nasal fracture revised

Nasal Fracture

Definition

• Broken nose aka. nasal fracture • Break or crack in a nasal bone (the

bone over the bridge)• Most common facial fracture (between

40–50%, because of protruding and fragile structure)

• 3rd most common fracture of the bony skeleton

Causes

• Contact sports

• Physical fights, assaults

• Falls (common in children)

• Motor vehicle accidents

• Falls from syncope or impaired balance in the elderly and etc.Sidenote. Force required to create a fracture of the nasal structure is small, possibly as little as 25 pounds of pressure.

Anatomic relationship between the nasal bones, cartilage,and septum

Pathogenesis

Direction of the force:

• Frontal direction infracture of the lower margin of the nasal bones

• High frontal nasal orbital ethmoid fracture

• Heavier force severe flattening or splaying of the nasal bones and fracture of the septum

• Lateral forces depression of the ipsilateral nasal bone, outfracture the contralateral nasal bone

• If twisted or buckled the fractured bony and/or cartilaginous fragments are often interlocked, septum dislocated off the maxillary crest

Note. This is important to identify because achieving an adequate result with a closed technique may be impossible in such a situation.

• Children’s noses mostly cartilaginous and their nasal bones are softer and more compliant, absorbing little of the energy from the force of trauma.

Note. Consider septal hematoma.

Bilateral septal hematomas

Symptoms

• Bruising of the skin and subcutaneous tissues

• Tenderness

• Swelling

• Mobility of the nose

• Deformity

• Difficulty breathing

• Excessive nosebleeds

History

• Any history of a fall or force directed toward the mid face

• Details of the injury (mechanism, location, direction of force)

History

• Mechanism of the trauma

• Was there an epistaxis at the time of trauma?

• Was there a previous history of facial trauma or surgery?

• The difference from the nasal appearance before the trauma

• Was there a previous functional impairment in breathing before the trauma? etc.

Physical examination

• Evidence of nasal fracture

• Nasal airway evaluation

–Obstruction

–Hematoma

– Septal deviation

Physical examination

• Evidence of trauma to the mid face

• Deformity can be the greatest clue

• Other signs:

– Edema

– Skin laceration

– Ecchymosis

– Epistaxis (implies mucosal disruption) and cerebrospinal fluid (CSF) rhinorrhea

– Rhinorrhea

– Nasal obsctruction

– Olfactory disorders

Internal examination

• Acute edema may hide deformities; however, a careful search for intranasal injury must take place

• Adequate lighting• Patient should be placed in a comfortable, slightly

reclined position• Nose should be externally observed from all angles• Bleeding can be controlled with topical cotton pledgets

soaked in vasoconstrictors – 0.25% phenylephrine– 4% cocaine, which also provides anesthesia

• Palpation

Internal examination

• Assessment of nasal cavity using speculum via direct visualization or using endoscopy

• Push the tip of the nose upward to check for integrity of the septal support system (diagnose if there are…)

• Retained blood clots should be removed with suctioning or swabbing

• Search for any deformity or septal hematoma (33-50% of the population normally has a septal defect)

• A cotton-tipped swab should be placed in each naris up to the septum to check for deformity and mobility

Nasal Endoscopy

• Not entirely necessary

• However may provide additional information and rule out the following:

– Mucosal tears

– Lacerations

– Ecchymosis

– Hematoma

ClassificationOndik, Lipinski, Dezfoli, and Fedok (2009)

Murray’s classification

Clinical pointers towards the diagnosis of fractures involving nasal bones:

1. Injuries involving middle third of face

2. History of bleeding from nose following injury

3. Oedema over dorsum of nose

4. Tenderness and crepitus over nasal bone area

5. Eyelid oedema

6. Subcutaneous emphysema involving eyelids

7. Periorbital ecchymosis

Early treatment

• May need resuscitation (other injuries)• Nose bleeding should be assessed • Check for other facial fractures, e.g. orbital rim,

mandible• Ensure airway patency, adequate ventilation• Ensure overall stability of the patient • Treatment begins with management of external

soft tissue injuries (clean lacerations and carefully repair them)

• It is critical to rule out septal haematomas

Septal Hematomas

• High risk of complications if left untreated

• Needle drainage ASAP

• Prophylactic treatment with an antibiotic (e.g., augmentin or clindamycin)

• Untreated may result in intracranial abscess, cavernous sinus thrombosis, or meningitis

Manipulation of fracture

Dislocation of the nasal bone is common. If a previously straight nose is bent following

an injury, it must be broken. If it is not bent after an injury, the bones will heal and there will be no external deformity.

