ACUTE MANAGEMENT OF NASOETHMOID

ORBITAL FRACTURES
LARRY A. SARGENT, MD

Injuries to the central midface frequently result in fractures of the nasoethmoid orbital skeleton. These fractures are
the most complex, both diagnostically and therapeutically. Successful treatment depends on identifying the pattern of
fracture combined with early aggressive management. The computed tomography scan defines the nasoethmoid
fracture pattern and determines the extent of adjacent fractures. The operative technique consists of wide exposure
with meticulous reduction and stabilization of the fracture fragments using the techniques of craniofacial surgery.
Reduction of the medial orbital rim segment with transnasal wiring is the key to the repair. The remaining orbital rim
fractures are reduced and stabilized by using microplates and miniplates. Internal orbital fractures are usually
visually assessed and reconstructed as needed with complete stabilization of any associated fractures. When middle
and distal-third nasal support is lost, a bone graft is used to restore dorsal contour and support to the nose. The
restoration of normal soft-tissue contour to the medial canthal area and "nasoethmoid valley" is crucial in obtaining
the best aesthetic result. The techniques of craniofacial surgery have greatly enhanced the ability to restore preinjury
appearance.
Copyright 9 1998 by W.B. Saunders Company

KEY WORDS: nasoethmoid, orbital fractures, transnasal canthopexy

Blunt t r a u m a to the midface can result in complex of nasal projection and the soft-tissue contour of the medial
injuries that are difficult to diagnose and treat. Fractures of canthal area and naso-orbital valley. 9-12
the nasoethmoid orbital (NOE) skeleton are perhaps the The goal in the treatment of the nasoethmoid orbital
most challenging in facial trauma reconstruction. These fracture is to restore (1) preinjury intercanthal distance, (2)
fractures m a y occur as isolated injuries or in combination normal nasal projection and dorsal contour, and (3) normal
with adjacent fractures. Soft-tissue e d e m a m a y obscure the
physical finding, and a high degree of suspicion is neces-
sary to confirm the diagnosis. A physical examination in
which the medial orbital rim segments are manipulated
can determine instability or displacement of the NOE
fracture. An axial and coronal c o m p u t e d t o m o g r a p h y (CT)
scan of the face can identify the NOE fracture pattern, and
adjacent fractures. Both of these evaluations are necessary
to establish a successful operative treatment plan. Failure
to diagnose these injuries or inadequate treatment can
result in functional and cosmetic deformities that m a y be
only partially correctable. 1-3
The complexity of the nasoethmoid skeleton can create
n u m e r o u s technical difficulties in restoring preinjury
anatomy. O p t i m u m surgical treatment involves wide expo-
sure, meticulous reduction of b o n y fragments, and ad-
equate stabilization. 4-13 M a n a g e m e n t of the medial orbital
rim segment, which contains the canthal t e n d o n attach-
ment, is the critical step in successful treatment of these
injuries. However, perfect reduction and stabilization of
these fractures will not in themselves ensure a good
aesthetic result. Two extremely i m p o r t factors that have
been u n d e r e m p h a s i z e d in the literature are the restoration

Fig 1. The central bone segment of the nasoethmoid com-

From the Department of Plastic and Reconstructive Surgery, University
of Tennessee, Chattanooga, TN.
Address reprint requests to Larry A. Sargent, MD, 979 E Third Street,
Suite 900, Chattanooga, TN 37403.
Copyright 9 1998 by W.B. Saunders Company
1071-0949/98/0503-000458.00/0
plex is shown in the shaded area. The medial canthal liga-
ment attachment is illustrated. (Reprinted with permission
from Markowitz BL, Manson PN, Sargent LA, et al: Manage-
ment of the medial canthal tendon in nasoethmoid orbital
fractures: The central fragment in classification and treat-
ment. Plast Reconstr Surg 87:843-852, 1991)

Operative Techniques in Plastic and Reconstructive Surgery, Vol 5, No 3 (August), 1998: pp 213-222 213
 Type I Fractures
I

Type II Fractures

l Fig 2. (A) Incomplete

Type I injury, displaced at
inferior orbital rim. (B)

1
Complete Type I injury.
Left, unilateral complete
injury. R~ght, complete bi-
lateral monobloc fracture.
(C) Type II injuries, com-
C minuted fractures. Left,
Type III Fractures unilateral injury. Right, bi-

