What is the treatment for pediatric nasal fracture?

Treatment of Pediatric Nasal Fractures

The primary treatment for pediatric nasal fractures is closed reduction under appropriate anesthesia, with timing and technique adjusted based on fracture severity, displacement, and the child's age. 1, 2

Initial Assessment

• Key clinical findings to evaluate:

  • Nasal deformity/asymmetry
  • Septal deviation or hematoma
  • Nasal airway obstruction
  • Presence of epistaxis
  • Associated facial injuries

• Imaging considerations:

  • CT imaging is appropriate for suspected complex midface injuries 3
  • Simple nasal fractures may not require imaging for treatment decisions

Treatment Algorithm

1. Non-displaced or Minimally Displaced Fractures

• Conservative management:
  • Observation with specific follow-up schedule: 3 days after injury, weekly for the first month, then at 1 month and 3 months 4
  • Ice application for the first 48-72 hours
  • Nasal decongestants if needed for comfort

2. Displaced Fractures

• Closed reduction:
  • Timing: Ideally within 3-7 days of injury while swelling is still present but not excessive
  • Anesthesia options:
    • General anesthesia typically preferred for children under 12 years 2
    • Local anesthesia with sedation may be considered for older children/adolescents
  • Technique: Manual realignment of nasal bones and septum using elevator instruments

3. Septal Hematoma

• Immediate drainage is mandatory to prevent cartilage necrosis, saddle nose deformity, and potential infection
• Nasal packing after drainage to prevent reaccumulation
• Prophylactic antibiotics while packing remains in place

4. Complex Fractures with Septal Involvement

• Septoplasty may be required for significant septal deviation causing airway obstruction
• Careful consideration needed for growing facial structures

Special Considerations in Pediatric Patients

1. Growth and Development:

   • Nasal trauma in childhood can affect future nasal development 4
   • Conservative approach to septal surgery is recommended to avoid growth disturbances

2. Timing of Definitive Correction:

   • For significant post-traumatic deformities, definitive rhinoplasty should be delayed until facial growth is complete (typically age 16-18 for females, 17-19 for males)
   • Functional issues causing airway obstruction may warrant earlier intervention

3. Follow-up Protocol:

   • More frequent follow-up than adults
   • Long-term monitoring through growth periods to detect development of deformities

Potential Complications

• Nasal deformity (most common)
• Septal deviation with airway obstruction
• Synechiae formation
• Saddle nose deformity (from untreated septal hematoma)
• Psychological impact of facial deformity in developing children 4

Common Pitfalls to Avoid

1. Delayed recognition of septal hematoma - Always examine the septum thoroughly in all nasal trauma cases
2. Inadequate reduction - Consider open approaches for complex fractures
3. Overlooking associated injuries - Evaluate for other facial fractures, particularly in high-energy trauma
4. Inappropriate surgical intervention timing - Too early (excessive swelling) or too late (healing begun) can compromise results

Research suggests there is no significant difference in outcomes between pediatric and adult nasal fracture management approaches, contradicting the traditional belief that pediatric fractures require earlier intervention 2. However, special attention to the growing facial skeleton remains important for long-term outcomes.