A 70-year-old man was the rear seat passenger in a taxi cab that
suddenly stopped short. He was thrown forward and hit the bridge
of his nose on the divider between the front and rear seats. He did
not lose consciousness and had no other injuries.
In the ED, a 2-cm laceration across the bridge of his nose was
cleaned and sutured. He was sent for nasal bone radiographs.
The nasal series is shown in Figure 1.
A. Right lateral nasal view. B. Left lateral nasal view. C. Waters view
A nasal radiographic series consists of left and right lateral
views of the nasal bones and a Waters view (Figure 1). Nasal radiographs
are generally not needed in ED patients with nasal trauma because
finding a nasal bone fracture does not alter initial management.
Displaced nasal factures may need operative reduction, although
this is not done at the time of injury because displacement is difficult
to assess when there is overlying soft tissue swelling. In some
instances, nasal trauma involves more extensive injury.
Further examination of the Waters view discloses
several additional injuries (Figure 4).
Waters view—Patient 2
(See text for explanation)
First, looking for soft tissue
signs of an injury reveals opacification of both maxillary sinuses
tracing the key midface skeletal contours (Dolan’s lines)
reveals, on the right, a fracture of the lateral orbital rim (arrow) and, on the left, a fracture of
the zygomatic arch (arrowhead).
These findings are associated with tripod fractures. However,
interpreting these injuries as “bilateral tripod fractures” would
be incorrect. Bilateral midface fractures are the hallmark of a
complex of fractures that were first described by René Le
Fort in 1901. He experimentally produced these injuries in cadavers.
On Patient 2’s nasal radiographs, a fracture is present,
although it is superior to the nasal bones (Figure 1). On the Waters
view, a fracture through the nasion is visible (Figure 2, arrow).
Patient 2—Waters view.
Nasion fracture (arrow).
A nasion fracture may be a component of a nasoethmoid
orbital fracture (NEO fracture). A NEO fracture is a comminuted
fracture of the nasion extending into the adjacent portions of the
frontal bone, maxilla and orbits ...