What is the recommended management for a pediatric nasal bone fracture?

Management of Pediatric Nasal Bone Fractures

Pediatric nasal bone fractures should be managed with closed reduction under appropriate anesthesia, with no evidence supporting the traditional recommendation for earlier treatment compared to adults—delayed reduction beyond 7 days yields equally good outcomes as early reduction. 1, 2

Initial Assessment and Diagnostic Approach

• Assess for associated injuries including other facial fractures, intracranial injuries, and septal involvement, as these will determine the complexity of management required 3
• Evaluate septal deviation carefully, as septal correction must precede nasal bone realignment and is critical to preventing postoperative deformity and obstruction 3, 4
• CT imaging is preferred for complex injuries with suspected associated facial fractures, though ultrasound offers high accuracy (90-100% sensitivity, 98-100% specificity) for isolated nasal bone fractures 3
• Conventional nasal radiographs have limited value with accuracy only 53-82% and rarely alter management 3

Timing of Intervention

The traditional dogma of treating pediatric nasal fractures within 3-7 days is not evidence-based. 1, 2

• Delayed treatment (>7 days) produces equivalent outcomes to early treatment in terms of cosmetic results and nasal obstruction, with median long-term satisfaction scores showing no statistical difference (P=0.939 for cosmetics, P=0.264 for obstruction) 1
• No significant differences exist between pediatric and adult nasal fracture management in terms of postoperative conditions or optimal timing 2
• Treatment can be safely performed when swelling has resolved and optimal surgical conditions are available, rather than rushing to meet an arbitrary deadline 1, 5

Treatment Algorithm

Step 1: Determine Fracture Complexity

For simple displaced fractures without septal involvement:

• Perform closed reduction using Walsham forceps to restore anatomic position 6
• Use the smallest manipulative force necessary to preserve periosteal and mucosal attachments 7
• General anesthesia is typically required in pediatric patients 2

For fractures with septal deviation:

• Reduce the dislocated or disrupted septum using Asch forceps 6
• Position the septum into midline using transverse root osteotomy if needed 3
• Place a strut between the medial crura for support and realignment 3
• Septal correction is mandatory as associated septal injuries are responsible for postoperative nasal deformity and obstruction 3, 8

For comminuted fractures:

• Consider camouflaging techniques using dorsal onlay grafts with septal cartilage to hide residual deviations 3
• Cartilage grafts may be required for structural support during complex septal reconstruction 8

Step 2: Address Contributing Factors

• Evaluate for turbinate hypertrophy contributing to bilateral obstruction, which may require turbinate reduction 8
• Assess nasal valve narrowing and internal valve stenosis, which may necessitate stenosis repair 8
• Consider piriform aperture reduction as part of comprehensive correction in complex cases 8

Special Considerations in Pediatric Patients

• High remodeling potential in children allows acceptance of more initial deformity than traditionally tolerated in adults, with options for corrective procedures later if needed 9
• Short nasal bones are a relative contraindication for osteotomies, as they risk bony communication while yielding limited results 3
• Most common causes are auto accidents (40%), sports injuries (25%), intended injuries (15%), and home injuries (10%) 4
• Careful attention to underlying structural anatomy during initial management is paramount, as closed reduction alone results in significant incidence of posttraumatic deformities requiring secondary surgery 4

Postoperative Management

• Follow-up should continue for 6-12 months to ensure proper healing and satisfactory results 5
• Long-term outcomes are consistently good regardless of timing, with minimal nasal obstruction and good cosmetic results at median 62-month follow-up 1
• Visible irregularities or step-off deformities may occur in areas with thin overlying skin, requiring monitoring 7

Common Pitfalls to Avoid

• Do not rush to operate within arbitrary 3-7 day windows—this traditional teaching is not supported by evidence and may compromise surgical conditions 1, 2
• Do not overlook septal involvement—failure to address septal deviation leads to persistent deformity and obstruction 3, 4
• Do not use excessive manipulative force—preserve periosteal and mucosal attachments to minimize destabilization 7
• Do not rely on conventional radiographs for diagnosis—they have poor accuracy and rarely change management 3