Complex Case of Pan Facial Fracture with Flail Nose
A 45-year-old male presented in the Emergency of Medanta - Ranchi with polytrauma. The patient was initially treated at another centre and referred to our hospital for further management.
On initial assessment, the patient was semiconscious and irritable. He had dyspnoea, pallor and tachycardia. There were signs of excessive bleeding from the nose and oral cavity as the nose and mouth were full of blood clots with gross laceration of the palate, nose and upper lip. There was considerable swelling and deformity of the face with malalignment of teeth, stitched wounds at the nose, upper lip and left eyebrow. The patient was breathing through the mouth as the nose was blocked with blood clots; the nasal bridge had collapsed completely, and was moving in and out with the patient’s breath - a condition known as a flail nose, just like a flail chest.
We immediately started resuscitating him and followed it up with basic investigations, including a CT scan of the brain, face and chest. CT brain was suggestive of diffuse axonal injury; CT chest revealed multiple rib fractures; CT face showed panfacial fracture, including a fractured mandible symphysis, right temporo-mandibular (TM) joint dislocation, fracture of the hard palate, bilateral fronto-zygomatic and maxillary fractures along with comminuted depressed fracture of the nasal bones.
After initial assessment and investigations, the patient was shifted to the intensive care unit (ICU) in view of his critical condition. A tracheostomy was done to secure the airway and the patient was put on ventilator support. We continued his resuscitation, administered intravenous (IV) fluids, did blood transfusion and took other measures. The neurosurgeon and chest surgeon evaluated the patient, and conservative treatment was planned for his head and chest injuries.
Management of facial injury was the main challenge. Almost all facial bones were fractured with moderate to gross displacement. There was also soft tissue laceration of the face and palate requiring time-consuming surgical procedures. To avoid permanent disability and deformity of the face, early surgical intervention for facial injury was necessary. However, due to the associated life-threatening condition – mainly the brain injury - the facial surgery was deferred for 3 days till the patient’s condition stabilised and he got a go-ahead from the neurosurgeon.
After 3 days, he was planned for surgical correction of the facial fractures. Close reduction of right TM joint was done, fracture symphysis of mandible was reduced with appropriate reduction forceps and clamps, and fixed with locking plates and screws. Bilateral fronto-zygomatic comminuted fractures were reduced and fixed with miniplates and screws. The fracture in the hard palate was reduced with maxillary disimpaction forceps and fixed with rectangular miniplate and screws; and the palatal laceration was repaired. The nasal fracture was approached through the existing wound on dorsum of the nose extending on left eyebrow. As the nasal bones were in multiple pieces, they were reduced by manipulation with nasal forceps and fixed with multiple miniplates and screws to achieve satisfactory nasal contour. The soft tissue of the nose and upper lip was repaired and maxillary fractures were taken care of using close reduction as they were relatively stable. Arch bars were applied to further stabilise the maxillary fractures, and to maintain satisfactory occlusion in post-operative period with dynamic rubber band traction.
The 5-hour-long surgery was uneventful with good clinical outcome; satisfactory and stable fixation of facial fractures was obtained. The patient was on ventilator support for 4 days after the surgery, mainly due to brain and chest injury. He was discharged in a stable condition on Day 1 4 of admission.
Discussion
Fractures of individual facial bones are common but panfacial fractures pose a special challenge, more so when associated with other injuries that are life-threatening. They need special surgical expertise, skilled anaesthetic backup along with a dedicated critical care team, a neurosurgeon, a chest surgeon and other specialities to deal with associated injuries.
Nose is a conspicuous projection, and is more likely to be involved in any facial injury. Hence fracture of the nose is the most common among all facial bones. Most nasal fractures can be managed effectively by close reduction and splinting.
However, nasal fracture with flail nose is not common, and requires special attention and expertise as these fractures are unstable and reduction cannot be maintained without internal fixation. Internal fixation of flail nose itself is challenging as nasal bones are fractured into multiple small pieces that are unstable. It is mandatory to reduce the fractured segments, and to maintain the reduction till screws are drilled over miniplates. This is also difficult because of the size of the fractured fragments. Moreover, every case of panfacial fracture is different and poses unique challenges; the surgeon has to take decisions as per the situation.
