What is the management of open nasal bone fractures in pediatrics?

Management of Open Nasal Bone Fractures in Pediatrics

Open nasal bone fractures in children require immediate surgical washout and reduction within 3-7 days, followed by careful fixation techniques that minimize disruption to nasal growth centers while addressing both the bony and septal components to prevent long-term deformity. 1, 2

Immediate Management (Emergency Department)

• Perform urgent irrigation and debridement of the open fracture site to prevent infection, similar to other pediatric open fracture management protocols 3
• Apply a windowed cast or external splint after initial washout to allow wound monitoring while providing stabilization 3
• Administer appropriate antibiotics and ensure tetanus prophylaxis
• Obtain CT imaging as the preferred diagnostic modality to fully characterize the fracture pattern, assess for septal involvement, and identify any associated facial or intracranial injuries 4
  • Conventional nasal radiographs have poor accuracy (53-82%) and should be avoided 4
  • Ultrasound may be considered as an alternative with 90-100% sensitivity for isolated nasal bone fractures 4

Timing of Definitive Repair

• Perform closed or open reduction within 3-7 days of injury, before significant soft tissue swelling resolves but early enough to prevent malunion 1, 2
• Earlier intervention (within 3 days) is preferable in pediatric patients due to rapid healing and the risk of early consolidation 2, 5

Surgical Technique Considerations

Septal Management (Critical First Step)

• Always assess and correct septal deviation before addressing nasal bone alignment, as the septum serves as the structural foundation 4
• Position the septum into midline using a transverse root osteotomy if significantly deviated 4
• Place a strut between the medial crura for support and realignment 4
• Minimize surgical manipulation of septal growth centers to avoid future midfacial growth disturbances, which is a unique concern in pediatric patients 2, 5

Nasal Bone Reduction

• Use Walsham forceps for nasal bone reduction and Asch forceps for septal manipulation 6
• Preserve periosteal and mucosal attachments to minimize destabilization of the osseous framework 7
• Apply the smallest manipulative force necessary to achieve reduction 7
• For complex fractures with significant deviation, perform lateral osteotomies followed by medial positioning 4

Fixation Methods

• External splinting is preferred over internal packing when possible to avoid pressure necrosis in pediatric tissues 6
• Consider the novel fixation techniques described for pediatric nasal fractures that provide stability without excessive tissue trauma 6
• Avoid aggressive internal manipulation that could damage growth centers 2, 5

Special Pediatric Considerations

Anatomic Differences

• Children have proportionally more cartilage and less ossified bone, making fracture patterns different from adults 2, 5
• The nasal bones are shorter in children, which is a relative contraindication for extensive osteotomies due to risk of bony communication 4
• Growth centers must be protected to prevent future midfacial hypoplasia 2, 5

Diagnostic Challenges

• Expect poor patient cooperation during examination, requiring careful clinical assessment and liberal use of imaging 2, 5
• Significant soft tissue swelling can obscure underlying bony injury 2
• Associated septal injuries are common and can be responsible for postoperative deformity if not addressed 4

Management of Complex Cases

For Comminuted or Severely Displaced Fractures

• Consider camouflaging techniques using dorsal onlay grafts with septal cartilage to hide residual deviations rather than aggressive osteotomies 4
• This approach avoids destabilizing the pediatric nasal framework while achieving acceptable aesthetic results 4

For Associated Septal Deviation

• Additional septal correction is required to achieve both functional and aesthetic improvement 7, 8
• Functional outcomes depend on adequate septal positioning 8

Common Pitfalls to Avoid

• Do not delay treatment beyond 7 days, as pediatric nasal bones consolidate rapidly and become difficult to reduce 2, 5
• Do not perform aggressive septal surgery that disrupts growth centers, as this can cause permanent midfacial deformity 2, 5
• Do not rely on conventional radiographs for diagnosis, as they miss significant injuries and do not alter management 4
• Do not ignore septal injuries, as they are responsible for the majority of posttraumatic nasal deformities and obstruction 4, 1
• Be aware that visible irregularities or step-off deformities may occur in areas with thin overlying skin 7

Expected Outcomes

• Significant incidence of posttraumatic deformities occurs even with treatment, often requiring secondary surgical correction 1
• Road traffic accidents and sports injuries account for the majority of pediatric nasal fractures (67% combined) 6
• Isolated injuries occur in 75% of cases, with 25% having associated facial bone fractures 6
• Proper initial management decreases the incidence of secondary deformities and reduces need for revision surgery 6, 9