Nasal Fracture

The commonest facial fracture, involving the nasal bones, the frontal processes of the maxilla, and frequently the septum. The nasal bones are thin, prominent and unsupported, and fracture with relatively low force.

Mechanism and resulting pattern

• Lateral impact, which is the commonest, produces depression of the ipsilateral nasal bone with outward displacement of the contralateral bone, giving a deviated dorsum.
• Frontal impact produces flattening and splaying of both nasal bones with telescoping, and frequently a comminuted septal fracture.
• Higher energy frontal impact produces nasoethmoidal fracture with telecanthus, which is a different injury requiring different management.

Septal involvement, which determines outcome

The septum is fractured in a large proportion of nasal fractures and is the single most important determinant of long term functional and cosmetic outcome. Two classical patterns occur:

• Chevallet fracture: a vertical fracture of the quadrangular cartilage from the dorsum to the maxillary crest, from a frontal blow.
• Jarjavay fracture: an oblique fracture running from the anteroinferior septum backward, from a lateral blow.

Failure to recognise and correct septal deformity is the commonest reason for persistent obstruction and deviation after nasal fracture reduction, and is the reason so many patients require later septorhinoplasty.

Injuries that must be excluded before attending to the nose

• Septal haematoma, which requires immediate drainage.
• Cerebrospinal fluid rhinorrhoea, indicating cribriform plate or skull base fracture.
• Nasoethmoidal fracture with telecanthus and medial canthal tendon disruption.
• Orbital fracture with entrapment.
• Cervical spine injury and significant head injury.
• Other facial fractures, particularly Le Fort patterns.

Timing, which governs everything

• Assess at presentation for haematoma and other injuries.
• Reassess at 5 to 7 days in adults, and 3 to 5 days in children, once oedema has settled, to determine whether reduction is needed.
• Reduce within 10 to 14 days in adults and 7 to 10 days in children, before fibrous union occurs. After 3 weeks, closed reduction is no longer feasible and formal septorhinoplasty is required, deferred by 3 to 6 months.

• Epistaxis at the time of injury, usually self limiting.
• Pain, tenderness and swelling.
• Visible deformity, which is frequently obscured by oedema in the first days.
• Nasal obstruction, which may be from oedema, clot, septal deviation or septal haematoma.
• Crepitus and mobility of the nasal bones.
• Periorbital ecchymosis and subconjunctival haemorrhage.
• Anosmia, which may indicate cribriform plate injury with olfactory nerve shearing.

Examination

• Inspect from the front, the side and from above looking down over the brow, which is the best view for detecting dorsal deviation.
• Compare with pre injury photographs, which is essential, since many patients have pre existing deviation and will otherwise expect an outcome that never existed.
• Palpate for step, mobility, crepitus and tenderness.
• Anterior rhinoscopy after suctioning clot and after decongestion, examining the septum specifically for haematoma, deviation, dislocation from the maxillary crest, and mucosal laceration. This step is not optional.
• Assess for clear rhinorrhoea, particularly increasing on leaning forward, and for the halo or double ring sign on a tissue.
• Measure the intercanthal distance. Normal is approximately 30 to 32 mm in adults, or roughly half the interpupillary distance. Telecanthus above 35 mm indicates a nasoethmoidal fracture.
• Bimanual examination of the medial canthal tendon, palpating the tendon while pulling laterally on the eyelid, to detect avulsion.
• Assess eye movements, acuity, diplopia and pupils.
• Assess the dentition, occlusion and facial buttresses.
• Full neurological and cervical spine assessment where indicated by the mechanism.

• Nasal fracture is a clinical diagnosis. Plain radiography of the nasal bones has poor sensitivity and specificity, does not change management, and should not be requested. Old fracture lines and normal suture lines produce false positives, and undisplaced fractures produce false negatives.
• Computed tomography of the facial bones is indicated for suspected nasoethmoidal, orbital, zygomatic or Le Fort fractures, for suspected skull base injury, for significant head injury, and when the examination is limited by swelling in a high energy mechanism.
• Beta 2 transferrin or beta trace protein testing of nasal fluid where cerebrospinal fluid leak is suspected. Glucose testing of nasal fluid is unreliable and should not be used.
• Photographic documentation at presentation and at review, which is valuable both clinically and medicolegally.
• Consider a coagulation screen where bleeding is disproportionate.
• In children, consider non accidental injury and follow safeguarding procedures where the history is inconsistent.

