What are the next management steps for a nasal fracture?

Management of Nasal Fractures

The management of nasal fractures should prioritize septal correction before nasal bone realignment, as the position of other nasal structures is largely determined by septal position. 1, 2

Initial Assessment

• 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
• Ultrasound may be considered as an alternative with high accuracy (sensitivity 90-100%, specificity 98-100%) particularly for isolated nasal bone fractures 1
• Assess for associated injuries including other facial fractures and intracranial injuries 1
• Determine the presence and degree of septal deviation, as this will guide treatment approach 1, 2

Treatment Algorithm

Step 1: Septal Correction (if deviation present)

• Position the septum into the midline using a transverse root osteotomy 1, 2
• 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:

  • Work from the less deviated side
  • Perform lateral osteotomy followed by medial osteotomy and outfracturing
  • Perform lateral osteotomy on the opposite side followed by infracturing
  • Smooth irregularities using a fine rasp 2

• To minimize destabilization of the osseous framework:

  • Preserve periosteal and mucosal attachments of the nasal bone
  • Use the smallest possible manipulative force necessary to achieve reduction 2

Step 3: Additional Techniques for Complex Cases

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

  • Use spreader grafts if concavity is associated with nasal valve collapse
  • Use simple onlay grafts if airway is adequate 2

• For comminuted fractures:

  • Consider camouflaging techniques using dorsal onlay grafts
  • Use septal cartilage cut in thin wafers with minimal crushing as the material of choice 1, 2

Special Considerations and Potential Pitfalls

• Short nasal bones are a relative contraindication for osteotomies, as they risk bony communication while yielding limited results 1, 2
• Intermediate osteotomies performed halfway up the nasal bone risk visible irregularities or step-off deformities, especially where skin covering is thin 2
• 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
• Associated septal injuries can be responsible for postoperative nasal deformity and obstruction, requiring additional correction 1, 3
• Adequate follow-up is essential to identify and address any developing deformities or functional issues 3

Timing of Intervention

• Manipulation under local anesthesia is an effective first-line treatment for simple nasal fractures 3
• For complex fractures with significant septal involvement, consider early intervention under controlled general anesthesia to reduce the incidence of posttraumatic nasal deformity 4
• The goal of treatment is to restore the pretraumatic state and normal function, with the surgical approach based on the degree of injury, presence of concomitant facial injuries, and the presence and degree of septal injury 5