British Journal of Oral Surgery 14 (I 977) 203-209

A METHOD OF INTERNAL SPLINTING FOR UNSTABLE NASAL

FRACTURES

A. J. SEAR,M.B.,Ch.B., B.D.S., F.D.S.

Worcester Royal Injirmary

Summary. A method of intra-nasal splinting has been outlined which revives principles and improves
on methods established particularly well by two French Stomatologists at the beginning of this
century. It uses a simple splint, carefully chosen from a range of sizes, that requires precise insertion,
and has proved to have several advantages over more commonly employed techniques.

Introduction
The numerous methods, ancient and modern, of splinting a fractured nose can be
divided into three main groups which are often combined to reduce their individual
limitations. Internal packs of soft material, when inserted firmly enough to support
the normally very narrow portion beneath the bridge, inevitably produce a widening
effect, if it is fragmented. Obstruction of the nasal airway is unpleasant for the patient
and it is often necessary to remove or replace these materials before stability has
been achieved.
External plasters, moulds and plates used to prevent widening and lateral deformity,
unless adjustable (Oldfield & Roberts, 1947; Terracol, 1953), are rarely effective for
more than a few days once oedema and haematoma are resolving. They obscure the
parts to which they are applied and may produce pressure ulceration.
Transnasal suspension wires attached to an external fixation apparatus, to be
effective, must pass through reasonably sized fragments of bone in their correctly
reduced position. Several wires may be required, supporting a rigid internal former,
if a cheese-cutting effect on the soft tissues is to be avoided (Maliniac, 1947).
A fourth group provides rigid internal support, for example by bent rods inserted
through the anterior nares. As long ago as 1912, Molinits’ apparatus was in use,
which supported the bridge from the floor of the nose. This was shortly after Claude
and Francisque Martin, French pioneer maxillo-facial surgeons, had outlined the
principles of accurate reduction and immobilisation of nasal fractures, using a range
of ingenious adjustable splints based on this principle (Martin & Martin, 1910).
These appliances have the disadvantage of protruding from the nose, but have
the major advantage of supporting the bridge exactly where required and tenting the
nasal soft tissues and septum to reduce any lateral displacement of fragments (Fig. 1).
These advantages, plus the added requirements of minimal airway obstruction and
tolerance until bone union is complete, led to the design and trial of an entirely
internal rigid nasal splint.

The i&a-nasal splint

The splints are constructed from oval section, soft, stainless steel &”(3.175 mm) x A”
(1.5875 mm). Identical pairs are bent in the form of a figure ‘7’ with the widest
(Received 26 April; accepted 2 June 1976)
204 BRITISH JOURNAL OF ORAL SURGERY

External RIgId Internal

Suspension Bridge Support

Soft Internal Pat ks

FIG. I. Methods of nasal splinting, showing the tenting effect of narrow internal bridge support.

FIG. 2 (left). The figure ‘7’ intra-nasal splint diagram and range of sizes found adequate in this
series of cases.

FIG. 3 (right). The complete range of paired splints, bending tools, 0.3 mm soft stainless steel wire
and awl.
 INTERNAL SPLINTING FOR UNSTABLE FRACTURES 205

FIG. 4 (left). Diagram of stages in splint insertion.

FIG. 5 (right). Diagram of splints secured in position. Note the short-arm tip behind the ridge
between vestibule and nasal cavity proper.

diameter flat. The short arm is rounded and polished at its tip. The long arm is
drilled and bevelled to a sharp point. The point must lie on a line dropped at right
angles from the mid-point of the supporting arm to obtain maximum stability. A
plan of the actual sizes of the range required facilitates accurate bending of the
varying angles and matching of the pairs (Figs 2 and 3).
Reduction and immobilisation of the maxillae and nasal floor is a prerequisite of
definitive nasal treatment, when fractures of these parts co-exist. After reduction of
the nose and prior to the insertion of splints, all soft tissue repair must be completed.
Septal haematomata must be drained and partial submucous resection of the septum
and septoplasty performed when appropriate.
A true lateral radiograph of the nose and maxillae, exposed to show nasal bones
and soft tissue outline without loss of hard palate definition, is used in selecting the
appropriate splint size. The required length of bridge support is estimated first and
the short limb of the splint chosen to err on the short side. When the splint is held at
the estimated post-reduction angle the sharpened long limb should just reach the
nasal floor.
Approximately 30 cm lengths of 0.35 mm soft, stainless steel wire are secured
through the eye of the splint by twisting on the inner side of its angle. The pointed
limb is inserted into the nasal cavity, parallel to its floor, until the bend can be tucked
into the vestibule (Fig. 4). The short supporting limb can then be raised into the vault
of the nasal cavity (Fig. 5). Use of a short Killian’s speculum and splint manipulation
with polyp forceps has been found to allow the best visualisation while the short
arm is being placed in position beneath the fractured nasal bones and, if dislocated,
the upper nasal cartilages. It is important that the rounded tip of the short arm is
always placed behind the limen nasi or ridge between the vestibule and nasal cavity
206 BRITISH JOlJRNAL OF ORAL SURGERY

FIG. 6. Radiograph of splints supporting fractured nasal bones and upper nasal cartilages.

