What is the management for a comminuted fracture of the nasal bone with deviation of the septum?

Management of Comminuted Nasal Bone Fracture with Septal Deviation

The optimal management for a comminuted fracture of the nasal bone with septal deviation requires a combined approach of septal correction followed by nasal bone realignment, with open reduction techniques providing superior outcomes compared to closed reduction alone. 1

Initial Assessment and Approach

• Septal correction must precede any nasal bone realignment work, as the position of other nasal structures is largely determined by septal position 2
• For comminuted fractures with septal deviation, a one-stage operation using endoscopic septoplasty combined with nasal bone reduction provides good visualization, accurate operation, minimal invasiveness, and fewer complications 3

Surgical Management Algorithm

Step 1: Septal Correction

• Position the septum into the midline using a transverse root osteotomy 2
• In most cases, place a strut between the medial crura for support and realignment 2
• A strut allows resection of the most caudal part of the deviated septum without risking columellar retraction 2

Step 2: Nasal Bone Realignment

• For severe bony deviation without dorsal lowering, use the "opening a book" technique: 2

  • Work from the less deviated side
  • Perform lateral osteotomy followed by medial osteotomy and outfracturing
  • Position the septum into midline using transverse root osteotomy
  • Perform lateral osteotomy on the opposite side followed by infracturing
  • Smooth irregularities using a fine rasp

• To minimize destabilization of the osseous framework: 4

  • Preserve periosteal and mucosal attachments of the nasal bone
  • Use the smallest possible manipulative force necessary to achieve reduction
  • Avoid periosteal tunnels as they are detrimental to support 2

Step 3: Additional Techniques for Optimal Results

• For unilateral concavity in the middle third of the nose: 2

  • Use spreader grafts if concavity is associated with nasal valve collapse
  • Use simple onlay grafts if airway is adequate
  • Sometimes a combination of both techniques is necessary

• For the nasal tip: 2

  • Reshape, reorient, and restructure alar cartilages using a combination of conservative reduction, suture repositioning, and grafting techniques
  • Consider limited resection of excess vestibular skin on the deviated side to enhance symmetry

Open vs. Closed Reduction

• Open reduction is strongly recommended for comminuted fractures with septal deviation 5, 1
• Studies show that in combined nasal bone and septal fractures: 1
  • 60% of patients treated with closed reduction had significant postoperative septal deviation
  • Only 12.5% of patients treated with open approaches suffered from residual septal deformity
  • Open approaches result in a statistically significant reduction in the need for revision surgery

Camouflaging Techniques

• When complete correction is impossible using reduction and osteotomy techniques alone, consider camouflaging techniques: 2
  • Use onlay techniques to visually straighten concave or depressed nasal bones
  • Apply dorsal onlay grafts to hide residual deviations
  • Use septal cartilage cut in thin wafers with minimal crushing as the material of choice

Common Pitfalls and Caveats

• Short nasal bones are a relative contraindication for osteotomies, as they risk bony communication while yielding limited results 2
• Intermediate osteotomies performed halfway up the nasal bone risk visible irregularities or step-off deformities, especially where skin covering is thin 2, 6
• Failure to address septal deviation during nasal bone fracture repair leads to higher rates of revision surgery and poorer functional outcomes 1, 7
• If the nose has no hump, a unilateral vertical osteotomy will achieve limited results since movement toward the septum is restricted by the dorsal plateau 2