What is the management plan for a nasal (nose) fracture?

Management of Nasal Fractures

For acute nasal fractures, perform closed reduction under general anesthesia within 3-10 days after swelling resolves, but address septal injuries immediately if present, as septal correction must precede nasal bone realignment to prevent long-term deformity and functional impairment. 1, 2

Initial Assessment and Imaging

Clinical Evaluation

• Assess for septal hematoma immediately – this requires urgent drainage to prevent cartilage necrosis and saddle nose deformity 3, 2
• Evaluate for septal deviation using rigid nasal endoscopy, as occult septal injuries are a major cause of treatment failure 2
• Check for associated facial fractures, intracranial injuries, and cerebrospinal fluid leak 4, 1
• Document malocclusion, facial asymmetry, and cranial nerve deficits 4

Imaging Strategy

• Order CT maxillofacial without IV contrast as the primary imaging modality – this provides superior fracture detection with multiplanar and 3D reconstructions for complex injuries 1, 5
• Plain radiographs are not recommended, as they have poor accuracy (53-82%) and do not alter management 1, 5
• Ultrasound may be used for isolated nasal bone fractures with 90-100% sensitivity and 98-100% specificity 1, 5
• CT head is only indicated if intracranial injury or other facial fractures are suspected, not for isolated nasal trauma 5

Treatment Algorithm

Timing of Intervention

• Delay definitive reduction for 3-10 days to allow edema resolution, except for grossly displaced fractures, open fractures, or septal hematomas which require immediate attention 3, 2
• This timing window allows accurate assessment and reduces the 14-50% rate of posttraumatic deformity seen with immediate reduction 6, 2

Surgical Approach

For Simple Nasal Bone Fractures

• Perform closed reduction under outpatient general anesthesia rather than local anesthesia for better patient comfort and surgical control 2
• Use lateral osteotomies starting at the piriform aperture just above the turbinate attachment, preserving periosteal and mucosal attachments to minimize destabilization 4
• End the osteotomy high on the nasal bone at the medial canthus level, sliding low over the nasal-facial groove to prevent step-off deformities 4

For Fractures with Septal Deviation

• Address the septum first – "as the septum goes, so goes the nose" 4, 1
• Perform complete bilateral mucoperichondrial elevation via hemitransfixion or open transcolumellar approach for severe deformities 4
• Use transverse root osteotomy to position the septum into the midline 4, 1
• Apply "contralateral subluxation locking" technique for slightly bowed caudal septum – reposition at least 1 cm width of untrimmed septum to the contralateral side of the nasal spine 4
• Reinforce with batten grafts from septal or rib cartilage for caudal and dorsal strut support 4
• Place struts between medial crura for additional support and realignment 1

For Complex or Comminuted Fractures

• Perform lateral osteotomy followed by medial osteotomy and outfracturing on the less deviated side first, working "like opening a book" 4
• Then infracture the opposite nasal bone after lateral osteotomy 4
• Use camouflaging techniques with dorsal onlay grafts from septal cartilage cut in thin wafers to hide residual deviations 4, 1
• Consider spreader grafts reaching into the bony vault to prevent recurrent collapse 4

Critical Pitfalls to Avoid

• Do not perform osteotomies on short nasal bones – this risks bony communication with limited benefit 4, 1
• Avoid aggressive cartilage shaving or morselization, as this increases absorption risk and makes revision extremely difficult 4
• Do not use intermediate osteotomies halfway up the nasal bone, as thin overlying skin risks visible irregularities 4
• Never ignore septal injuries even if nasal bones appear well-aligned – these cause postoperative deformity and obstruction in up to 50% of cases 6, 2

Special Considerations

• For noses without dorsal hump but with deviation, resect half the dorsal plateau on the deviated side before performing unilateral osteotomy to allow free medial movement 4
• Use high lateral augmentation with onlay grafts to camouflage concave nasal bones and create the illusion of straightening 4
• Preserve periosteal attachments during osteotomies to maintain stability – periosteal tunnels are detrimental to support 4