What is the management of nasal fractures?

Management of Nasal Fractures

CT imaging is the preferred diagnostic modality for nasal fractures, offering superior detection and characterization compared to conventional radiography, especially for complex injuries with associated facial fractures. 1

Diagnostic Approach

• CT provides high-resolution imaging with thin-section acquisitions that can detect subtle nondisplaced fractures and offers multiplanar and 3D reconstructions for better characterization of complex fractures 1
• Conventional nasal radiographs have limited diagnostic value with accuracy ranging only from 53% to 82% and do not significantly alter diagnosis or management of nasal fractures 1
• Ultrasound may be considered as an alternative with high accuracy (sensitivity 90-100%, specificity 98-100%) particularly for isolated nasal bone fractures and can better detect nondepressed fractures of the nasal bridge and anterior septal cartilage deviation than CT 1
• Diagnosis should be made after swelling has subsided (typically 3-10 days post-injury) except in cases of grossly displaced fractures, open fractures, and septal hematomas which require immediate attention 2

Treatment Algorithm

Step 1: Initial Assessment

• Evaluate for septal hematoma which requires immediate drainage to prevent cartilage necrosis and saddle nose deformity 2, 3
• Assess for associated injuries including other facial fractures and intracranial injuries 1
• Determine the presence and degree of septal deviation, as septal correction must precede nasal bone realignment 4

Step 2: Timing of Intervention

• For simple fractures without significant displacement: wait 3-10 days until edema resolves before definitive treatment 2, 5
• For grossly displaced fractures, open fractures, and septal hematomas: immediate intervention is required 2

Step 3: Treatment Based on Fracture Type

For Minimally Displaced Fractures:

• Closed reduction under local anesthesia is the first-line treatment 6, 3
• Preserve periosteal and mucosal attachments of the nasal bone during manipulation 6
• Use the smallest possible manipulative force necessary to achieve reduction 6

For Complex Fractures with Septal Deviation:

• Position the septum into the midline using a transverse root osteotomy 4
• Place a strut between the medial crura for support and realignment 4
• For severe bony deviation without dorsal lowering, use the "opening a book" technique:
  • Work from the less deviated side, performing lateral osteotomy followed by medial osteotomy and outfracturing 4
  • Perform lateral osteotomy on the opposite side followed by infracturing 4
  • Smooth irregularities using a fine rasp 4

For Comminuted Fractures:

• When complete correction is impossible using reduction and osteotomy techniques alone, consider camouflaging techniques 1, 4
• Apply dorsal onlay grafts using septal cartilage cut in thin wafers to hide residual deviations 4

Special Considerations

• Short nasal bones are a relative contraindication for osteotomies as they risk bony communication while yielding limited results 4
• Intermediate osteotomies performed halfway up the nasal bone risk visible irregularities or step-off deformities, especially where skin covering is thin 4
• 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 4
• Associated septal injuries can be responsible for postoperative nasal deformity and obstruction, requiring additional correction 6, 3

Post-Reduction Care

• External nasal splinting for 7-10 days to maintain reduction and minimize edema 7, 5
• Internal nasal packing may be used for 24-48 hours if significant mucosal injury or bleeding is present 3
• Follow-up evaluation at 1-2 weeks to assess alignment and function 5
• Secondary rhinoplasty may be necessary for patients with persistent deformity or functional issues (9% to 50% of cases depending on initial management) 5