From the Guidelines
Assessment of a broken nose after an assault in the emergency department requires a systematic approach, prioritizing patient stability and evaluating the nasal injury specifically, as outlined in the most recent guidelines 1. The approach should begin with ensuring the patient is stable with no life-threatening injuries, followed by a thorough history of the assault mechanism and timing. A physical examination should look for septal hematoma (a medical emergency requiring immediate drainage), nasal deformity, epistaxis, and signs of other facial fractures, as these can significantly impact morbidity, mortality, and quality of life.
Key considerations in the assessment include:
- Checking for cerebrospinal fluid leakage (clear rhinorrhea), which suggests a more serious skull base fracture
- Assessing nasal airway patency and evaluating for orbital or neurological involvement
- Obtaining facial X-rays or CT scans if there's significant trauma or suspected complications, as recommended by recent studies 1
Management strategies may include:
- Simple, uncomplicated nasal fractures can be managed with ice, elevation of the head, analgesia (acetaminophen or NSAIDs like ibuprofen 400-600mg every 6 hours), and nasal decongestants
- Significant deformity may require closed reduction, ideally within 7-10 days of injury
- Documenting injuries thoroughly with photographs if possible, as this was an assault case
- Providing tetanus prophylaxis if needed and considering antibiotic prophylaxis only if there's an open fracture
- Arranging follow-up with an otolaryngologist within 3-5 days, and providing return precautions for worsening symptoms, as suggested by clinical practice guidelines 1
This structured approach ensures proper management while preserving evidence for potential legal proceedings, ultimately prioritizing the patient's morbidity, mortality, and quality of life outcomes.
From the Research
Assessment of Broken Nose
- A broken nose, or nasal fracture, is a common condition that can result from road accidents, sports injuries, and physical confrontations 2.
- The goal of treatment for nasal fractures is to restore the pretraumatic state and normal function 3.
Clinical Assessment
- Each patient's history must be recorded, including the cause of trauma, previous facial injuries, prior nasal deformity, or obstruction 2.
- A careful physical examination is necessary to guide the choice of treatment, including open vs closed reduction, timing, and type of anesthesia required 2.
- A thorough examination of the nose and surrounding structures, including the orbits, mandible, and cervical spine, should be completed 4.
Treatment Options
- Manipulation under local anesthesia is an effective first-line treatment for simple nasal fractures and should become a standard practice 2.
- The decision by the surgeon regarding the surgical approach should be based on the degree of injury, the presence of concomitant facial injuries, patient compliance, training of the surgeon, and the presence and degree of septal injury 3.
- Treatment in the primary care setting consists of evaluation, pain and infection management, minimal debridement, and, when the physician is appropriately trained, closed reduction 4.
Imaging and Referral
- Imaging studies are necessary for facial or mandibular fractures 4.
- Patients with septal hematomas, cerebrospinal fluid rhinorrhea, malocclusion, or extraocular movement defects should be referred to a subspecialist 4.