1
lateral injury. (D) Type III
injuries, fractures extend-
ing into canthal tendon
insertion. Left, unilateral
injury. Right, bilateral in-
jury. (Reprinted with per-
mission from Markowitz
BL, Manson PN, Sargent
LA, et ah Management of
the medial canthal ten-
don in nasoethmoid or-
bital fractures: The central
fragment in classification
and treatment. Plast Re-
o M constr Surg 87:843-852,
1991)

soft-tissue contour in the medial canthal area (NOE valley).
This report presents an operative technique to accomplish
these goals and restore preinjury appearance.
ANATOMY
The nasoethmoid orbital skeleton is the complex area in the
midface where the orbit, nose, maxilla, and cranium join.
The thicker bony buttresses provide the structural support
to this region. The frontal process of the maxilla forms the
principal vertical buttress. The horizontal buttresses com-
prise the frontal bone or supraorbital rims superiorly and
the infraorbital rims inferiorly. The thinner, more fragile
bones of the medial orbit surround these thicker buttresses.
The lacrimal bone, lamina papyracea, and the ethmoid
bone form the internal medial orbital wall; these delicate
bones comrninute easily and can produce a medial wall
"blowout." Fractures can extend into the deep posterome-
dial orbit, but rarely is there displacement of the posterior
third of the orbit.
Fractures of the nasal bones, which are anterior to the
nasoethmoid skeleton, should not be confused with naso-
ethmoid orbital fractures. The NOE fracture includes the
lateral aspect of the nasal bones, inferior orbital rim, frontal
process of the maxilla, and medial orbital wall (Fig 1). This
type of fracture is a disruption of the canthal-bearing
fragment of the medial orbital rim. 9 Displacement of this
medial wall segment cannot occur without the described
fracture lines; however, the degree of comminution can
vary. Fractures through the tendon insertion are rare but
may occur in the comminuted injury. These require careful
identification of the canthal tendon with reinsertion into a
bone fragment or bone graft by using a wire suture.
The interorbital space is located below the floor of the
anterior cranial fossa and between the medial orbital walls.
It contains the two ethmoidal labyrinths divided by the

21 4 LARRY A, SARGENT
perpendicular plate of the ethmoid and nasal septum. The
interorbital space offers no significant structural support to
midface trauma, and invariably the bone comminutes and
collapses. These fractures can extend into the anterior
cranial fossa adjacent to the cribriform with resultant
cerebrospinal fluid rhinorrhea and pneumocephalus. Addi-
tional injuries, such as frontal lobe contusion and olfactory
nerve disruption, may occur.
Understanding the complex anatomy in this area and
identifying the nonstable central fragment are the first
steps to successful management of these injuries.
DIAGNOSIS
The best way to confirm the diagnosis of nasoethmoid
orbital fractures is the combination of physical examina-
tion and CT examination. Frequently, on physical examina-
tion there is the posterior "telescoping" displacement of
the NOE complex. The dorsum of the nose may be
flattened with the tip of the nose turned up at an obtuse
nasolabial angle. A telecanthus may be present because of
widening of the medial orbital walls. However, when
undisplaced fractures are present, the physical examina-
tion can determine fracture stability and the need for open
reduction. A manual examination in which the thumb and
index finger are placed over the canthal-bearing medial
orbital rim-bone fragments is required to assess stability.14
~ oo
,oooQee~176176176176176176
I~176 Q~
e. "O
~
p6~
J
Fig 3. Diagram showing incision options to provide expo-
sure of nasoethmoid orbital complex. (Reprinted with permis-
sion from Sargent LA: Nasoethmoid Orbital Fractures. Prob-
lems in Plast Reconstr Surg 1:426-445, 1991)
NASOETHMOID ORBITAL FRACTURES
Fig 4. A displaced right unilateral single segment NOE
fracture is illustrated. This fracture requires stabilization at
the superior and inferior orbital rims. (Reprinted with permis-
sion from Sargent LA: Nasoethmoid Orbital Fractures. Prob-
lems in Plast Reconstr Surg 1:426-445, 1991)
If the finger and thumb are placed too superiorly or
anteriorly nasal bone fractures may be palpated, which can
lead to a misdiagnosis; nasal bone fractures are not NOE
fractures. The instability of these fractures may vary from
very slight movement to obvious gross mobility in cases of
severe injury. However, any movement implies instability
and requires open reduction and stabilization.
The CT scan plays an important role in identifying the
pattern and extent of the nasoethmoid orbital injury.
Coronal and axial images spaced at 1.5 mm are necessary
to determine the extent and degree of comminution of the
fractures. 15These scans require careful analysis to diagnose
associated fractures such as frontal sinus, Le Fort, and
additional internal orbital fractures. This information will
determine the surgical approach that will be needed. The
three-dimensional CT reconstructions are helpful to visual-
ize the fracture lines on the NOE skeleton; however, these
reconstructions can often give an underestimated view of
the injury.
Once the diagnosis of the NOE is made, dassif3ring the
type of fracture is helpful in establishing the treatment
plan. A number of classification systems have been de-
scribed in the literature. 12,16The key factors in a classifica-
tion system for fractures are to distinguish the unilateral
fracture from the bilateral and the simple from the commi-
nuted. In addition, the presence of an isolated NOE
fracture versus one that extends to associated fractures
should be identified. Analysis of NOE fractures reveals
three distinct patterns. A classification system based on the
central medial orbital fragment is shown in Figure 2. Type I
is a single central fragment that contains the medial canthal
tendon. Comminution of the central fragment without
extension into the canthal insertion is Type II. Type III
injuries involve comminution that extends into the canthal
tendon insertion. Canthal avulsion may be present.
A combination of the CT scan and physical examination
is necessary to decide if operative intervention is necessary.
All displaced NOE fractures require operative interven-
tion. Any instability on NOE manual examination requires
open reduction and stabilization. Fractures that do not
show any movement on examination or displacement of
the NOE fracture on CT scan do not need operative repair.
215
 C D

