What is the treatment for nasal bone fractures?

Treatment of Nasal Bone Fractures

Closed reduction is the preferred treatment for displaced nasal bone fractures, ideally performed within 2 weeks of injury, with mandatory assessment and correction of septal fractures before or concurrent with nasal bone realignment. 1, 2, 3

Initial Assessment and Imaging

CT maxillofacial imaging is the diagnostic modality of choice for nasal bone fractures, providing superior detection and characterization compared to plain radiographs, which have limited accuracy (53-82%) and rarely alter management decisions. 1, 2, 4

Critical screening priorities include:

• Airway compromise from hemorrhage, soft-tissue edema, or loss of facial architecture 1
• Associated injuries including intracranial injuries, other facial fractures, and cervical spine injuries (68% of maxillofacial trauma patients have associated head injury) 1
• Naso-orbital-ethmoid fractures which can cause telescoping of the nose and require subspecialist management to prevent enophthalmos, telecanthus, lacrimal obstruction, and ptosis 1

Ultrasound may serve as an alternative with high accuracy (sensitivity 90-100%, specificity 98-100%) particularly for isolated nasal bone fractures and can better detect nondepressed fractures and anterior septal cartilage deviation than CT. 2, 4

Treatment Algorithm

Step 1: Evaluate for Septal Involvement

Septal fractures occur in 96.2% of simple nasal bone fractures and must be addressed before or concurrent with nasal bone reduction. 5 Physical examination findings of mucosal tearing are statistically significant for septal fracture, though CT cannot accurately predict severity and cannot definitively determine if septoplasty is needed. 5

Step 2: Timing of Intervention

Closed reduction should be performed within 2 weeks after injury for optimal outcomes. 3 Earlier intervention within the first week is preferable before significant soft tissue healing occurs.

Step 3: Surgical Technique Based on Fracture Pattern

For simple fractures without significant septal deviation:

• Perform closed reduction using the smallest manipulative force necessary 2
• Preserve periosteal and mucosal attachments to minimize destabilization of the osseous framework 2
• Avoid creating periosteal tunnels as these are detrimental to support 2

For complex fractures with septal deviation:

• Septal correction must precede nasal bone realignment 1
• Position the septum into midline using transverse root osteotomy 1
• Place a strut between the medial crura for support and realignment 2
• Perform septoplasty or submucosal resection for severe septal fractures (perioperative septal grade 3 or higher) 5

For comminuted fractures with residual deformities:

• Consider camouflaging techniques such as dorsal onlay grafts using septal cartilage to hide residual deviations 2, 4

Step 4: Antibiotic Management

Routine perioperative antibiotics are NOT recommended for uncomplicated nasal bone fracture surgery. 6 A retrospective study of 373 patients showed zero cases of surgical site infection regardless of antibiotic use, with infection-related complications (2.1%) occurring only in the antibiotic usage group. 6

Exception: Prophylactic antibiotics ARE recommended for deep nasal lacerations with exposed cartilage to prevent infection. 1, 4

Critical Contraindications and Technical Pitfalls

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

Avoid intermediate osteotomies as they risk visible irregularities or step-off deformities in areas with thin overlying skin. 2

Do not rely solely on CT findings to determine the need for septoplasty—the correlation between CT septal grading and perioperative findings is only 33.5%, requiring direct visualization via hemitransfixion incision for accurate assessment. 5

Post-Treatment Management

• Nasal saline irrigation to keep nasal passages clean and prevent crusting 1, 4
• Monitor for nasal airway obstruction from septal deviation or mucosal edema 1, 4
• Assess for postoperative deformity (11.2% incidence), nasal obstruction (6.1%), and olfactory disturbances (1.1%), with higher rates in more severe fractures 3

Expected Outcomes

Closed reduction demonstrates significant improvement in both functional parameters (airway patency, nasal obstruction resolution) and esthetic parameters (facial symmetry, reduction of nasal deviation) with high patient satisfaction on visual analog scale assessments. 7 However, untreated or inadequately treated septal fractures can lead to posttraumatic nasal deformity requiring secondary rhinoplasty. 8, 5