What is the treatment for a nasal bone fracture?

Treatment of Nasal Bone Fractures

Closed reduction is the primary treatment for most nasal bone fractures, with open reduction reserved for complex fractures or those with significant septal involvement.

Diagnosis and Assessment

• Imaging:

  • CT maxillofacial scan is the first-line diagnostic modality (sensitivity superior to plain radiographs at 82%) 1
  • Plain radiographs (lateral and Waters view) have limited diagnostic value with only 82% reliability 2
  • Ultrasound may be used for isolated nasal fractures (90-100% sensitivity, 98-100% specificity) 1

• Physical Examination:

  • Check for mucosal tearing (statistically significant indicator of septal fracture) 3
  • Assess for clear rhinorrhea (suggesting dural tear) 1
  • Evaluate for enophthalmos, diplopia, and infraorbital nerve paresthesia 1

Classification of Nasal Fractures

Based on CT findings 2:

• Type I: Simple without displacement (8%)
• Type IIA: Simple with unilateral displacement without telescoping (36%)
• Type IIAs: Unilateral with septal fracture (13%)
• Type IIB: Simple with bilateral displacement without telescoping (18%)
• Type IIBs: Bilateral with septal fracture (21%)
• Type III: Comminuted with telescoping or depression (4.3%)

Treatment Algorithm

1. Initial Management:

   • Control active bleeding with direct pressure 1
   • Perform manual reduction of grossly displaced fragments if airway patency is compromised 1
   • Consider intermaxillary fixation if the patient is conscious and not at risk of vomiting 1

2. Timing of Definitive Treatment:

   • Early definitive repair (within 24 hours) if patient is hemodynamically stable 1
   • Average timing for nasal reduction: 6.5 days post-injury 2
   • Delayed repair for patients with severe associated injuries 1

3. Treatment Selection:

   • Closed reduction (93% of cases) 2:

     • Performed under local anesthesia in an outpatient setting
     • Appropriate for simple displaced fractures

   • Open reduction (4% of cases) 2:

     • Indicated for complex fractures or significant septal involvement
     • Techniques include mobilization, trimming/thinning, "contralateral subluxation locking"
     • May require reconstruction with "figure 8" sutures and batten grafts

   • Septoplasty or submucosal resection:

     • Required in 78.8% of patients with severe septal fractures (perioperative septal grade 3 or higher) 3
     • Critical to address as septal fractures occur in 96.2% of simple nasal bone fractures 3

   • No surgical intervention (3% of cases) 2:

     • For minimally displaced fractures (Type I)

Special Considerations

• Septal Fractures:

  • Often unrecognized and untreated at time of injury 3
  • CT can help diagnose but cannot accurately predict severity (33.5% correlation between CT and perioperative findings) 3
  • Meticulous physical examination is crucial to identify septal fractures requiring intervention 3

• Pediatric Patients:

  • Common causes: auto accidents (40%), sports injuries (25%), intended injuries (15%), home injuries (10%) 4
  • Careful attention to underlying structural anatomy is critical to prevent posttraumatic deformities 4

• Osteotomies for Deviated Nasal Bones:

  • For severe bony deviation without dorsal lowering, use sequential osteotomies "like opening a book" 5
  • Work from less deviated side: lateral osteotomy → medial osteotomy → outfracturing 5
  • Position septum into midline using transverse root osteotomy 5
  • Infracture opposite nasal bone after lateral osteotomy 5

Follow-up and Complications

• Monitor for persistent nasal deformity, nasal airway obstruction, and breathing difficulties 1
• Watch for septal perforation and cerebrospinal fluid leak 1
• Be aware that inadequate treatment of septal fractures can lead to posttraumatic nasal deformity 3

Trends in Nasal Fractures

• Incidence of severe nasal bone fractures has increased over time 6
• Frequency of nasal bone fractures due to traffic accidents has decreased, but their severity has increased 6
• Combined facial bone fractures have become more common 6