What is the treatment for a nasal fracture?

Treatment for Nasal Fractures

For simple nasal fractures, perform closed reduction under local anesthesia within 7-10 days after swelling resolves, but if septal deviation is present, address the septum first before realigning the nasal bones. 1

Diagnostic Imaging

CT maxillofacial imaging is the preferred diagnostic modality for evaluating nasal fractures, providing superior detection of subtle nondisplaced fractures and comprehensive characterization of complex injuries. 2, 3, 1

• Plain radiographs should be avoided as they have poor diagnostic accuracy (53-82% sensitivity) and rarely alter management decisions. 2, 1
• Ultrasound may serve as an alternative for isolated nasal bone fractures with excellent sensitivity (90-100%) and specificity (98-100%), particularly for detecting nondepressed fractures. 2, 1
• Always assess for associated facial fractures and intracranial injuries, as 68% of patients with maxillofacial trauma have concomitant head injuries. 2

Treatment Algorithm

Step 1: Timing of Intervention

• Allow facial swelling to resolve completely before attempting reduction (typically 3-7 days post-injury). 4
• Perform definitive treatment within 7-10 days before significant healing occurs. 5
• Optimal conditions require a surgical suite with appropriate anesthesia. 4

Step 2: Assess for Septal Involvement

Critical pitfall: Septal injuries are frequently missed and are responsible for postoperative nasal deformity and obstruction. 1, 5

• If septal deviation is present, the septum must be corrected before nasal bone realignment. 1
• Use a transverse root osteotomy to position the septum into the midline. 1
• Place a strut between the medial crura for support and realignment. 1

Step 3: Choose Reduction Technique

For Simple Fractures Without Septal Deviation:

• Closed reduction under local anesthesia is the first-line treatment and should become standard practice. 5
• This approach is effective for most isolated nasal fractures without significant comminution. 6

For Complex or Comminuted Fractures:

• Consider open reduction if closed techniques fail or for severe comminution. 6
• Use camouflaging techniques such as dorsal onlay grafts with septal cartilage to hide residual deviations. 1
• Preserve periosteal and mucosal attachments to minimize destabilization of the nasal framework. 3

Step 4: Special Considerations

• Avoid osteotomies in patients with short nasal bones as they risk bony communication with limited benefit. 1
• For deep lacerations with exposed cartilage, administer prophylactic antibiotics immediately. 3
• If infection is suspected, obtain deep tissue cultures (minimum five samples) before starting antibiotics; avoid swab cultures due to poor sensitivity. 3

Post-Treatment Management

• Nasal saline irrigation should be used to prevent crusting and maintain nasal hygiene. 3
• Follow-up must continue for 6-12 months to ensure proper healing and satisfactory results. 4
• Monitor for complications including nasal airway obstruction from septal deviation or mucosal edema. 3
• Secondary rhinoplasty may be required for residual cosmetic deformities after complete healing. 3

Common Pitfalls to Avoid

The most critical error is failing to address septal injuries during initial treatment, which leads to persistent deformity and obstruction requiring secondary surgery. 1, 5 Many nasal fractures are not promptly diagnosed in the setting of multiple trauma, resulting in chronic problems. 5 Additionally, attempting reduction before swelling resolves or after significant healing has occurred compromises outcomes. 4