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Nasal Fracture


Introduction

  • The prominent, central position of the nose on the face makes it highly vulnerable to facial trauma.

  • The nasal bones are the most commonly fractured facial bone and the third most common fracture in the human body.

  • The most common cause of a nasal fracture is blunt trauma.

  • When not promptly identified and treated, resultant nasal deformity and/or nasal airway obstruction may persist.

  • Most fractures occur between the thicker proximal segment of the nasal bone and the thinner distal segment and generally result in depression at the point of impact.

  • Depending on the severity of the trauma there can be lateral displacement of the contralateral nasal bone, or the fracture may be comminuted ( Fig. 184.1 ).

    Fig. 184.1, Nasal fracture patterns. A, Isolated right nondisplaced nasal bone fracture. B, Right and left displaced nasal bone fracture with sepal fracture. C, Comminuted fracture of nasal bones with septal fracture.

Key Operative Learning Points

  • Nasal fractures should be reduced within 2 weeks of the original injury.

  • Not all nasal fractures need to be repaired.

  • Careful evaluation of the nasal septum should be performed during the evaluation of a nasal fracture.

  • A closed reduction of a nasal fracture can be done under local or general anesthesia (GA).

  • The reduction of complex nasal fractures may require an open approach.

Preoperative Period

History

  • Key points include time frame, mechanism of injury, and consideration of whether or not additional injuries may be present.

  • It can take several days for the edema associated with nasal trauma to subside. If immediate evaluation is not possible (within hours of the injury), an accurate assessment of cosmetic change may not be possible until the edema subsides in several days.

  • Inquire about a history of prior facial trauma and facial fractures, nasal deformity, or nasal airway obstruction.

    • Pre-existing conditions that are not the result of acute injury cannot be repaired using closed techniques.

    • Preinjury photographs can assist in determining a particular area of concern or determining a baseline, but often the quality is not adequate to assess for subtle changes.

    • Patients may not have a clear idea of what their baseline appearance was. Subtle changes to their nose can be perceived as changes when in fact they were present prior to the injury.

Physical Examination

  • Externally, the nose should be viewed in all orientations and gentle palpation can identify areas of step-off. However, in the acute phase, soft tissue edema may obscure the fracture site.

  • Patient feedback and explanation of the site of injury can aid with the assessment.

  • The septum should be evaluated for fracture or hematoma.

    • Septal hematomas should be addressed immediately if present.

  • Nasal endoscopy can be used to allow for complete evaluation of the septum.

    • Unrecognized septal trauma is a common indication for need of revision surgery.

  • Damage to the upper/lower lateral cartilages are often overlooked and should be carefully examined for.

Imaging

  • Nasal fracture is a clinical diagnosis, and imaging is not required to confirm a fracture, although patients often present with imaging obtained through the emergency department (ER) ( Fig. 184.2 ).

    Fig. 184.2, A, Axial noncontrast computed tomography (CT) of a patient struck on the right side of his nose with resultant depression of the right nasal bone and lateral shift of the left nasal bone. B, Intraoperative photograph of same patient depicted in the CT demonstrating depression of the right nasal bone and resultant shift to the left side.

  • Generally speaking, nasal fracture does not occur without epistaxis. If other facial fractures are suspected, noncontrast high-resolution computed tomography (CT) scan through the facial bones with coronal and sagittal reconstructions is indicated ( Fig. 184.3 ).

    Fig. 184.3, Axial noncontrast computed tomography of a patient who fell striking his nose in direct fashion with the ground resulting in severe comminuted bilateral nasal bone fractures. This imaging was obtained secondary to concern for additional orbital fractures. P, posterior. L, left.

Indications

  • If the patient is comfortable with his or her external appearance and nasal breathing, the patient can be observed.

  • Reduction of nasal fractures can be performed in any age group.

    • Closed reduction:

      • Unilateral or bilateral nasal bone fracture(s) without significant dislocation

    • Open reduction:

      • Extensive fractures of the nasal bones with major dislocation with or without fracture of the caudal septum

      • Open septal fracture or persistent deviation following prior closed reduction

Contraindications

  • Isolated nasal fracture repair in the context of a severe nasoethmoid complex fracture. This can result in cerebrospinal fluid leak or worsen a pre-existing leak. Concurrent repair of the nasal fracture as part of the larger midface repair is indicated.

Preoperative Preparation

  • There is no specific preoperative preparation of the patient for nasal reduction. Patients may wish to place ice on their face to further decrease edema.

  • If GA is indicated, standard medical risk assessment should be performed.

  • In children, it is suggested that the reduction of the fracture be performed within 7 to 10 days to provide for more rapid healing.

  • In adults, the general guideline is within 10 to 14 days.

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