Nasal Fracture Surgery

  • Author: Vipul R Dev, MD; Chief Editor: Deepak Narayan, MD, FRCS  more...
 
Updated: Mar 18, 2016
 

Background

Nasal fractures represent the third most commonly broken bone in the body, and the nose is the most commonly broken facial bone. Despite the frequency of their occurrence, nasal fractures are often undertreated. As a consequence, significant long-term functional and cosmetic problems may result. Treatment of long-term complications after significant injury is difficult.

For patient education resources, see the Back, Ribs, Neck, and Head Center and Breaks, Fractures, and Dislocations Center, as well as Broken Nose and Facial Fracture.

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History of the Procedure

In 1947, Maliniac published a classic description of the treatment of nasal fractures. Since then, considerable controversy has existed regarding the optimum treatment of nasal fractures. The debate concerns timing of repair, open versus closed reduction, and specific techniques. In recent years, the trend has been toward open reduction and repair.

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Problem

Nasal fractures occur in a great number of patterns. The complex 3-dimensional anatomy of the nasal bones, upper and lower lateral cartilages, and bony and cartilaginous septum underscores the importance of a precise assessment of the specific injury to maximize the results of treatment. Blunt trauma may occur anteriorly or laterally, and the resulting pattern of fractures reflects this direction of force. Optimum management is particularly important because of the unique forces of contraction that occur on this complex 3-dimensional structure over the ensuing months following injury. External nasal deformities and significant airway obstruction occur in a significant number of patients, and their presentation may be delayed by as many as several months.

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Etiology

Blunt trauma is the most common cause of nasal fractures. Automobile accidents, altercations, and falls account for approximately 85% of nasal fractures. A study by Liu et al of 100 cases of pediatric nasal deformity from an urban, tertiary pediatric otolaryngology practice found sports-related trauma to be the most common injury mechanism (28%), with the next most common mechanisms being accidental trauma (21%), interpersonal violence (10%), motor vehicle collision (6%), and alcohol-related trauma (2%).[1]

For more information on the treatment of all kinds of trauma, visit Medscape’s Trauma Resource Center.

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Pathophysiology

The pattern of nasal fractures varies depending on the direction of force applied. Force applied from a frontal direction may cause an injury as simple as the infracture of the lower margin of the nasal bones (which are thinner than the heavier, upper portion) or a severe flattening of the nasal bones and septum. (Nasoethmoid complex fractures are discussed in the article Facial Trauma, Nasoethmoid Fractures.) Splaying of the nasal bones with widening of the nasal width may occur.

Lateral forces may cause only a depression of the ipsilateral nasal bone or may also be forceful enough to outfracture the contralateral nasal bone. When twisting or buckling of the nose is present, the fractured bony and/or cartilaginous fragments are often interlocked. This is important to identify because achieving an adequate result with a closed technique is likely impossible in such a situation. The septum is often fractured and may be dislocated off the maxillary crest. Proper reduction of the septum is critical to obtaining optimum results. The fracture pattern of the septum varies according to the location of the fracture. Anterior fractures tend to be vertical, while posterior fractures are usually horizontal in orientation.

Forces from below may cause a third pattern of fractures. In these instances, the septum in particular is fractured and dislocated. The quadrangular cartilage is often dislocated from the crest of the maxilla.

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Presentation

The history should note the mechanism of injury. The patient may note the immediate change in nasal appearance that accompanies a significantly displaced nasal fracture. Epistaxis may indicate the presence of a fracture.

The nose must be inspected both internally and externally. Adequate anesthesia, decongestion, lighting, suction, and, preferably, endoscopic equipment are imperative to examine the internal nose. Lacerations, ecchymosis, hematomas, mucosal tears, and epistaxis internally strongly suggest fracture. Septal hematomas require prompt diagnosis and treatment with drainage and packing to prevent subsequent complications such as cartilage necrosis and resultant saddle nose deformity. The septum may be displaced off the maxillary crest. Externally, ecchymosis is often observed. If a significant amount of edema has not yet occurred, the displacement of the bone and cartilage may be apparent. A stepoff may be palpated. Nasal fractures are frequently accompanied by lid edema, periorbital ecchymosis, chemosis, and subconjunctival hemorrhage.

Pseudotelecanthus may be noted. Telecanthus noted during the physical examination is an indication of a more severe telescoping naso-orbito-ethmoid complex fracture, and further workup (including CT scanning) with more extensive reconstruction is required.

The initial evaluation may be compromised by the amount of edema present. In such cases, once other injuries have been excluded and if the patient is stable and does not require immediate intervention (eg, for epistaxis or septal hematoma), then the physical examination may be repeated in 3-5 days. Photographs of the patient taken preinjury are helpful. Some nasal deformities may have been present prior to the current injury.

Click here to complete a Medscape CME activity on physical examination of the ears, nose, and oral cavity in older patients.

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Indications

Reduction of a nasal fracture is indicated in any patient with a significant cosmetic deformity or functional compromise. The best time for reduction may be within the first 3 hours following injury. Otherwise, most believe that waiting 3-7 days is preferable. This allows edema to resolve, and positioning the bones correctly with more stability may be easier because inflammation and fibrosis may make the fragments less mobile by this time. If reduction is not possible within the first 7-10 days, then the fractured segments begin forming a fibrous union. This may make manipulation quite difficult. In this scenario, in which the fractured segments are no longer mobile, many surgeons advocate delaying treatment (up to several months) to allow for full healing prior to performing corrective rhinoplasty in which osteotomies are necessary. This may enable a more predictable rhinoplasty (particularly the osteotomies) at that time.

