For an adolescent or adult with suspected nasal fracture after facial trauma (bruising, swelling, deformity, epistaxis, or breathing difficulty), when is a plain X‑ray indicated instead of CT imaging?

Plain X-ray is NOT Indicated for Nasal Fracture

Plain radiographs should not be ordered for suspected nasal fractures in adolescents or adults, as they demonstrate poor diagnostic accuracy (53-82%) and do not change clinical management. 1

Imaging Algorithm for Suspected Nasal Fracture

Clinical Examination Alone (No Imaging)

• For isolated nasal bone fractures with visible or palpable deformity, tenderness, or epistaxis, clinical examination is sufficient for diagnosis and management planning. 1, 2
• Plain radiographs are not cost-effective and should be abandoned in routine nasal trauma management. 3
• Patients without imaging are actually more likely to proceed to surgery than those with imaging, indicating that radiographs do not aid surgical decision-making. 4

When CT Maxillofacial (Without IV Contrast) IS Indicated

Order CT imaging when any of the following are present:

• Suspected complex midface fractures (naso-orbital-ethmoid, Le Fort, or zygomaticomaxillary complex injuries) 1, 2
• Deep lacerations with exposed cartilage 1
• Signs suggesting extension beyond isolated nasal bones (orbital involvement, midface instability, malocclusion) 1
• Need for surgical planning in complex fractures requiring multiplanar and 3D reconstructions 1

Point-of-Care Ultrasound as an Alternative

• For isolated nasal bone fractures, ultrasound demonstrates 90-100% sensitivity and 98-100% specificity, superior to plain radiographs. 1, 5, 6
• Lateral-view ultrasound reliably identifies fractures through disruption of bone continuity and displacement of fracture segments. 7, 5
• Ultrasound detects non-displaced fractures and anterior septal cartilage deviation better than CT in some cases. 1
• When available, ultrasound should be the first-line imaging for isolated nasal fractures. 5

Key Clinical Pitfalls to Avoid

Do NOT Order Plain Radiographs Because:

• Accuracy is only 53-82%, significantly inferior to both CT (94.4%) and ultrasound (85.0%) 1, 6
• They do not influence treatment decisions or surgical planning 4, 3
• They have no substantial medicolegal value despite common physician misconceptions 3
• Sensitivity for lateral nasal wall fractures is particularly poor at only 28% compared to 98% for ultrasound 5

Additional Imaging Considerations

• Screen for intracranial injury with head CT if signs of head trauma are present, as 68% of maxillofacial trauma patients have concomitant head injuries. 1, 2
• Head CT is NOT required for isolated nasal bone injury without other concerning findings. 1
• If a tooth is missing after facial trauma, obtain chest radiograph to exclude aspiration. 1

Management Based on Imaging Findings

Isolated Nasal Fracture (Clinical Diagnosis or Ultrasound Confirmation)

• Refer to ENT/Otolaryngology for closed reduction with or without septal correction 2
• Septal correction must precede nasal bone realignment when septal deviation is present 2, 8

Complex Midface Fractures on CT

• Immediately refer to maxillofacial surgery to prevent severe functional and cosmetic complications including telecanthus, enophthalmos, lacrimal drainage obstruction, and eyelid ptosis 2

Urgent Referral Indications (Regardless of Imaging)

• Septal hematoma requires urgent ENT drainage to prevent septal necrosis 2
• Open fracture with exposed cartilage 2
• Cerebrospinal fluid leak suggesting cribriform plate involvement requires neurosurgical consultation 2
• Persistent epistaxis despite conservative measures 2