What is the management plan for nasal fractures?

Management of Nasal Fractures

For nasal fractures, perform closed reduction using minimal manipulative force while preserving periosteal and mucosal attachments, but only after addressing any septal deviation first, as septal correction must precede nasal bone realignment to prevent postoperative deformity and obstruction. 1, 2

Initial Assessment

Evaluate for the following critical elements before proceeding with treatment:

• Associated injuries: Screen for other facial fractures, intracranial injuries, and cervical arterial injuries using the clinical context 3, 1
• Septal involvement: Determine the presence and degree of septal deviation through direct examination, as this dictates your treatment sequence 1, 2
• Fracture complexity: Assess whether the fracture is simple displaced, comminuted, or involves multiple facial bones 1, 4
• Timing: Document when the injury occurred, as this affects reduction feasibility 5

Diagnostic Imaging

CT imaging is the preferred diagnostic modality for nasal fractures, particularly when complex injuries or associated facial fractures are suspected. 1

• CT offers superior detection and characterization compared to conventional radiography 1
• Conventional nasal radiographs have poor accuracy (only 53-82%) and rarely alter management decisions 1, 2
• Ultrasound is an acceptable alternative for isolated nasal bone fractures, with sensitivity of 90-100% and specificity of 98-100%, and can better detect nondepressed fractures and anterior septal cartilage deviation than CT 1, 2

Treatment Algorithm

Step 1: Address Septal Deviation First

This is the most critical step—failure to correct septal deviation before nasal bone realignment leads to persistent deformity and obstruction. 1, 2, 5

• Reduce dislocated or disrupted septum using Asch forceps 2
• Position the septum into midline using a transverse root osteotomy if needed 1, 2
• Place a strut between the medial crura for support and realignment 1

Step 2: Perform Nasal Bone Reduction

For simple displaced fractures without significant septal involvement:

• Use the smallest manipulative force necessary to achieve reduction 6, 2
• Preserve periosteal and mucosal attachments of the nasal bone to minimize destabilization of the osseous framework 3, 6
• Avoid creating periosteal tunnels, as these are detrimental to support 3

For complex fractures with bony deviation:

• If profile reduction is performed, this should precede repositioning of nasal bones, as lowering the nasal dorsum removes the most anterior lateral components and decreases the degree of deviation 3
• Perform osteotomies while preserving periosteal and mucosal attachments 3
• Use the smallest possible osteotomies (intranasal and/or percutaneous) for mobilization 3

Step 3: Manage Comminuted or Severe Fractures

• Consider camouflaging techniques such as dorsal onlay grafts using septal cartilage to hide residual deviations when complete correction is impossible 1, 3
• For severe bony deviation without hump removal, change the sequence: work from the less deviated side with lateral osteotomy followed by medial osteotomy and outfracturing, then position septum into midline using transverse root osteotomy 3

Critical Contraindications and Pitfalls

Short nasal bones are a relative contraindication for osteotomies—they risk bony communication while yielding limited results. 1, 2, 3

Common pitfalls to avoid:

• Never overlook septal involvement: Associated septal injuries are responsible for postoperative nasal deformity and obstruction 1, 2, 5
• Avoid excessive force: Aggressive manipulation destabilizes the osseous framework 6, 2
• Do not rely on conventional radiographs: They have poor accuracy and do not change management 1, 2
• Avoid intermediate osteotomies: These risk visible irregularities or step-off deformities in areas with thin overlying skin 3, 6

Special Populations

In pediatric patients, the high remodeling potential allows acceptance of more initial deformity than in adults, with options for corrective procedures later if needed. 2

Return to Activity

For athletes with isolated nasal fractures, return to play is generally permitted, but wearing a face mask for 6 weeks after injury is recommended for protection. 7