What is the initial treatment for nasal bone fractures in the emergency room (ER)?

Initial Treatment for Nasal Bone Fractures in the Emergency Room

In the ER, prioritize airway stabilization and hemorrhage control first, then perform closed reduction under local anesthesia within 2 weeks for simple nasal fractures, while screening for associated facial and intracranial injuries with CT imaging if clinically indicated. 1

Immediate Life-Threatening Concerns

Before addressing the nasal fracture itself, the emergency physician must complete a primary survey focusing on "airway, breathing, and circulation" for patient stabilization. 1 Maxillofacial trauma can lead to airway compromise secondary to:

• Hemorrhage control - Active bleeding must be addressed immediately 1
• Soft-tissue edema - Can progress to airway obstruction 1
• Loss of facial architecture - Severe displacement may compromise the airway 1

Diagnostic Imaging Strategy

CT imaging is the preferred diagnostic modality for nasal fractures, offering superior detection compared to conventional radiography, especially when complex injuries or associated facial fractures are suspected. 2

• Conventional nasal radiographs have limited diagnostic value with accuracy ranging only 53-82% and do not significantly alter management 2
• Screen for associated injuries including other facial fractures, intracranial injuries, and cervical arterial injuries based on clinical context 1, 2
• Ultrasound may be considered as an alternative with high accuracy (sensitivity 90-100%, specificity 98-100%) particularly for isolated nasal bone fractures 2

Treatment Algorithm for Simple Nasal Fractures

Step 1: Assess Fracture Complexity and Timing

Closed reduction under local anesthesia is the effective first-line treatment for simple nasal fractures and should be performed within 2 weeks after injury. 3, 4

• Determine the presence and degree of septal deviation, as septal correction must precede nasal bone realignment 2
• Document any associated septal injuries, which can be responsible for postoperative nasal deformity and obstruction 2, 3

Step 2: Closed Reduction Technique

Preserve periosteal and mucosal attachments of the nasal bone to minimize destabilization of the osseous framework, using the smallest manipulative force necessary to achieve reduction. 2, 5

• Avoid creating periosteal tunnels, as these are detrimental to support 2
• For cases with associated septal deviation, additional septal correction may be required to achieve both functional and aesthetic improvement 5, 6

Step 3: Stabilization Methods

After reduction, stabilization is typically achieved with:

• Internal and/or external splints - Standard approach for most reducible fractures 7
• Transmucosal endonasal Kirschner wires - For "flail" nasal bones that are reducible but unstable, severely displaced, or when external drape lacerations preclude use of nasal splints 7
• Nasal bone clips - Novel device providing satisfactory nasal airway and improved comfort compared to traditional gauze packing 8

Special Considerations and Contraindications

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

For Complex Fractures with Septal Deviation

• Position the septum into the midline using a transverse root osteotomy 2
• Place a strut between the medial crura for support and realignment 2

For Comminuted Fractures

• Consider camouflaging techniques, such as dorsal onlay grafts using septal cartilage, to hide residual deviations when complete correction is impossible 2

Common Pitfalls to Avoid

• Intermediate osteotomies - Risk visible irregularities or step-off deformities in areas with thin overlying skin 2, 5
• Delayed diagnosis - Many broken noses associated with multiple trauma are not promptly diagnosed, leading to secondary nasal deformities and chronic obstructions 3
• Inadequate follow-up - Essential to detect complications including postoperative deformity (11.2%), nasal obstruction (6.1%), and olfactory disturbances (1.1%) 4

Complications Requiring Vigilance

Patients with more severe nasal bone fractures have higher rates of complications. 4 Monitor for:

• Postoperative deformity
• Nasal obstruction
• Olfactory disturbances
• Visible irregularities or step-off deformities, especially in areas with thin overlying skin 5