At presentation

• Control epistaxis with first aid measures, topical vasoconstrictor and, where necessary, cautery or packing.
• Drain any septal haematoma immediately, as an emergency, with a drain or quilting sutures and antibiotic cover.
• Analgesia with paracetamol 1 g every 6 hours and a nonsteroidal anti inflammatory drug, avoiding the latter if bleeding continues.
• Ice packs for the first 24 to 48 hours and head elevation to reduce swelling.
• Advise against nose blowing, which risks surgical emphysema and, with a skull base fracture, pneumocephalus.
• Tetanus prophylaxis where there is an open wound.
• Antibiotics only for open fractures, contaminated wounds, or where packing is in place. Co amoxiclav 625 mg three times daily is appropriate.
• Refer for review at 5 to 7 days for reassessment once swelling settles.
• Give clear safety netting advice: return immediately for increasing nasal obstruction, pain or swelling, which indicates a developing septal haematoma, and for clear nasal discharge.

Reduction

Indications: a cosmetically or functionally significant displacement confirmed at the 5 to 7 day review.

• Closed reduction under local anaesthesia with topical cocaine or lidocaine with adrenaline pledgets plus infiltration, or under general anaesthesia, which is required in children and preferred for comminuted fractures.
• Use Walsham forceps for the nasal bones and Asch forceps for the septum. Digital pressure alone suffices for simple laterally displaced fractures.
• Disimpact the fracture first by elevating the depressed side, then mould the dorsum.
• Address the septum at the same sitting where it is deviated or dislocated. Reposition a caudal dislocation onto the maxillary crest. Where the septal fracture is significant, a limited septoplasty at the time of reduction improves outcomes and reduces the need for later revision, though some surgeons prefer to defer formal septoplasty.
• Apply an external thermoplastic or plaster splint for 7 to 10 days, and internal silastic splints where the septum has been manipulated.
• Warn the patient before the procedure that closed reduction produces a satisfactory result in around 60 to 90 percent, that some residual deviation is common, and that a proportion require later septorhinoplasty. This conversation before rather than after the procedure prevents most dissatisfaction.

Nasoethmoidal fracture

• A different injury requiring open reduction and internal fixation with transnasal wiring or plating of the medial canthal tendon, performed by an appropriate facial trauma surgeon.
• Delayed or inadequate treatment produces permanent telecanthus, a flattened nasal dorsum, epiphora from lacrimal obstruction, and a result that is very difficult to correct secondarily.
• Assess and manage the lacrimal system.

Cerebrospinal fluid leak

• Most traumatic leaks close spontaneously within 7 to 10 days with conservative management: bed rest with head elevation, avoidance of straining, nose blowing and Valsalva, and stool softeners.
• Avoid nasal packing where a skull base fracture is present.
• Prophylactic antibiotics for cerebrospinal fluid leak are not routinely recommended, since they do not reduce meningitis and select resistant organisms.
• Pneumococcal vaccination is appropriate.
• Persistent leak beyond 7 to 14 days requires localisation with high resolution computed tomography and magnetic resonance cisternography, and endoscopic repair with a multilayer technique and a vascularised nasoseptal flap where the defect is large.

Children

• Reduce earlier, within 7 to 10 days, since bone heals faster.
• Use general anaesthesia.
• Drain any septal haematoma immediately, since cartilage necrosis in a growing nose produces progressive midface hypoplasia and severe deformity through adolescence.
• Defer definitive septorhinoplasty until facial growth is complete, around 16 to 18 years, except where obstruction is severe.
• Arrange long term follow up through the growth period.

Late presentation and revision

• Fractures presenting after 3 weeks with fibrous union cannot be reduced closed. Defer for 3 to 6 months and perform formal septorhinoplasty with osteotomies, septal correction, and grafting as required.
• Persistent obstruction after reduction requires assessment for septal deviation, nasal valve collapse and turbinate hypertrophy, each of which needs its own solution.
• Persistent deformity requires septorhinoplasty, and it should be made clear that this is a reconstructive procedure with its own risks and a revision rate of its own.

Follow up

Review at 1 week after splint removal and again at 6 to 12 weeks with photographic comparison and assessment of nasal airflow. Document the outcome objectively with a validated obstruction score where symptoms persist.