Fig 5. (A) Bilateral comminuted nasoethmoid orbital fracture is illustrated. (B) One technique of transnasal wiring used to
stabilize central bone fragments. (C) Superior and inferior orbital rims are stabilized with miniplates and microplates as
illustrated. (D) Cantilever calvarial bone graft used to restore support to the nose. (Reprinted with permission from Sargent LA:
Nasoethmoid Orbital Fractures. Problems in Plast Reconstr Surg 1:426-445, 1991)

SURGICAL TECHNIQUE
Repair of the nasoethmoid complex is the most technically
challenging of all facial fractures. Once the diagnosis of a
NOE fracture has been made, the fracture pattern should
be identified (classification) and the associated fractures
assessed. These two factors determine the surgical inci-
sions and the type of exposure needed.
The different types of incisions are shown in Fig 3. For
complete exposure of the nasoethmoid skeleton, the follow-
ing three incisions are required: the coronal a lower eyelid,
and upper buccal sulcus. The coronal incision provides
excellent exposure of the NOE region. However, the most
difficult area to expose is the medial orbital wall segments.
Care must be taken when dissecting the medial wall
fragments so that inadvertent stripping of the canthal
insertion is avoided. This makes the repair more difficult
because the tendons have to be reinserted. A lower-eyelid
or subciliary incision is used to raise a skin muscle flap and
expose the inferior orbital rim. Reduction and stabilization
of the inferior medial orbital rim fracture site as well as
exploration of the orbital floor are performed with this
exposure. A maxillary gingivobuccal sulcus incision is
required to provide exposure of the fracture sites of the
nasomaxillary buttress and pyriform.
Use of existing lacerations over the nose or frontal region
may provide limited exposure of the NOE skeleton and can
be used in the isolated fracture. The author's preference for
a local incision in this area is the vertical midline. 9 A short
incision that is positioned over the dorsum of the upper
nose is aesthetically superior to incisions that extend into
the medial canthal area. The vertical midline incision is a
good option in the elderly or bald patient with an isolated
NOE fracture. The local incision provides limited but
excellent exposure of the central medial orbital wall seg-
ments in which the accuracy of the reduction can be easily
assessed.
The Type I fracture may involve a single segment that is
minimally displaced at the inferior orbital rim and "green-

216 LARRY A. SARGENT

sticked" at the nasofrontal suture. This type of fracture can
be managed with simple plate and screw fixation (Fig 4).
The displaced single fragment fracture requires reduction
and stabilization of both the inferior and superior orbital
rims. Any lateral displacement of the canthal segment may
require transnasal wires in addition to rigid fixation of the
orbital rims. The more common fracture pattern is the
comminuted unilateral or bilateral fracture (Types II and
III). These fractures are more difficult to reduce and
stabilize, and a much wider exposure is necessary. The
coronal lower-eyelid, and maxillary gingivobuccal sulcus
incision are all needed to provide adequate exposure. After
complete exposure of this area is obtained, the central bone
fragment with the medial canthal tendon attached is
identified. Dissection must be performed carefully so that
inadvertent stripping of the canthal tendon is avoided.
Once the canthal-bearing bone segment is identified, addi-
tional subperiosteal dissection should be minimized on
this fragment. In the more comminuted fracture, identify-
ing this bone fragment may be difficult. It may be neces-
sary to make a small transverse incision over the medial
canthus to identify the tendons and the bone fragment to
which they are attached. The nasal bones are temporarily
dislocated or removed at the fracture site to provide better
exposure of the medial orbital walls. This is an important
maneuver because it provides excellent exposure for place-
ment of the transnasal wires and for assessment of the
accuracy of the reduction. Placement of the transnasal

