What is the management of an open nasal bone fracture?

Management of Open Nasal Bone Fracture

For open nasal bone fractures, perform immediate irrigation with simple saline solution (without additives), administer a first-generation cephalosporin (cefazolin 2g IV) as soon as possible after injury, and proceed with closed reduction without requiring extended antibiotic prophylaxis beyond 24 hours post-closure.

Initial Wound Management

• Irrigate the open wound immediately with simple saline solution without any additives 1
• Avoid using soap or antiseptics, as they provide no additional benefit over saline alone 1, 2
• The evidence strongly supports this simplified approach to initial wound cleansing 1

Antibiotic Selection and Timing

• Administer cefazolin 2g IV as the first-line antibiotic as soon as possible after injury, ideally within 3 hours 2, 3
• For patients with beta-lactam allergies, use clindamycin 900mg IV as an alternative 3
• If the patient has severe beta-lactam allergy, vancomycin 30mg/kg over 120 minutes can be substituted 3

The key distinction for nasal fractures is that they do NOT require the same extended antibiotic coverage as extremity open fractures, despite being classified as "open." 4, 5, 6

Duration of Antibiotic Therapy

• Limit systemic antibiotics to a maximum of 24 hours after wound closure 2, 3
• For nasal bone fractures specifically, prophylactic antibiotics beyond the perioperative period show no benefit in reducing infection rates (2.0% with antibiotics vs 2.2% without, P=0.90) 4
• Extended postoperative antibiotic courses (4-5 days) are unnecessary and increase antibiotic resistance without clinical benefit 5, 6

Surgical Management Timing

• Perform closed reduction within 24 hours when feasible, though the traditional "6-hour rule" is not supported by current evidence 1
• All documented infections in nasal fractures occurred with bedside management rather than operating room procedures, though this requires further validation 4

Important Caveats Specific to Nasal Fractures

• Open nasal fractures do NOT have significantly higher infection rates than closed nasal fractures (OR 1.9, P=0.64) 4
• The severity of nasal fracture by Rohrich classification does not impact infection risk (OR 0.68, P=0.46) 4
• Infection rates in nasal fractures remain extremely low (approximately 2%) regardless of antibiotic use 4, 5, 6
• Do NOT add aminoglycosides for open nasal fractures—this is only indicated for Gustilo-Anderson Type III extremity fractures with extensive soft tissue damage 2, 3

Common Pitfalls to Avoid

• Do not extrapolate extremity open fracture protocols to nasal fractures—the infection risk profile is completely different 4, 5, 6
• Avoid prescribing extended oral antibiotic courses (4-5 days) postoperatively, as this increases costs and resistance without reducing infection 5, 6
• Do not delay initial antibiotic administration beyond 3 hours, as this significantly increases infection risk in true open fractures 2, 3
• Avoid applying antibiotic ointment to nasal packing, as bacterial colonization patterns are similar with or without antibiotics 5