proper. This ridge corresponds to the margin of the lower nasal cartilage (Hamilton &
Harrison, 1971). During fitting, minor adjustments to the shape of the short arm
can be made with pliers or Levo-type bar benders. The splint is raised and brought
forward under the nasal bridge using forceps and traction on the wire, until a satis-
factory profile has been achieved and a definite resistance to further movement can
be felt. If the splint size has been estimated correctly, the point should, in this position,
just reach the nasal floor. Relaxation of traction will allow it to engage securely in
the nasal floor. The second splint is placed in the opposite nasal cavity in exactly
the same way, while gentle tension is maintained on the first splint’s wire to prevent
displacement. Tension is maintained on both wires by an assistant holding them at
their mid-point. The upper lip is raised and a sharp mandibular awl is passed from
one side of the fraenum, as close as possible to the anterior nasal spine, to emerge
in the nasal cavity. The wire is threaded through the eye of the awl in the nasal cavity
and drawn back into the labial sulcus without kinking. The awl is reinserted via
the same mucosal puncture, but passed under the nasal spine to the opposite nasal
 INTERNAL SPLINTING FOR UNSTABLE FRACTURES 207
cavity to draw back the other wire. They are twisted together for about 1 cm until
tight beneath the spine. The trimmed twisted end is looped back and buried beneath
the mucosa. A non-absorbable suture is passed through the wire loop while closing
the puncture site to act as a marker. Radiographs will check the splints positions in
relation to the support required (Fig. 6).
When a fracture of the nasal spine precludes this method of securing the wires,
eyelet wires, splints or per alveolar loops may be used.
A pack can still be used after splinting to control haemorrhage if necessary. The
splints may remain in place as long as deemed necessary.
A short general anaesthetic using an oral endotracheal tube has been found most
satisfactory for their removal. The twisted wire loop is presented by pulling on the
marker suture and after untwisting can be cut off close to the mucosa. Each splint
is disengaged by an upward and backward displacement of its long arm, which allows
the tip of the short arm to appear in the vestibule and be delivered down and then
forward. A short bleed should be anticipated and controlled with adrenaline gauze,
before termination of the anaesthetic.
A total of 74 patients have been treated by this method over five years. Their age
range was 3 to 65 years and averaged 26 years. Fifty-seven were promptly treated
fractures, five associated with fractures of the maxilla and one with an adjacent
fracture of the orbital floor. Nineteen of these had a submucous resection type
approach to the nasal septum. Three had external pressure applied initially adjacent
to the inner canthi. Fourteen were fractures more than three weeks old, 12 of which
required osteotomy or refracture combined with an SMR approach. One involved
the support of an onlay bone graft. Three were growth deformities associated with
airway obstruction, all these requiring osteotomy and submucous resection of the
nasal septum.
Antibiotics were used in all cases for the first week. The average duration of splinting
was 46 days. One busy contractor chose 385 days, without any ill-effects, and sup-
ported the comments of many patients that they were not conscious of having splints
in their nose.
Complications are summarised in Table I and account for 15 per cent of the cases
treated. In no case was penetration of the nasal floor evident or suspected.

Table I
Complications in 74 Cases

Inflammation
Of nasal bridge Resolved by antibiotic 4
Requiring splint removal 2
Stitch abscess -Resolved spontaneously 1
Epistaxis Pressure on turbinate? 1
Loose splints 2
Adhesions Complicating splint removal I

Results
In spite of pre-operative and final result photographs, objective assessment is
difficult without good pre-injury profile and frontal face records. The end results
satisfied or pleased all the patients and their relatives in this series.
Figure 7 is a case of naso-ethmoidal collapse involving the frontal sinus treated
208 BRITISH JOURNAL OF ORAL SURGERY

FIGS 7a, b, c. d. Pre-operative and end-result photographs of a case of naso-ethmoidal collapse

involving the frontal sinus treated by this method.

by this method and Fig. 8 is a case of nasal bone fracture with dislocation of the
cartilages treated in a similar fashion.
Two were considered to show some bridge sag and one bridge widening. These
were cases where splints had either been loose or had been removed too early in
relation to the extent of the injury. It is now suggested that six weeks is a reasonable
period using this method in the absence of extensive soft tissue laceration. Three
showed tip fall, attributed to excessive anterior septal cartilage resection and one
old injury showed persisting lateral deviation thought due to inadequate soft tissue
mobilisation.
 INTERNAL SPLINTING FOR UNSTABLE FRACTURES 209

FIGS 8a, b, c, d. Pre-operative and end-result photographs of a case of nasal bone fracture with
cartilagenous dislocation treated by this method.

Acknowledgements
1 wish to thank Mr T. S. Stewart, my colleague in the E.N.T. Department, for his encouragement
to me in developing this method and for his prior instruction in the techniques of nasal surgery.

References
Hamilton, W. J. & Harrison, R. J. (1971). Scott Brown’s Diseases offhe Ear, Nose and Throat, 3rd
Ed., pp. 131-142. London: Butterworths.
Maliniac, J. W. (1947). Rhinoplasty and Restoration of Facial Contour. Philadelphia: F. A. Davis.
Martin, C. & Martin, F. (1910). Lyon Chirurgical, 3, 1.
Oldfield, M. C. & Roberts, W. R. (1947). British Medical Journal, 1, 886.
Terracol, J. (1953). Les Maladies des Fosses Nasales, 2nd Ed., pp. 454-477. Paris: Masson et Cie.
14/3-B