When is surgery indicated for nasal bone fractures?

Surgical Indications for Nasal Bone Fractures

Surgery is indicated for nasal bone fractures when there is displacement requiring reduction, associated septal deviation causing obstruction, cosmetic deformity, or when closed reduction alone will not achieve adequate functional and aesthetic outcomes. 1, 2, 3

Absolute Indications for Surgical Intervention

Immediate Surgery Required

• Septal hematoma - requires urgent drainage to prevent cartilage necrosis 4
• Open (compound) fractures - require immediate debridement and reduction 4
• Grossly displaced fractures - should be reduced urgently before significant edema develops 4
• Associated septal deviation from trauma - requires septal correction to achieve both functional and aesthetic improvement 1, 2

Delayed Surgery (3-10 Days Post-Injury)

• Most nasal fractures with displacement should be definitively treated after 3-10 days once swelling has resolved, as accurate reduction cannot be performed through significant edema 4
• Septal fractures occur in 96.2% of simple nasal bone fractures and require assessment for septoplasty or submucous resection 5
• Closed reduction can be successfully performed within 2 weeks after injury 6

Surgical Decision Algorithm

Step 1: Assess Fracture Complexity and Associated Injuries

• Screen for other facial fractures, intracranial injuries, and cervical arterial injuries using CT imaging 7, 3
• CT is the preferred diagnostic modality with superior detection compared to plain radiographs (which have only 53-82% accuracy) 3
• Evaluate for septal involvement - mucosal tearing on physical examination is statistically significant for septal fracture 5

Step 2: Classify Fracture Type

• Type I (simple fracture) - 40% of cases 8
• Type II (fracture line mimicking nasal osteotomy) 8
• Type III (comminuted fracture) - requires consideration of camouflaging techniques such as dorsal onlay grafts 3, 8

Step 3: Determine Surgical Approach

For Simple Fractures WITHOUT Septal Deviation

• Closed reduction alone may be adequate 4, 6
• Preserve periosteal and mucosal attachments using the smallest manipulative force necessary 1, 3

For Fractures WITH Septal Deviation (78.8% require septoplasty)

• Septal correction must precede nasal bone realignment 3
• Position septum into midline using transverse root osteotomy 3
• Place strut between medial crura for support 3
• CT cannot accurately predict septal fracture severity (only 33.5% correlation with operative findings), so direct visualization via hemitransfixion incision is needed 5

For Complex/Comminuted Fractures

• Consider concomitant rhinoplasty with fracture reduction during acute stage for better aesthetic outcomes (mean satisfaction score 7.62-8.0) 8
• Use camouflaging techniques with dorsal onlay grafts using septal cartilage to hide residual deviations 3
• May require cartilage grafts for structural support during complex septal reconstruction 2

Contraindications to Surgery

Relative Contraindications

• Short nasal bones - osteotomies risk bony communication while yielding limited results 3
• Avoid intermediate osteotomies in areas with thin overlying skin due to risk of visible irregularities or step-off deformities 1, 3

When Surgery is NOT Indicated

• Minimally displaced fractures without functional impairment - may be observed
• Fractures presenting beyond 2-week window may require delayed rhinoplasty rather than acute reduction 6

Critical Pitfalls to Avoid

• Do not rely on plain radiographs - they do not significantly alter diagnosis or management 3
• Do not perform closed reduction through significant edema - wait 3-10 days for swelling to resolve 4
• Do not ignore septal involvement - 96.2% of simple nasal fractures have associated septal fractures that can cause postoperative deformity if untreated 5
• Do not create periosteal tunnels - these are detrimental to support 3
• Do not assume CT findings predict operative severity - direct visualization is required for definitive assessment 5

Special Population Considerations

Pediatric Patients

• Nasal fractures are among the 3 most common pediatric facial bone fractures 9
• Closed reduction has significant incidence of posttraumatic deformities requiring secondary surgery, emphasizing need for careful attention to underlying structural anatomy during initial management 9
• Traffic accidents (40%) and sports injuries (25%) are most common causes 9