Diagnosis of Pediatric Nasal Fractures
CT imaging is the most accurate diagnostic method for pediatric nasal fractures, but ultrasound offers an excellent radiation-free alternative with sensitivity of 90-100% and specificity of 98-100% for isolated nasal fractures. 1
Clinical Assessment
History
- Mechanism of injury (auto accidents 40%, sports injuries 25%, intentional injuries 15%, home injuries 10%) 2
- Timing of injury
- Previous nasal trauma or deformities
- Respiratory symptoms (obstruction)
- Associated injuries
Physical Examination
- External nasal deformity (asymmetry, depression)
- Nasal airway patency
- Point tenderness
- Mobility/crepitus of nasal bones
- Septal hematoma or deviation (critical to identify)
- Signs of other facial fractures
- Complete skin examination for associated injuries 1
Diagnostic Imaging
Ultrasound
- Highly accurate for isolated nasal fractures (90-100% sensitivity, 98-100% specificity) 1
- Advantages:
- No radiation exposure (ideal for children)
- Can evaluate cartilaginous septum
- Multiple imaging planes without position changes
- Can detect nondepressed fractures and anterior septal deviation better than CT 1
- Sonographic findings include:
- Disruption of bone continuity
- Displacement of bone segments
- Septal deviation
- Soft tissue edema and hematoma 3
CT Maxillofacial
- Gold standard for complex nasal injuries
- Indicated when:
- Associated facial fractures are suspected
- Complex nasal injuries are present
- Surgical planning is needed
- Provides high-resolution images with multiplanar and 3D reconstructions 1
- More sensitive than radiographs in confirming nasal bone fractures 1
Radiography
- Limited diagnostic value (53-82% accuracy) 1
- Does not significantly alter diagnosis or management 1
- Not recommended as primary imaging modality 4
Critical Findings to Identify
Septal Hematoma
- Must be identified and evacuated immediately
- Can lead to cartilage necrosis, septal perforation, and saddle nose deformity if untreated 5
- Appears as a bluish-purple bulging mass on one or both sides of the septum
Septal Deviation
- May require surgical correction if causing obstruction
- Can be better visualized with nasal endoscopy in complex cases 1
Open Fractures
- Require immediate treatment
- Higher risk of infection
Common Pitfalls
Missing septal hematomas - Always examine the nasal septum thoroughly in all pediatric nasal trauma cases 5
Relying on radiographs - Plain films have poor sensitivity and do not alter management 1, 4
Immediate reduction in presence of significant edema - Except for grossly displaced fractures, open fractures, and septal hematomas, definitive treatment should be delayed 3-10 days until swelling resolves 4
Failure to consider child abuse - Nasal fractures in non-ambulatory children or with inconsistent history should raise suspicion 1
Overlooking associated injuries - Nasal fractures may be part of more extensive facial trauma requiring comprehensive evaluation 1
By following this diagnostic approach, clinicians can accurately identify pediatric nasal fractures and associated injuries that require immediate attention, while minimizing radiation exposure through appropriate use of ultrasound when indicated for isolated nasal trauma.