What is the treatment for a fracture of the nasal bones?

Treatment of Nasal Bone Fractures

For simple nasal bone fractures, perform closed reduction under local anesthesia after 3-10 days once swelling has resolved, but always assess and address septal fractures first, as septal correction must precede nasal bone realignment to prevent postoperative deformity and obstruction. 1, 2, 3

Immediate Assessment and Imaging

Initial Diagnostic Workup

• CT maxillofacial imaging is the preferred diagnostic modality, offering superior detection of fractures with high resolution and multiplanar reconstructions that are critical for surgical planning 4, 1
• Plain radiographs should be avoided as they have poor diagnostic accuracy (53-82%) and do not alter management decisions 4, 1
• Ultrasound may serve as an alternative for isolated nasal fractures, with sensitivity of 90-100% and specificity of 98-100%, particularly for detecting nondepressed fractures and anterior septal cartilage deviation 4, 1

Critical Associated Injuries to Exclude

• Evaluate for other facial fractures, as 68% of patients with maxillofacial injuries have associated head injury 4
• Assess for septal hematoma requiring immediate drainage to prevent cartilage necrosis 2
• Check for open fractures or grossly displaced fractures requiring urgent intervention 2
• Examine for naso-orbital-ethmoid fractures which can lead to enophthalmos, telecanthus, lacrimal obstruction, and ptosis without proper treatment 4

Treatment Algorithm

Step 1: Timing of Intervention

• Delay definitive treatment for 3-10 days to allow edema resolution, except for:
  • Septal hematomas (immediate drainage required) 2
  • Grossly displaced fractures 2
  • Open fractures 2
• Most injuries present with significant edema preventing accurate reduction at initial presentation 2

Step 2: Assess Septal Involvement

• 96.2% of simple nasal bone fractures involve septal fractures 5
• Physical examination finding of mucosal tearing is statistically significant for septal fracture 5
• CT cannot accurately predict severity of septal fractures; direct visualization via hemitransfixion incision is necessary for definitive assessment 5
• Septal correction must precede nasal bone realignment to prevent postoperative deformity and obstruction 1, 3

Step 3: Choose Reduction Technique

For Simple Fractures Without Significant Septal Deviation

• Closed reduction under local anesthesia is effective first-line treatment 2, 3
• This should become standard practice for uncomplicated cases 3

For Fractures With Significant Septal Involvement

• Perform septoplasty or submucosal resection for severe septal fractures (perioperative septal grade 3 or higher) 5
• 78.8% of patients with simple nasal fractures require septoplasty or submucosal resection 5
• Position the septum into midline using transverse root osteotomy 1
• Place strut between medial crura for support and realignment 1

For Complex or Comminuted Fractures

• Consider open reduction with miniplate osteosynthesis for nasal fractures associated with midface fractures 6
• Use camouflaging techniques such as dorsal onlay grafts using septal cartilage to hide residual deviations 1

Special Considerations and Contraindications

Anatomic Limitations

• Short nasal bones are a relative contraindication for osteotomies, as they risk bony communication while yielding limited results 1

Wound Management for Open Injuries

• Administer prophylactic antibiotics for deep nasal lacerations with exposed cartilage 7
• Obtain deep tissue cultures (minimum five samples) if infection is suspected, avoiding swab cultures due to low sensitivity 7
• Preserve periosteal and mucosal attachments to minimize destabilization of nasal framework 7

Follow-Up Care

Postoperative Management

• Nasal saline irrigation to prevent crusting and maintain clean nasal passages 7
• Monitor for nasal airway obstruction from septal deviation or mucosal edema 7
• Assess for cosmetic deformities that may require secondary rhinoplasty after complete healing 7

Common Pitfall to Avoid

The most critical error is treating the nasal bone fracture without addressing the septal injury. Unrecognized and untreated septal fractures are responsible for postoperative nasal deformity and chronic obstruction, occurring in over 96% of cases. 3, 5 Direct visualization of the septum via hemitransfixion incision is necessary because CT findings do not correlate well with perioperative severity (correlation coefficient only 33.5%). 5