Fracture, Nasal

By admin On Dec 15, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Fracture, Nasal

Daryl A. Rosenbaum

Brandon A. Bockewitz

Basics

Epidemiology

Most frequently injured and fractured facial structure due to its prominence:
- 3rd most commonly fractured structure of the skeleton
Most fractures occur in the lower half of the nasal bones, where they are thinner and broader.

Etiology

The upper third of the nose is a bony tripod formed by a pair of nasal bones that meet in the midline, with the thin perpendicular plate of the ethmoid as a weak center strut.
A pair of upper and lower lateral cartilages supported by the central quadrangular septal cartilage make up the lower 2/3.

Commonly Associated Conditions

Fracture of other facial bones
Septal hematoma
Septal dislocation
Cribriform plate injury with leakage of cerebrospinal fluid
Laceration
Orbital fracture
Concussion
Cervical spine injury

Diagnosis

History

Force: Low-velocity trauma, such as a blow from an elbow, usually causes a simple fracture pattern. High-velocity trauma from a stick or fast-moving ball/puck more likely causes a complex comminuted fracture as well as associated injuries to the face, head, and cervical spine.
Direction of blow: Lateral is most common and can cause fracture displacement and dislocation of the septum. Direct blows can lead to nasal obstruction. Inferior blows can disrupt the septal cartilage and nasal tip.

Physical Exam

Nasal deformity
Epistaxis
Nasal airway obstruction
Periorbital swelling and ecchymosis
Nasal bone reduction: Best if done either immediately after the injury or 3–5 days later when swelling will not interfere with assessment
Palpate nasal bones for deformity and crepitus.
Ring test to rule out cerebrospinal fluid (CSF) leak by collecting fluid from the nose onto filter paper to see if a clear ring of CSF diffuses out beyond the central area of blood.
Intranasal examination must be performed on each side to evaluate for a bulging septal hematoma or septal dislocation. Use suction and a topical decongestant to control bleeding, then a nasal speculum, otoscope, or rigid nasal endoscope along with a light source for adequate visualization.
Palpate all bony structures of the face, including teeth, to assess for associated trauma.

Diagnostic Tests & Interpretation

Imaging

Diagnosis is clinical, as radiographs have not been shown to be helpful for diagnosis or management (1)[A].
If suspicious for fracture of other facial bones, CT is study of choice.

Treatment

Head-up position; lean forward to aid expectoration of blood
Direct pressure, ice
Topical decongestant
Cautery of visible bleeding sites in Kiesselbach plexus using silver nitrate sticks
For refractory epistaxis, may have to pack both sides of the anterior nose with a tampon or antibiotic-soaked petrolatum gauze
Posterior epistaxis can require inflation of a Foley bulb within the nasal fossa in addition to anterior packing to achieve hemostasis.

P.227

In-Patient Considerations

Initial Stabilization

Can consider immediate closed reduction before swelling develops if the nose is severely displaced and health care provider is well trained
In most cases, simply provide analgesics and re-examine in 2–5 days.
Adults with nondisplaced fractures that cause minimal deformity may not require reduction.

Ongoing Care

Closed reduction (2)[B]:
- Ideally performed in 1st 3–6 hr after injury, before significant swelling occurs
- If delayed, should be done within 10–14 days of the injury, before significant bone healing occurs.
- Indications for adult population:
  - Unilateral or bilateral nasal bone fracture
  - Nasal deviation <½ the width of the nasal bridge
- Local anesthesia using a 5% or 10% topical cocaine solution is highly effective for both analgesia and vasoconstriction, but rarely available.
- Topical nasal sprays, including lidocaine, bupivacaine, and Pontocaine, are alternatives for adequate anesthesia.
- Topical vasoconstrictors, such as phenylephrine hydrochloride and oxymetazoline, provide adequate hemostasis and decrease edema.
- A 1:1 mixture of topical oxymetazoline or phenylephrine and 4% topical lidocaine has been cited as an equally efficacious alternative to topical cocaine (3).
- Blunt probe is placed within the nose and used to elevate the depressed nasal bone. Forceps are used to reduce septal deformity.
- External splint and packing for 1–2 wks
Open reduction (2)[B]:
- Indications for adult population:
  - Extensive/complicated fracture-dislocation of nasal bones and septum
  - Nasal deviation <50% the width of the nasal bridge
  - Open fracture
  - Persistent nasal deformity after closed reduction
  - Involvement of the caudal septum

References

1. Nigam A, Goni A, Benjamin A, et al. The value of radiographs in the management of the fractured nose. Arch Emerg Med. 1993;10:293–297.

2. Mondin V, Rinaldo A, Ferlito A. Management of nasal bone fractures. Am J Otolaryngol. 2005;26:181–185.

3. Kucik CJ, Clenney T, Phelan J. Management of acute nasal fractures. Am Fam Physician. 2004;70:1315–1320.

4. Procacci P, Ferrari F, Bettini G, et al. Soccer-related facial fractures: postoperative management with facial protective shields. J Craniofac Surg. 2009;20:15–20.

Additional Reading

Rubinstein B, Strong EB. Management of nasal fractures. Arch Fam Med. 2000;9:738–742.

Codes

ICD9

802.0 Closed fracture of nasal bones
802.1 Open fracture of nasal bones

Clinical Pearls

Physician responses to common patient questions:

When can I return to play after a broken nose?
- It can take 6 wks for a nasal fracture to completely heal. An athlete should be advised that returning to competition before complete healing means that even minor contact could disrupt a minimally displaced or previously reduced fracture and require additional intervention. A general guideline is no contact for 1–2 wks followed by return to play while wearing a nasal protective device for another 2–4 wks. Case reports have been published of return to play within 7–10 days with nasal protective device worn for 4 wks post-reduction with encouraging results (4)[C].