• Stand behind and above the patient’s head and look down on the nose

– If there is no deformity, no manipulation or splinting is needed

– If the nasal bones are displaced, plan a reduction of the fracture

Manipulation of fracture

Nasal injury often results in deviation of the nasal septum, causing airway

obstruction.

• Rarely needs immediate treatment

• If there is no external deformity, an ENT surgeon will arrange septal surgery –‘septoplasty’ – after a period of weeks or months

Manipulation of fracture

• If there is a complex injury to both the bones and the cartilage simultaneous correction of both before the bones have set

• The optimum timing for straightening the nose is usually 7–10 days after the injury

Late treatment of nasal fractures

• If presented months or years after injury, manipulation is clearly not possible

• Formal corrective surgery to both the bones and the cartilage – septorhinoplasty – is the only way to correct the deformity

It is a difficult procedure and it is far better to treat a nasal fracture well at the

time of injury.

Closed Reduction (CR)

• Most preferred treatment modality

• Even if large deviations are seen closed reduction can be attempted prior to rhinoplasty as this would simplify the task of the plastic surgeon

• Indications for closed reduction according to Bailey:1. Unilateral / Bilateral fracture of nasal bones

2. Fracture of nasal septal complex with nasal deviation of less than half of the width of the nasal bridge

CR

• Preoperative profile photograph of the patient is a must

• Both topical and infiltrative anaesthesia is used for reduction of nasal bones– 4% xylocaine topical

• Infiltrative. 2% xylocaine is infiltrated in the following areas:1. Through the intercartilagenous area over the nasal bones

2. Over the canine fossa

• After successful reduction the nasal cavity should be packed with antibiotic ointment impregnated gauze

Reduction Instruments

• (Left) Asch forceps

• (Center) Walsham forceps

• (Right) Boies elevator

Reduction Instruments

External splint providing pressure and support

OR

• Indications:

1. Extensive fractures associated with dislocation of the nasal bones and septum

2. Deviation of nasal pyramid of more than half of the width of the nasal bridge.

3. Fracture dislocation of caudal septum

4. Open fractures involving the nasal septum

5. Persistent nasal deformity even after meticulous closed reduction

Imaging

• In an uncomplicated nasal fracture, plain x-ray films are rarely indicated

• X-rays can be helpful in some cases, but cause confusion in most cases. May be useful in checking the adequacy of reduction.

• Plain x-rays will not identify cartilaginous disruptions • If cerebrospinal fluid (CSF) rhinorrhea is suspected

CT scan NOTE: CSF leaks are rare and are associated with a

fracture of the cribriform plate or posterior wall of the frontal sinus. The leak may not be apparent for several days after injury.

X-ray and CT

Complications

• Soft tissue injury• Infection• Fracture of the facial skeleton• Septal hematoma• Fracture or dislocation of septum• Possible development of a saddle nose • Blowout fractures• Nasolacrimal duct injury• Inflammation• Fracture of the cribriform plate

Saddle Nose Deformity

• Can occur when there is a loss of dorsal septal cartilage• Physical exam: marked “saddle” or “dipping” of the

external structures between the nasal bones and nasal tip upward tilting of the nasal tip

• This can collapse the nasal valve area (complaints of nasal congestion)

• Determine: classification of deformity, status of the internal and external nasal valves, and the structural integrity of the support structures

• Surgical management: reconstruction of the septal cartilage and/or bridge of the nose

• However, persons with a disease that can destroy the septal cartilage are at risk for continuing damage despite surgery

Causes

• Septal hematoma

• Nasal surgeries: septoplasty, rhinoplasty, or both

• Trauma

• Diseases that destroy septal cartilage (Wegener’s

granulomatosis, relapsing polychondritis)

• Large septal perforation

• Cocaine use