Management and Treatment of Nasal Fractures
CT maxillofacial scan should be used as the first-line diagnostic modality for nasal fractures, followed by appropriate reduction techniques based on fracture severity, with closed reduction for simple displaced fractures and open reduction for complex fractures with significant septal involvement. 1
Diagnostic Evaluation
Imaging:
Clinical Assessment:
- Document patient history including cause of trauma, previous facial injuries, and prior nasal deformity or obstruction 2
- Perform primary survey focusing on "airway, breathing, and circulation" before evaluating facial trauma 1
- Be vigilant for airway compromise from hemorrhage, soft-tissue edema, or loss of facial architecture 1
- Use rigid nasal endoscopy to assess for occult septal injury, which is a common cause of treatment failure 3
Treatment Approach
Simple Displaced Fractures
- Closed reduction is the first-line treatment for simple nasal fractures 1, 2
- Often performed under local anesthesia in an outpatient setting 1
- Manipulation under local anesthesia is effective and should be standard practice for simple fractures 2
Complex Fractures
- Open reduction is indicated for:
- Complex fractures
- Fractures with significant septal involvement
- Failed closed reduction 1
Surgical Techniques for Severe Bony Deviation
- Sequential osteotomies working from the less deviated side:
- Start with lateral osteotomy
- Follow with medial osteotomy
- End with outfracturing 1
- Position septum into midline using transverse root osteotomy 1
- After lateral osteotomy, infracture the opposite nasal bone 1
Specialized Techniques for Cartilaginous Injuries
- Mobilization
- Trimming/thinning
- "Contralateral subluxation locking"
- Reconstruction with "figure 8" sutures and batten grafts 1
Timing of Treatment
- Early definitive repair (within 24 hours) if patient is hemodynamically stable with no severe associated injuries 1
- Delayed definitive repair in cases of:
- Severe visceral injuries
- Circulatory shock
- Respiratory failure 1
- Use damage control approach for unstable patients 1
Intraoperative Management
- Maintain systolic blood pressure >110 mmHg
- Use fluid resuscitation and vasopressors (phenylephrine, norepinephrine) if needed to correct hypotension
- Control active bleeding with direct pressure
- Consider COVID-19 testing prior to procedures involving the nasal cavity due to aerosolization risk 1
Postoperative Care and Follow-up
- Monitor for:
- Clear rhinorrhea (suggesting dural tear)
- Enophthalmos, diplopia, and infraorbital nerve paresthesia
- Cerebrospinal fluid leak, especially with frontal sinus fractures 1
- Begin with non-opioid analgesics, escalating to opioids only when necessary for severe pain 1
- Follow up with a specialist to monitor healing and address developing complications 1
Common Pitfalls and Complications
- Missed diagnosis: Many broken noses are not promptly diagnosed, leading to secondary deformities 2
- Overlooked septal injury: Associated septal injury is responsible for many postoperative nasal deformities and obstructions 2, 3
- Inadequate assessment: Preexisting nasal deformity and traumatic edema can complicate accurate reduction 3
- Potential complications:
- Persistent nasal deformity
- Nasal airway obstruction
- Breathing difficulties
- Septal perforation 1
Evidence-Based Approach to Reduce Secondary Deformities
A clinical algorithm including detailed patient history, physical examination with rigid nasal endoscopy, outpatient controlled general anesthesia, and primary septal reconstruction in cases with severe septal fracture dislocation has been shown to reduce the incidence of posttraumatic nasal deformity to as low as 9% (compared to typical rates of 14-50%) 3