Nasal bone fracture

Traumatic maxillary sinusitis

This pathology occurs as a direct complication of midface bone fractures (including the maxilla and zygomatic bone). As a result of mechanical impact, small bone fragments, foreign bodies, or tooth root fragments penetrate into the sinus cavity.

Pathogenesis of changes in the sinus:

• Rupture and detachment of the mucous membrane occur.
• Exposed bone areas become covered with granulation tissue, which subsequently scars (encapsulating foreign objects).
• Polyps proliferate.
• Impacted bone fragments can become encapsulated by the mucosa, forming isolated purulent cavities.

Clinically, the patient complains of difficulty with nasal breathing on the affected side, foul-smelling purulent discharge, and a feeling of heaviness in the maxillary area, which aggravates when tilting the head forward. Treatment for this type of sinusitis is strictly surgical (maxillary sinusotomy with creation of an anastomosis).

Disorders of reparative osteogenesis

Normally, facial bone fractures (using the mandible as an example) fuse in 4–5 weeks. If the process takes 2–3 weeks longer, it is referred to as delayed consolidation. The main cause lies in genetic predisposition, aggravated by local (poor immobilization, tissue interposition) and general (diabetes, vitamin deficiency) factors.

In pronounced tissue hypoxia, metabolism switches to anaerobic glycolysis. Under these conditions, pericytes transform into fibroblasts and chondrocytes rather than osteoblasts. Defective collagen is synthesized, and a cartilaginous periosteal callus forms instead of normal bone.

If bone loss is less than 5 mm and mobility persists for a long time, a false joint (pseudarthrosis) forms. The ends of the fragments become covered with a terminal plate and are connected by a fibrous cord. Treatment of a pseudarthrosis requires scar excision and surgical osteosynthesis.

Malunion

Fusion of fragments with deformity occurs due to inadequate fixation, late presentation, or patient non-compliance with the regimen.

Signs of maxillary deformity:

• Impaired nasal breathing and loss of smell (anosmia).
• Double vision (diplopia), sinking of the eyeball (enophthalmos).
• Dysfunction of the nasolacrimal duct and lacrimation.
• Step-like deformity of the midface bones.

If no more than 4–5 weeks have passed since the trauma and the fragments retain tight mobility, conservative traction can be used. In chronic cases, open reduction is the only indication.

Temporomandibular joint dislocations

Traumatic impact (e.g., a blow to the chin with the mouth open) or even excessive yawning can lead to dislocation. The most common is anterior dislocation, in which the articular head jumps over the articular tubercle and ends up on its anterior slope.

Clinical picture of bilateral dislocation:

• The patient cannot close their mouth.
• Speech is difficult, and profuse salivation is noted.
• The face is elongated, the cheeks are flattened, and the masticatory muscles are tense.
• A characteristic depression is palpated anterior to the tragus of the ear.

Conservative methods are used for reduction (e.g., Hippocrates' method, Blechman's or Popescu's method). After successful reduction, a sling bandage must be applied for 3–5 days with a ban on wide mouth opening for up to 10 days.

Class and exam questions

What else to study on this topic

• Pathogenesis of osteogenesis according to D.D. Sumarokov in hypoxia
• Manual reduction techniques for dislocations: Hippocrates, Blechman, Popescu
• Orthopedic appliances: Petrosov, Burgonskaya, Yadrova splint
• Differential diagnosis of jaw defect and pseudarthrosis
• Surgical treatment of chronic anterior dislocations

Other topics in the section "Chapter 11. Non-ballistic and ballistic facial injuries. Thermal and radiation lesions of the maxillofacial region (V.V. Afanasyev)"

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