What are the investigation and treatment options for a nasal bone or septum fracture?

Investigation and Treatment for Nasal Bone or Septum Fracture

For nasal bone or septum fractures, obtain CT maxillofacial imaging without IV contrast as the primary diagnostic modality, and perform closed reduction with septoplasty when septal deviation exceeds half the bridge width to prevent long-term deformity and obstruction. 1, 2

Initial Clinical Assessment

Evaluate for specific high-risk features that mandate imaging and subspecialist referral:

• Septal hematoma (requires immediate drainage to prevent cartilage necrosis) 3
• Cerebrospinal fluid rhinorrhea (indicates skull base fracture) 3
• Malocclusion (suggests midface fracture patterns) 3
• Extraocular movement defects (indicates orbital involvement) 3
• Deep lacerations with exposed cartilage (requires prophylactic antibiotics and CT imaging) 4
• Mucosal tearing (statistically significant predictor of septal fracture requiring surgical correction) 5

Any of these findings necessitate immediate subspecialist referral rather than primary care management alone. 3

Diagnostic Imaging

Primary Imaging Modality

CT maxillofacial without IV contrast is the gold standard for nasal trauma, offering superior fracture detection and characterization compared to plain radiographs. 1, 2 This modality provides:

• High-resolution thin-section acquisitions to detect subtle nondisplaced fractures 1
• Multiplanar and 3D reconstructions for characterizing complex fractures 1
• Superior sensitivity compared to conventional radiography (which has only 53-82% accuracy) 2

Alternative Imaging Options

Ultrasound may be considered for isolated nasal bone fractures, with sensitivity of 90-100% and specificity of 98-100%. 1, 2 Ultrasound has particular advantages in detecting nondepressed fractures of the nasal bridge and anterior septal cartilage deviation that CT may miss. 2

Imaging to Avoid

Plain radiographs should not be used as they have limited diagnostic value (53-82% accuracy) and do not significantly alter diagnosis or management. 2 CT head is not indicated for isolated nasal bone injury unless signs of intracranial injury or other associated facial fractures are present. 1

Treatment Algorithm

Step 1: Assess Fracture Severity and Septal Involvement

96% of simple nasal bone fractures involve septal fractures, making septal assessment critical. 5 The key decision point is whether nasal deviation exceeds half the bridge width:

• Deviation >50% bridge width: Indicates C-shaped fracture of bony and cartilaginous septum requiring open reduction with septoplasty 6
• Deviation <50% bridge width: May be amenable to closed reduction alone 6

CT imaging cannot accurately predict septal fracture severity (correlation coefficient only 33.5%), so direct visualization via hemitransfixion incision during surgery is necessary for definitive assessment. 5

Step 2: Timing of Intervention

Perform reduction within 3-5 days after injury when swelling permits adequate assessment but before significant healing occurs. 3 For patients with deep lacerations and exposed cartilage, initiate prophylactic antibiotics immediately. 4

Step 3: Surgical Approach Selection

For Simple Fractures Without Significant Septal Deviation

Closed reduction under local anesthesia is effective first-line treatment for simple nasal fractures. 7 However, this approach has a 30-40% failure rate when septal injuries are not addressed. 6

For Fractures With Septal Deviation >50% Bridge Width

Open reduction with septoplasty or submucosal resection is required. 6 The surgical sequence is critical:

• Position the septum into midline first using transverse root osteotomy before addressing nasal bones 2
• Place strut between medial crura for support and realignment 2
• Perform endoscopic septoplasty combined with nasal bone reduction for optimal visualization and minimal invasiveness 8

This combined approach has been shown to be statistically superior to closed reduction alone in preventing posttraumatic nasal deformity. 6

For Comminuted Fractures

Camouflaging techniques using dorsal onlay grafts with septal cartilage may be necessary to hide residual deviations. 2

Step 4: Preservation Principles

Preserve periosteal and mucosal attachments to minimize destabilization of the nasal framework. 4 This is particularly important in preventing long-term complications.

Management of Deep Lacerations With Exposed Cartilage

When cartilage is exposed:

• Administer prophylactic antibiotics immediately to prevent infection 4
• If infection is suspected, obtain deep tissue cultures (minimum five samples) before antibiotic administration 4
• Avoid swab cultures due to low sensitivity and high contamination risk 4
• Recommend nasal saline irrigation to prevent crusting 4

Critical Pitfalls to Avoid

The most common error is performing closed reduction without addressing septal fractures, which occurs in 96% of cases and leads to postoperative nasal deformity and obstruction. 5 The evidence clearly shows that manipulation alone has a 30-40% failure rate when septal deviation exceeds half the bridge width. 6

Short nasal bones are a relative contraindication for osteotomies as they risk bony communication while yielding limited results. 2

Follow-Up Requirements

Arrange close follow-up within 3-5 days after injury, possibly with a subspecialist, to assess healing and determine if secondary rhinoplasty will be needed for residual cosmetic deformities. 3, 2

Monitor for:

• Nasal airway obstruction from septal deviation or mucosal edema 4
• Cosmetic deformities requiring secondary correction 4