Does a patient with depressed/displaced fractures of the nasal bones and related soft tissue edema following a fall require a plastic surgery consult?

Management of Depressed/Displaced Nasal Fractures: Plastic Surgery Consultation Recommendations

Patients with depressed/displaced nasal fractures and related soft tissue edema following a fall should be referred for plastic surgery consultation to ensure optimal functional and cosmetic outcomes.

Assessment of Nasal Fractures

Nasal fractures are the most common facial fractures and require careful evaluation to determine appropriate management:

• CT imaging is the gold standard for accurate diagnosis of nasal fractures, providing high-resolution images with multiplanar and 3D reconstructions 1, 2
• Physical examination should assess:
  • External nasal deformity
  • Nasal airway patency
  • Point tenderness
  • Mobility/crepitus of nasal bones
  • Presence of septal hematoma (requires immediate drainage to prevent cartilage necrosis)
  • Signs of other associated facial fractures 2

Indications for Plastic Surgery Consultation

Plastic surgery consultation is indicated for:

1. Displaced/depressed nasal fractures - These require reduction to prevent both functional and cosmetic complications 2
2. Complex nasal injuries - Especially those involving both bony and cartilaginous components 3
3. Unstable or "flail" nasal fractures - Where the nasal bones are severely displaced and unstable 4
4. Cases with significant soft tissue edema - As mentioned in your CT findings 2

Timing Considerations

The timing of intervention is critical:

• The American College of Surgeons recommends intervention within 1-2 weeks (acute phase) for optimal outcomes 2
• Early intervention (within 4 weeks) is critical for best correction of deformities 2
• Most nasal fractures should be treated after 3-10 days once swelling has resolved, except in cases of:
  • Grossly displaced fractures
  • Open fractures
  • Septal hematomas 5

Treatment Approaches

Plastic surgery specialists can provide:

1. Closed reduction - For simple displaced fractures, often performed under local anesthesia in an outpatient setting 6
2. Open reduction - For complex fractures or those with significant septal involvement 3
3. External fixation techniques - For unstable "flail" nasal fractures 4
4. Specialized techniques for cartilaginous injuries:
   • Mobilization, trimming/thinning for mild deviations
   • "Contralateral subluxation locking" for moderate deviations
   • Reconstruction with "figure 8" sutures and batten grafts for severe deviations 2

Potential Complications Without Proper Management

Without appropriate plastic surgery consultation and treatment, patients may experience:

• Persistent nasal deformity (crooked nose or saddle nose) 3
• Nasal airway obstruction and breathing difficulties 7
• Septal perforation if septal hematomas are not properly managed 2
• Long-term functional and cosmetic complications 2

Conclusion

Given the presence of depressed/displaced nasal fractures with soft tissue edema, plastic surgery consultation is necessary to ensure proper evaluation and treatment. The American Academy of Otolaryngology recommends surgical correction as the definitive treatment for nasal fractures to prevent long-term functional and cosmetic complications 2.