Nasal fracture

1. Nasal Fracture

2. 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

3. 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.

7. Anatomic relationship between the nasal bones, cartilage,
and septum

8. 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

9. • 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.

11. Bilateral septal hematomas

13. Symptoms
• Bruising of the skin and subcutaneous tissues
• Tenderness
• Swelling
• Mobility of the nose
• Deformity
• Difficulty breathing
• Excessive nosebleeds

14. History
• Any history of a fall or force directed
toward the mid face
• Details of the injury (mechanism,
location, direction of force)

15. 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.

16. Physical examination
• Evidence of nasal fracture
• Nasal airway evaluation
–Obstruction
–Hematoma
–Septal deviation

17. 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

18. 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

19. 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

20. Nasal Endoscopy
• Not entirely necessary
• However may provide additional information
and rule out the following:
– Mucosal tears
– Lacerations
– Ecchymosis
– Hematoma

21. Classification
Ondik, Lipinski, Dezfoli, and Fedok (2009)

22. 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

23. 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

24. 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

26. 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

27. 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

28. 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

29. 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.

30. 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

31. 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

36. Reduction Instruments
• (Left) Asch forceps
• (Center) Walsham
forceps
• (Right) Boies elevator

37. Reduction Instruments

38. External splint providing pressure and support

39. 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

41. 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.

42. X-ray and CT

43. 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

44. 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

45. 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