What is the immediate management for a patient with an acute comminuted right-sided nasal bone fracture?

Immediate Management of Acute Comminuted Right-Sided Nasal Bone Fracture

For an acute comminuted nasal bone fracture, immediately control epistaxis with anterior pressure and topical vasoconstrictors, assess for septal hematoma and associated facial/intracranial injuries, obtain CT imaging to characterize the fracture pattern, and plan definitive reduction within 2-10 days while managing pain and swelling in the interim. 1, 2, 3

Initial Emergency Assessment and Stabilization

Control Active Bleeding

• Instruct the patient to lean forward and pinch the soft part of the nose for at least 5 minutes, continuing for a full 15 minutes if bleeding slows 1
• If bleeding persists, spray 2 sprays of oxymetazoline (topical vasoconstrictor) in the bleeding nostril and continue holding for 5 minutes, which achieves 65-75% resolution of bleeding 1
• This approach is recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1

Exclude Life-Threatening Associated Injuries

• Screen for other facial fractures (zygomatic, maxillary, frontal sinus), intracranial injuries, and cervical arterial injuries using clinical context 4, 1, 2
• The American College of Radiology notes that one-third of patients with frontal sinus fractures have concomitant intracranial injury 4
• Immediately refer to otolaryngology if you identify septal hematoma, open fracture with exposed cartilage, or suspected cerebrospinal fluid leak 1

Obtain Definitive Imaging

• CT imaging is the preferred diagnostic modality for comminuted nasal fractures, offering superior detection and characterization compared to conventional radiography 2, 5
• Plain radiographs have limited diagnostic value with only 53-82% accuracy and should not be used 1, 2
• CT is particularly essential for comminuted fractures to assess the full extent of bony disruption and plan surgical approach 5

Pain and Swelling Management

Pharmacologic Pain Control

• Prescribe regular paracetamol (acetaminophen) for pain management unless contraindicated 1
• Use opioids with caution, particularly in elderly patients with renal dysfunction 1
• Avoid non-steroidal anti-inflammatory drugs in patients with renal dysfunction 1

Reduce Acute Swelling

• Apply ice to reduce swelling in the first 48-72 hours 1
• Use humidification and saline nasal spray to maintain humidity and promote healing 1

Patient Education and Precautions

• Instruct patients to avoid further trauma: no vigorous nose-blowing, avoid contact sports, and avoid touching or manipulating the nose 1
• Provide clear instructions on preventive measures including eliminating digital trauma and using proper nasal hygiene 1
• Advise patients on anticoagulation not to stop their medications without consulting the prescribing physician 1

Definitive Treatment Planning (Within 2-10 Days)

Assess Septal Involvement

• Evaluate the presence and degree of septal deviation, as 96.2% of simple nasal bone fractures involve septal fractures 6
• Septal correction must precede nasal bone realignment, as associated septal injuries are responsible for postoperative nasal deformity and obstruction 7, 2, 6
• Physical examination findings of mucosal tearing are statistically significant for septal fracture 6
• CT can help diagnose septal fracture but cannot predict severity accurately enough to determine if septoplasty is needed 6

Surgical Approach for Comminuted Fractures

For comminuted fractures with displacement, plan open or closed reduction within 2-10 days post-injury 3:

Closed Reduction Technique

• Use the smallest manipulative force necessary to preserve periosteal and mucosal attachments 7, 2
• Perform reduction under general or local anesthesia 3
• Apply nasal cast for 2 weeks post-reduction 3

Open Reduction for Severe Comminution

• For severe comminuted fractures with lacerations at fracture sites, consider open reduction through laceration openings with internal fixation using fibrin glue under general anesthesia 8
• This approach may be simpler and more effective than traditional fixation methods for complicated comminuted open nasal fractures 8

Address Septal Deviation

• Reduce the dislocated or disrupted septum using Asch forceps 7
• Position the septum into midline using transverse root osteotomy if needed 7, 2
• Place a strut between the medial crura for support and realignment 2

Camouflaging Techniques for Residual Deformity

• Consider dorsal onlay grafts using septal cartilage cut in thin wafers to hide residual deviations when complete correction is impossible 2
• This is particularly useful for comminuted fractures where anatomic restoration may be challenging 2

Common Pitfalls to Avoid

• Do not overlook septal involvement—failure to address septal deviation leads to persistent deformity and obstruction in the majority of cases 7, 6
• Do not delay reduction beyond 10 days—early evaluation and treatment within 2-10 days post-injury is critical to avoid complications 3
• Do not rely on plain radiographs—they have poor accuracy (only 82% reliability) and rarely change management 1, 2, 5
• Do not use excessive manipulative force—preserve periosteal and mucosal attachments to minimize destabilization 7, 2

Follow-Up

• Document the outcome of intervention within 30 days for quality assurance and to identify any delayed complications requiring further management 1
• Monitor for visible irregularities or step-off deformities in areas with thin overlying skin 7
• Consider septorhinoplasty months later if closed technique fails (occurs in approximately 23% of cases) 3