NOE type III fractures represent comminuted fractures where the medial canthus has become detached from the bone. A transnasal canthopexy must be performed. The most important aspect is the medial and posterior positioning of the medial canthal ligament. In order to accomplish this, a cantilever technique (plate 4 in the illustration) may be utilized. The cantilever technique is described in detail further below.
Commonly, a minimum of three points of fixation will be needed. This will include a plate at the NOE/frontal bone (1), a plate along the orbital rim (2), and a plate along the piriform aperture (3). In addition to these plates, additional plates may be needed to further stabilize the comminuted fracture segments. Following the reduction and fixation of the other bony fragments, the transnasal wire (5) needs to be placed.
Order of fixation
A suggestion is to place the first plate where the surgeon has the best visualization and access, with the most well defined landmarks. If a surgeon has good visualization at all three points, a consideration is to first stabilize the NOE fracture to the frontal bone (1), achieving stabilization to the calvarium, with the second plate placed along the orbital rim (2), and the third plate placed along the piriform aperture (3). This prioritizes plate placement according to the order of aesthetic importance.