Are nasal bone fractures best treated by a plastic surgeon or an Emergency Room (ER) physician?

Who Should Treat Nasal Bone Fractures?

The appropriate provider for treating nasal bone fractures depends on fracture complexity: simple, isolated nasal fractures can be managed by trained ER physicians through closed reduction, while complex fractures involving significant septal deviation, comminution, or associated facial injuries require specialist management by plastic surgeons, facial plastic surgeons, or otolaryngologists.

Initial Assessment and Triage

Diagnostic Evaluation

• CT imaging is the preferred diagnostic modality for nasal fractures, offering superior detection and characterization compared to conventional radiography, particularly for complex injuries 1, 2
• Plain radiographs have limited value with diagnostic accuracy of only 53-82% and do not significantly alter management 1
• Ultrasound may serve as an alternative with high accuracy (sensitivity 90-100%, specificity 98-100%) for isolated nasal bone fractures 1

Critical Assessment Points

• Evaluate for septal involvement immediately - 96.2% of simple nasal bone fractures involve septal fractures, with 78.8% requiring septoplasty or submucosal resection 3
• Screen for associated facial fractures, as 20-40% of patients have additional injuries 1
• Assess for mucosal tearing on physical examination, which is statistically significant for septal fracture 3

Treatment Algorithm by Complexity

Simple Fractures (ER Physician Capable)

Criteria for ER management:

• Isolated nasal bone fracture without significant displacement
• No septal deviation requiring surgical correction
• No associated facial fractures
• No open fractures or septal hematomas requiring immediate intervention 4

Timing considerations:

• Grossly displaced fractures, open fractures, and septal hematomas require immediate treatment 4
• Most other nasal fractures should be definitively treated after 3-10 days once swelling resolves 4

Complex Fractures (Specialist Required)

Indications for plastic surgeon/specialist referral:

• Septal deviation requiring correction - septal correction must precede nasal bone realignment 2
• Comminuted fractures requiring open reduction and internal fixation 5
• Associated facial fractures (zygomaticomaxillary complex, Le Fort patterns) 1
• Fractures requiring osteotomies with preservation of periosteal and mucosal attachments 1, 6
• Need for cartilage grafting or reconstruction techniques 1, 2

Technical Considerations for Complex Cases

Septal Management

• Position the septum into midline using transverse root osteotomy 2
• Place struts between medial crura for support and realignment 2
• Perform septoplasty or submucosal resection for severe septal fractures (perioperative septal grade 3 or higher) 3

Comminuted Fractures

• Consider camouflaging techniques using dorsal onlay grafts with septal cartilage 2
• Open reduction through laceration openings with internal fixation may be necessary 5
• Preserve periosteal and mucosal attachments using smallest possible osteotomies 1, 6

Critical Pitfalls

Common diagnostic errors:

• CT findings do not accurately predict septal fracture severity (Spearman correlation coefficient only 33.5%) and cannot definitively determine need for septoplasty 3
• Relying on radiographs alone misses the majority of clinically significant injuries 1
• Failing to assess for septal involvement leads to posttraumatic nasal deformity and obstruction 2, 3

Treatment complications:

• Short nasal bones are a relative contraindication for osteotomies due to risk of bony communication with limited results 2
• Inadequate septal correction is responsible for postoperative nasal deformity and obstruction 2
• Visible irregularities or step-off deformities occur with improper technique, especially in areas with thin overlying skin 6

Quality of Life Considerations

Mismanagement of nasal fractures leads to both aesthetic and functional deformities that significantly impact patient quality of life 7, 4. The high frequency of septal involvement (96.2% of cases) means that simple closed reduction by ER physicians without addressing septal pathology results in poor long-term outcomes requiring secondary rhinoplasty 3. Proper initial evaluation and appropriate specialist referral when indicated minimizes secondary surgeries, lowers overall healthcare costs, and increases patient satisfaction 8.