Fig 7. Alternate method for securing central bone fragments

(A). Two drill holes have been placed and a 26g or 28g wire
inserted and twisted down tight to the bone (B). The twisted
wires in each central bone fragment can then be twisted
together to obtain reduction.

wires with a parallel-type reduction of the medial orbital

Fig 6. (Top) Anterior placement of transnasal wires results in
lateral displacement of the medial orbital rims. (Bottom)
Transnasal wires should be placed posterior to the canthus
to obtain adequate reduction of the medial orbital walls.
(Reprinted with permission from Sargent LA: Nasoethmoid
Orbital Fractures. Problems in Plast Reconstr Surg 1:426-
445, 1991)
rim is the key to obtaining the best aesthetic results. In
addition, the medial canthal tendon insertion should al-
ways be preserved when possible. Transnasal wires (26 or
28 gauge) are passed through drill holes placed superior
and posterior to the medial canthus on the central bone
fragment (Fig 5B). On larger bone fragments an additional
wire placed inferiorly may be used to further stabilize and
prevent any rotation of the medial orbital walls. Transnasal
wires that are placed too anteriorly will cause a posterior

NASOETHMOID ORBITAL FRACTURES 217

 Fig 8. (A) Isolated bilateral comminuted nasoethmoid orbital
fractures. (B) Profile shows telescoping displacement of nose,
(C) Close-up of displaced canthi, (D and E) Preoperative CT
scan.

flaring of the medial walls, resulting in a telecanthus (Fig stabilized with interosseous wires. Stabilization at the
6). Tightening of the transnasal wires should be performed superior and inferior orbital rims is obtained with
to the point of overcorrection to obtain the best results (Fig miniplates or microplates (Fig 5C). All plates are to be
7). The remaining comminuted fragments are reduced and avoided in the medial canthal area to avoid an unnatural

218 LARRYA. SARGENT


contour once the edema resolves. After the nasoethmoid
fractures are stabilized, the associated midface fractures
are addressed and the internal orbits explored with defects
repaired as needed. This technique is illustrated in Fig 5
and clinically shown in Figs 8, 9, and 10.
It is extremely unlikely for the medial canthal tendon to
be avulsed unless there is a penetrating laceration in the
medial canthal area. Although rare, the comminuted frac-
ture may extend through the tendon insertion, leaving too
small a fragment to use in reconstruction. If this unusual
situation does occur, the medial canthal tendon should
then be identified through a separate transverse incision
overlying the tendon. A 3-0 wire suture is used to place a
modified Kessler stitch in the tendon. The canthal tendon
NASOETHMOID ORBITAL FRACTURES
Fig 8 (Cont'd). (F-H) Postoperative result.
is then reinserted into the medial wall bone fragment by
passing the 3-0 wire through two drill holes and twisting
together. If the medial wall segment is too small or missing,
a bone graft is used to reconstruct it. The bone grafts or
medial wall segments can then be reduced and stabilized
with transnasal wires.
BONE GRAFTS
Bone grafts are frequently required to reconstruct the nose
and internal orbit in NOE fractures. Defects of the medial
orbital wall and floor are reconstructed with bone grafts or
metal mesh. 17 This restores normal orbital volume and
21 9
 Fig 9. (A) A 51-year-old woman involved in motor vehicle
accident who sustained comminuted bilateral NOE fractures
and extensive soft-tissue injuries. (B) NOE fractures are
reduced and stabilized, and nose reconstructed with cantile-
ver calvarial bone graft. (C) Postoperative appearance after
one-stage reconstruction. (D) Intercanthal distance restored
as well as nasal contour (E).

