGES:

101. Curved incision over
lateral nasal bones
anterior to MCL
attachment.
Skin here is thin-allows
easy exposure.
Sufficient or limited
reconstruction.
Cannot be used in
bilateral
canthopexies,bone
grafting.

102. Skin incision approx. 3 cm in length made
along the superior medial orbital rim
from 1 cm medial to medial canthus to the
lower border of the medial eyebrow.
Angles of limbs of the W-110 to 120
degree
Four limbs of the W can be placed
parallel or oblique to the RTSL
The lateral limb of the .W can be
extended laterally long the lower
border of the medial eyebrow,
depending on the desired exposure.

103. Muscledissection,supratrochlea r
nerve located and preserved.
Periosteum is incised from upper
half of the MCT to the medial
portion of superior orbital rim-
periorbita is laterally reflected.

104. Advantages:
W has small segmented limbs parallel or
oblique to the relaxed skin tenion lines.
W limbs break up the scar into smaller
components- minimal external scar.
Pulling both ends of the W along its
longitudinal axis provides the increase of its
longitudinal length- allows implant up to 3
cm to be inserted.
Superior access to medial orbital wall.

105. 1. Both MCL remain attached and the
laterization of the complex is counteracted by
the orbicularis oculi. Type I : b/l single
segment NOE #
2. Tendon is still attached to the bone but the
bone fragment is separate from complex
: U/l single segment type I injury.
3. Avulsion of tendon from bony connection
type III.
4. Bone into which the tendon inserts is
missing

109. Biomechanics of midface made
complicated by:
– Nonuniform geometry of bones
– Number and orientation of various attached
ligaments and soft tissues.
Treatment aimed to restrict three types of
movements of a fractures segment in 6
directions
Translatory movement essentially 2D
restricted by wires as well as plates

110. Rotatory movements : 3-D need
platesrestrictions at 3 separate points
more effective.
Farther apart the fixation points better
the stability wider plates thus preferred.
3 wires or several small plates oriented
at different angles increase stability.

111. Adjunct to primary bone
grafting.
Avoids supplemental
maxillomandibular or
extraskeletal fixation .
Better rigid support and
immobilization.
Prevents overriding of the
fractured fragments.

112. Transnasal reduction of canthal bearing
fragment most important step in
preserving intercanthal distance.
Loose nasal bones may be removed
temporarily for better access.
Fragment bearing the MCL identified.
If fragment is large enough reduce and
fix it to adjacent bone with miniplates

113. Importance:
Toregain anatomic morphology
Toregain lost orbital volume in blow out #
Toachieve normal eye position after injury.

114. Bone material of choice for
reconstruction calvarial graft/rib graft.
Long pieces of bone used should
extend just behind the medial orbital rim.
Fixed with lag screws or miniplates.
If Bone pieces extend too posteriorly
poor access. loss of stability

115. Canthal ligament was identified and
tagged earlier.
Followed by orbital wall and rim
reconstruction.
Steps demanded greatest traction.
If canthopexy performed earlier :
– Vigorous traction could pull through the
MCL and further damage the ligament.

116. Transnasal wiring
Ipsilateral/homolateral techniques:
•Nylon anchor suture,
•Stainless steel screw,
•Cantilevered miniplate (Y-shaped, five
holes),
•Bone anchor systems.

117. Nasal bone forming medial orbital wall and the
bridge of the nose fragile ?
Withstand wire tightening.
Glabellar portion of the frontal bone is solid and
can withstand wire tightening. • The fixation is
secure.
Due to the relatively large amount of soft tissue
covering the twisted wire, extrusion of the wire
through the skin does not occur.
No injury to delicate structures of the
contralateral medial orbit such as the
lacrimal sac or lacrimal duct.

118. Technically difficult.
Necessitates wide exposure sufficient to
allow transverse passage of a wire through a
bony fenestration deep within the orbit.
Weakening of the bones ( when central
fragment is drilled twice),
Dissection of the contralateral orbit.

119. A Kirschner wire with one of
the tips hammered and
shaped into a simple drill is
passed from the left orbit
toward the right thru
central fragment.
Plastic catheter is pushed
forward over the Kirschner
wire guide and through the
transnasal hole.

