What is the treatment for nasal bone fractures?

Treatment of Nasal Bone Fractures

For simple nasal bone fractures, perform closed reduction under local anesthesia within 2 weeks of injury after ensuring airway stability and hemorrhage control, using CT imaging for diagnosis rather than plain radiographs. 1

Immediate Management

Life-Threatening Priorities

• Stabilize the airway first before addressing the fracture itself, as soft-tissue edema can progress to airway obstruction 1
• Control hemorrhage immediately to prevent airway compromise 1
• Screen for associated injuries including other facial fractures, intracranial injuries, and cervical arterial injuries based on clinical presentation 1, 2

Diagnostic Imaging Strategy

• Use CT maxillofacial imaging as the first-line diagnostic modality for nasal fractures, as it provides superior detection with thin-section acquisitions and multiplanar reconstructions compared to radiographs 3, 1, 2
• CT is more sensitive than radiographs in confirming nasal bone fractures and can fully characterize complex injuries with associated facial fractures 3
• Avoid conventional nasal radiographs, as they have limited diagnostic value with accuracy ranging only 53-82% and do not significantly alter management 3, 2
• Ultrasound may be considered as an alternative with high accuracy (sensitivity 90-100%, specificity 98-100%) particularly for isolated nasal bone fractures 3, 2

Treatment Algorithm

Step 1: Assess Septal Involvement

• Determine the presence and degree of septal deviation before proceeding, as septal correction must precede nasal bone realignment 1, 2
• Document any associated septal injuries, as they can cause postoperative nasal deformity and obstruction 1, 2

Step 2: Simple Nasal Fractures

• Perform closed reduction under local or general anesthesia within 2 weeks after injury 1, 4, 5
• Preserve periosteal and mucosal attachments to minimize destabilization of the osseous framework 2
• Use the smallest manipulative force necessary to achieve reduction 2
• Closed reduction is effective for improving both functional parameters (airway patency, nasal obstruction) and aesthetic parameters (facial symmetry, nasal deviation) 4
• C-arm fluoroscopy during closed reduction significantly reduces complication rates and re-operation rates by allowing indirect visualization of the fracture during manipulation 6

Step 3: Complex Fractures with Septal Deviation

• Position the septum into the midline using a transverse root osteotomy 1, 2
• Place a strut between the medial crura for support and realignment 1, 2

Step 4: Comminuted Fractures

• Consider camouflaging techniques such as dorsal onlay grafts using septal cartilage to hide residual deviations when complete correction is impossible 1, 2

Perioperative Considerations

Antibiotic Use

• Routine perioperative antibiotics are not recommended for uncomplicated nasal bone fracture surgery 7
• In a retrospective study of 373 patients undergoing closed reduction, there were no cases of surgical site infection, and infection-related complications (2.1%) occurred only in the antibiotic usage group 7
• The use of nasal packing and anesthesia type did not affect infection-related complication rates 7

Timing Considerations

• Closed reduction can be successfully performed within 2 weeks after injury 5
• Earlier intervention within this window is preferable before significant soft tissue edema and early healing complicate reduction 1

Critical Contraindications and Pitfalls

Relative Contraindications

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

Common Pitfalls to Avoid

• Avoid intermediate osteotomies, as they risk visible irregularities or step-off deformities in areas with thin overlying skin 1, 2
• Do not create periosteal tunnels, as these are detrimental to support 2
• Use the smallest possible osteotomies for mobilization to preserve structural integrity 2

Expected Outcomes and Complications

Complication Rates

• Postoperative deformity occurs in approximately 11.2% of patients 5
• Nasal obstruction occurs in approximately 6.1% of patients 5
• Olfactory disturbances occur in approximately 1.1% of patients 5
• Patients with more severe nasal bone fractures have higher rates of complications 5

Success Rates

• Closed reduction shows significant improvement in both functional and aesthetic parameters when performed appropriately 4
• Using C-arm guidance during closed reduction significantly reduces complication morbidity and re-operation rates compared to blind reduction 6