220 LARRY A. SARGENT

Fig 10. (A) Comminuted bilateral nasoethmoid fractures as-
sociated with extensive panfacial fractures. (B) Preoperative
CT scan. (C) Postoperative result.

shape, thus avoiding enophthalmos and vertical orbital
dystopia.
One of the principle goals of NOE repair should be to
restore the normal projection and contour of the nose.
Reduction and stabilization of the nasal bones do not
guarantee the return of preinjury nasal appearance. The
nasal septum should be carefully assessed on CT and
clinical examination. Collapse of the nasal septum with
loss of support to the distal half of the nose is frequently
present in these injuries. If, on physical examination, the
tip of the nose can be pressed down to the nasal spine,
septal support has been lost. Reduction of the septum is

Fig 11. A cantilever calvarial bone graft can be used to restore support and contour to the nasal
dorsum. The graft can be secured with lag screws or a miniplate. (Reprinted with permission from
Sargent LA: Nasoethmoid Orbital Fractures. Problems in Plast Reconstr Surg 1:426-445, 1991)

NASOETHMOID ORBITAL FRACTURES ~)21

not a d e q u a t e treatment, a n d a cantilever calvarial bone
graft is necessary to restore n o r m a l projection to the tip and
s m o o t h contour to the nasal d o r s u m (Fig 11). The cantile-
ver b o n e graft can be secured w i t h t w o lag screws or a
small miniplate, is Both can be c o u n t e r s u n k to a v o i d palpa-
tion. The existing nasal b o n e s m a y n e e d to be b u r r e d flat
(2-5 ram) so that the bone graft will h a v e better contact.
This will a v o i d an increase in nasal height at the radix, and
the resultant a b n o r m a l nasofrontal angle. It is crucial that
the b o n e graft be r o u n d e d and s h a p e d to the a p p r o p r i a t e
contour, size, and length. A bone graft that has not b e e n
contoured will result in a b r o a d flat d o r s u m that is not
aesthetically pleasing. If the graft extends to the tip of the
nose, it s h o u l d be placed b e n e a t h the lower lateral carti-
lages so the tip will be cartilaginous a n d not bony. The
majority of c o m m i n u t e d N O E fractures will h a v e loss of
septal support, m a k i n g a nasal b o n e graft essential to
restore preinjury appearance.
NASO-ORBITAL SOFT-TISSUE CONTOUR
Despite excellent reduction and stabilization of the NOE
fracture, h e m a t o m a and chronic e d e m a can cause scarring
in the thin tissue of the medial canthal area. This can result
in the a p p e a r a n c e of an increased intercanthal distance
despite satisfactory bone reduction. The skin and soft
tissue anterior to the canthal t e n d o n are v e r y thin, which
gives the m e d i a l canthal area its characteristic appearance.
All plates should be a v o i d e d in the area anterior to the
t e n d o n insertion because this results in a thickened b l u n t e d
contour, w h i c h is undesirable.
R e d r a p i n g of the soft tissue in the naso-orbital valley is a
crucial step in restoring the preinjury appearance. The
dissection that is necessary to reduce the b o n y f r a g m e n t s in
this area h a s resulted in elevation of the soft tissue f r o m the
bone. If steps are not taken to ensure p r o p e r r e d r a p i n g of
this soft tissue, h e m a t o m a a n d scarring can result in loss of
the thin delicate contour. P a d d e d nasal plates or bolsters
are positioned over the naso-orbital valley a n d lateral nose
to r e d r a p e a n d assist a d a p t a t i o n of the skin to the underly-
ing bone. These compression bolsters are m a d e with 2 - m m
thick plastic on lead plates (15 • 30 m m ) p a d d e d with
orthopedic felt w r a p p e d in Xeroform ( S h e r w o o d Medical,
St Louis, MO). Transnasal pull-out wires are placed with a
spinal needle to secure the bolsters. It should be e m p h a -
sized that these p a d s h a v e no role in m a i n t a i n i n g the
intercanthal distance but are v e r y effective in controlling
soft-tissue contour.
222
SUMMARY
An organized t r e a t m e n t p l a n is presented for the reduction
and stabilization of n a s o e t h m o i d orbital fractures, Meticu-
lous reduction a n d stabilization of the fracture segments,
c o m b i n e d w i t h transnasal wiring to restore intercanthal
distance, yield the best results. However, preinjury a p p e a r -
ance cannot be achieved w i t h o u t equal attention to restor-
ing nasal contour a n d projection as well as r e d r a p i n g of
soft tissue in the naso-orbital valley. Early aggressive
m a n a g e m e n t w i t h w i d e exposure using the techniques of
craniofacial surgery offers the best chance of restoring
preinjury a p p e a r a n c e a n d avoiding the difficult task of late
reconstruction.
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LARRY A. SARGENT