Who do we refer a patient with a nasal bone fracture to?

Referral for Nasal Bone Fracture

Patients with nasal bone fractures should be referred to a plastic surgeon, especially for displaced/depressed fractures, complex nasal injuries, unstable fractures, or cases with significant soft tissue edema. 1

Assessment Before Referral

Before referral, the initial evaluation should include:

• Assessment of airway patency and control of bleeding
• Evaluation for septal hematoma (requires immediate evacuation if present)
• Examination for external deformity, point tenderness, and mobility/crepitus of facial bones
• Assessment for associated injuries (orbital, mandibular, or cervical spine injuries)

Imaging Considerations

• Maxillofacial CT with thin sections (1-2mm) is the gold standard for diagnosing facial bone fractures 1
• Ultrasound is an excellent radiation-free alternative for isolated nasal fractures with 90-100% sensitivity 1
• Radiographs have limited diagnostic value (53-82% accuracy) and rarely alter management 1

Referral Decision Algorithm

1. Immediate specialist referral required for:

   • Septal hematoma (requires immediate evacuation)
   • Cerebrospinal fluid rhinorrhea
   • Malocclusion
   • Extraocular movement defects
   • Open or complex fractures
   • Significant displacement or depression of nasal bones
   • Unstable or "flail" nasal fractures
   • Significant soft tissue edema obscuring assessment

2. Timing of referral:

   • The American College of Surgeons recommends intervention within 1-2 weeks (acute phase) for optimal outcomes 1
   • Early intervention (within 4 weeks) is critical for best correction of deformities 1

Treatment Options After Referral

The plastic surgeon may employ various techniques:

• Closed reduction for simple displaced fractures, often performed under local anesthesia in an outpatient setting 1
• Open reduction for complex fractures or those with significant septal involvement 1
• Specialized techniques for cartilaginous injuries, including mobilization, trimming/thinning, and reconstruction 1

Potential Complications if Not Properly Referred

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

• Persistent nasal deformity
• Nasal airway obstruction
• Breathing difficulties
• Septal perforation
• Long-term functional and cosmetic complications 1

Special Considerations

• In children, consider child abuse as a possible etiology in any child younger than 5 years with nasal trauma, especially with inconsistent history 1
• For simple closed fractures without significant displacement, some patients may be managed with closed manipulation under anesthesia, with similar outcomes reported for procedures performed under local or general anesthesia 2
• Complex cases involving multiple facial fractures may require combined surgical approaches 3

Remember that the overall treatment failure rate, defined as a deformity requiring revision, can be as low as 6.2% with appropriate specialist management 4, highlighting the importance of proper referral.