120. A bent, looped wire is
introduced from left to
right through the plastic
tube left in the transnasal
hole after t Kirschner wire
removed.

121. A titanium microplate is placed in
the loop at the second penetration
site.
Second microplate is placed
between the exiting wires at the
first penetration site,
Ends of the wires are twisted
together
The free tips of the wire at the
site of first penetration can be
used for canthopexy without
microplate placement, if desired

123. After passing thru ligament;The 30G wire is
passed through the posterior hole of the
miniplate and loosely twisted.
The plate is positioned, with the medial canthal
tendon pushed deep, near the posterior lacrimal
crest. The drill hole is made in the area of the
anterior hole of the plate and fixed with a stainless
steel screw (2 × 6 mm).
The stainless steel wire is then tightened.
The frontal process of the maxilla in the region of
the lacrimal crest is utilized for fixing the two- hole
plate transversely .

127. NOE # are associated with fractures of
perpendicular plate of ethmoid, septal
deviation, septal hematomas.
Goal should be to
–assure midline positioning of septum to
prevent airway compromise.
–Reduce septal fractures

130. n
g
Collapse of the bony
architecture broadening of
base.
Weakening of nasal
septal structures.
Damage to upper lateral
cartilages.
Complete loss of dorsal nasal
projection and loss of support.

132. Reinforcement of thin bones
Prevention of overriding and
displacement of fragments
Maintenance of vertical dimension
Provides substrate for osseous union
Prevention of soft tissue scarring

133. excellent
gently tapering it
Bone graft sites: calvarial
choice.
Shape it like a surf boat at
the end.
Length should extend from frontonasal
junction to nasal tip.
Colummelar strut if needed.
Fixation:
- Single lag screw into the nasal pyramid.
-Microplate to cantilever off the frontal bone.

135. Persistent Cerebrospinal fluid leakage.
Unconsciousness
Skull fractures
Increasing intracranial pressure
Meningitis

136. Temporary or permanent parasthesia.
CSF leak.
Meningitis.
Sinus infection or mucocoele.
Anosmia.
Infection of implants.
Postoperative telecanthus is a relatively
common complication of nasoorbitoethmoid
(NOE) fracture repair.

137. Pseudotelecanthus.
Enophthalmos results from inadequate
repair of the medial orbital wall or orbital
floor.
Midface retrusion may occur.
Extraocular dysfunction.
Blindness.
Possible need for additional surgery.

138. Postoperative ophthalmologic is examination
recommended, as well as gross visual acuity checks every
6 hours for a 24-hour period.
The Penrose drains are removed from the scalp at 24
hours, and the pressure dressing is discontinued after 3
days. The lead bolsters and scalp sutures are removed at
10 days postoperatively.
The patient should be examined and queried again, looking
for any evidence of a CSF leak. Patients should be asked to
perform standard nasal hygiene (nasal saline irrigations
and no nose blowing).

139.  Disruption of the delicate ethmoid complex
and comminution of the nasal bones can
make the repair of nasoorbitoethmoid
(NOE) complex fractures extremely
difficult.
These injuries often test the capabilities of
even the most experienced surgeons.

140. Toobtain an aesthetic surgical result, the
surgeon must meticulously identify,
accurately reduce, and rigidly fixate the
medial canthal tendon and central fragment.
Special attention also must be focused on
the overlying soft tissue to avoid
hematoma, chronic induration, and
pseudotelecanthus.

141. Aesthetic reconstruction of the nasal bone and
medial canthal region continues to be a
significant surgical challenge.
Future advances may address this issue with the
use of surgical navigation systems and/or
intraoperative imaging, which returns the bony
architecture to its premorbid state more
accurately.

142. NOE injuries can be difficult to manage.
Proper assessment and early surgical
management of the NOE and concomitant
injuries are key to optimal outcomes.
Overcorrection of the bony position and
compression of the soft tissue overlying the MCT
are critical. Residual telecanthus tends to be
recalcitrant despite the best efforts.