What is the treatment for a patient with a broken nose?

Treatment of Nasal Fractures

For acute nasal fractures, closed reduction under local anesthesia within 5-14 days is the first-line treatment for simple fractures, while complex fractures with significant septal involvement or severe deformity should be considered for delayed open surgical correction after 3 months. 1, 2

Initial Assessment and Stabilization

Immediate priorities focus on controlling epistaxis and ruling out life-threatening complications:

• Apply firm sustained compression to the lower third of the nose for 10-15 minutes with the head tilted slightly forward to control bleeding 3
• Most traumatic epistaxis stops within 5-15 minutes with proper compression; bleeding beyond 15 minutes requires medical evaluation 3
• Seek emergency care immediately if there are signs of brain injury, obvious nasal deformity suggesting severe fracture, hemodynamic instability, or facial fractures 3
• Document risk factors that may complicate management: anticoagulant/antiplatelet use, bleeding disorders, prior nasal surgery, or nasal trauma 4

Diagnostic Imaging

CT maxillofacial imaging is the gold standard for characterizing nasal fractures:

• MDCT with thin-section acquisitions and 3-D reconstructions provides superb delineation of osseous structures and is critical for surgical planning in complex injuries 4
• CT is more sensitive than plain radiographs (which have only 53-82% diagnostic accuracy) and should be used when there are complex nasal injuries or associated facial fractures 4
• Plain nasal radiographs have limited diagnostic value and do not considerably alter diagnosis or management 4

Treatment Timing and Approach

The timing of intervention depends on fracture complexity and patient factors:

Early Closed Reduction (Within 5-14 Days)

• Manipulation under local anesthesia is effective first-line treatment for simple nasal fractures without significant septal involvement 1, 2
• This approach is cost-effective and minimizes the need for secondary surgeries when appropriately selected 2
• Perform closed reduction before significant edema develops but after initial swelling subsides (typically 3-7 days post-injury) 1

Delayed Open Surgical Correction (After 3 Months)

• Consider delayed open approach for fractures with significant septal involvement, severe dorsal or caudal L-strut deformities, nasal valve issues, or severe bony deviation 2
• Delayed intervention has lower revision rates, improved ability for rigid fixation and support, and better correction of complex deformities compared to early closed technique 2
• The high rate of subsequent open treatment after closed reduction, particularly with septal involvement, supports initial consideration of delayed open approach in complex cases 2

Specific Technical Considerations

For deviated or asymmetric noses requiring surgical correction:

• Septal correction is fundamental—"as the septum goes, so goes the nose"—and severe deformities require extensive septal manipulation 4
• Osteotomies should preserve periosteal and mucosal attachments to minimize destabilization, using the smallest possible osteotomies tailored to patient anatomy 4
• For severe bony deviation without hump removal, medialize nasal bones and septum "like opening a book" using lateral osteotomy followed by medial osteotomy and outfracturing 4
• Camouflaging techniques with onlay grafts may prevent need for destabilizing osteotomies in limited external deviations 4

Management of Associated Epistaxis

If bleeding persists despite compression:

• Use topical vasoconstrictors and identify the bleeding site after clot removal via anterior rhinoscopy 4
• Perform nasal cautery with anesthesia, restricting application only to active or suspected bleeding sites 4
• Place nasal packing (preferably resorbable) for ongoing active bleeding not controlled by compression or cautery 4
• Use resorbable packing specifically for patients with bleeding disorders or those on anticoagulant/antiplatelet medications 4

Post-Treatment Care and Follow-Up

Proper patient education and monitoring are essential:

• Avoid straining, lifting over 10 pounds, bending over, and exercising to prevent rebleeding 4
• Sleep with head slightly elevated and avoid aspirin/ibuprofen (acetaminophen is safe) 4
• Keep nose moist with nasal saline sprays to reduce crusting and facilitate healing 4
• Document treatment outcome within 30 days or document transition of care 4
• Long-term follow-up shows 90% patient satisfaction and 84% normal nasal airflow with closed reduction, though some secondary deformities may develop 5

Common Pitfalls

• Failing to identify significant septal involvement leads to high revision rates after closed reduction 2
• Attempting closed reduction on complex fractures with severe septal deformity results in poor outcomes 2
• Performing osteotomies on short nasal bones risks bony communication with limited results 4
• Missing tooth aspiration in patients with dental trauma—chest radiograph may be warranted if a tooth is absent 4