Indications for closed reduction are as follows:

  • Unilateral or bilateral fracture of the nasal bones
  • Fracture of the nasal septal complex that is deviated less than one half of the width of the nasal bridge

Indications for open reduction are as follows:

  • Extensive fractures
  • Deviation of the nasal pyramid greater than one half of the width of the nasal bridge [2]
  • Displaced fracture of the caudal septum
  • Open septal fracture
  • Persistent deformity after closed reduction
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Relevant Anatomy

The bony nasal pyramid consists of the paired nasal bones and the frontal process of the maxilla bilaterally. The nasal bones are thick superiorly at the attachment to the frontal bone and thin inferiorly at the point where they attach to the upper lateral cartilages. They are more susceptible to fracture in this region. Fractures of the nasal bone account for 40% of all facial fractures.

The upper lateral cartilages insert on the undersurface of the nasal bones and are important determinants of nasal appearance. Trauma to this complex can result in internal collapse of the upper lateral cartilages. The upper lateral cartilages articulate with the lower lateral cartilages. This articulation defines the region of the nasal valve, critical to nasal airflow dynamics. The paired lower lateral cartilages define the contour of the tip and the shape of the nostrils, and they provide much of the tip support.

The nasal septum includes the quadrangular cartilage anteriorly, the vomer inferiorly, and the perpendicular plate of the ethmoid posteriorly. Fractures may result in displacement of the bony and cartilaginous septum. These fragments can become interlocked, which is difficult to reduce in a closed technique.

Blood supply

The ophthalmic artery branches off of the internal carotid artery, which subsequently subdivides into the anterior and posterior ethmoidal artery and dorsal nasal artery. Facial and internal maxillary branches off of external carotid artery.

Nerve supply

The internal nose is supplied by the ethmoidal nerve, the sphenoidal nerve, and the nasopalatine nerve. The external nose is supplied by the anterior ethmoid nerve, the supratrochlear nerve, and the infraorbital nerve.

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Contraindications

Many cases of nasal fracture do not require treatment when the fragments are not displaced. In cases of severe nasoethmoid complex fractures, simple reduction of the nasal fracture is contraindicated.[3] This does not adequately address the patient's injury and may precipitate or worsen a cerebrospinal fluid (CSF) leak.

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Contributor Information and Disclosures
Author

Vipul R Dev, MD Chief Medical Director, California Institute of Cosmetic and Reconstructive Surgery; Director, Regional Wound Care Center; Chief Executive Officer, HealtheUniverse, Inc

Vipul R Dev, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, Association for Academic Surgery, California Medical Association, National Medical Association, Sigma Xi, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, Texas Medical Association, Texas Society of Plastic Surgeons

Disclosure: Received honoraria from lifecell for speaking and teaching; Received honoraria from pfizer for speaking and teaching.

Coauthor(s)

David W Kim, MD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Director, Division of Facial Plastic and Reconstructive Surgery, University of California at San Francisco

David W Kim, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Patrick Byrne, MD Associate Professor, Department of Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine

Patrick Byrne, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate-Craniofacial Association, American College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jaime R Garza, MD, DDS, FACS Consulting Staff, Private Practice

Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, Texas Society of Plastic Surgeons

Disclosure: Received none from Allergan for speaking and teaching; Received none from LifeCell for consulting; Received grant/research funds from GID, Inc. for other.

Chief Editor

Deepak Narayan, MD, FRCS Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center

Deepak Narayan, MD, FRCS is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Plastic Surgery Research Council, Royal College of Surgeons of England, Royal College of Surgeons of Edinburgh, Indian Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

James F Thornton, MD Associate Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center

Disclosure: Nothing to disclose.

Acknowledgements

Darshan Patel Research Assistant, Undergraduate Biochemistry and Cell Biology, Rice Quantum Institute

Disclosure: Nothing to disclose.

Adel R Tawfilis, DDS Assistant Clinical Professor, Department of Surgery, Division of Plastic Surgery, University of California at San Diego Medical Center

Adel R Tawfilis, DDS is a member of the following medical societies: American Association of Oral and Maxillofacial Surgeons, American Dental Association, and American Society of Maxillofacial Surgeons

Disclosure: Nothing to disclose.

References
  1. Liu C, Legocki AT, Mader NS, Scott AR. Nasal fractures in children and adolescents: mechanisms of injury and efficacy of closed reduction. Int J Pediatr Otorhinolaryngol. 2015 Dec. 79 (12):2238-42. [Medline].

  2. Murray JA, Maran AG, Mackenzie IJ, Raab G. Open v closed reduction of the fractured nose. Arch Otolaryngol. 1984 Dec. 110(12):797-802. [Medline].

  3. Sargent LA. Nasoethmoid orbital fractures: diagnosis and treatment. Plast Reconstr Surg. 2007 Dec. 120 (7 Suppl 2):16S-31S. [Medline].

  4. Javadrashid R, Khatoonabad M, Shams N, Esmaeili F, Jabbari Khamnei H. Comparison of ultrasonography with computed tomography in the diagnosis of nasal bone fractures. Dentomaxillofac Radiol. 2011 Dec. 40(8):486-91. [Medline].

  5. Yi CR, Kim YJ, Kim H, et al. Comparison study of the use of absorbable and nonabsorbable materials as internal splints after closed reduction for nasal bone fracture. Arch Plast Surg. 2014 Jul. 41(4):350-4. [Medline]. [Full Text].

  6. Yu SS, Cho PD, Shin HW, Rhee SC, Lee SH. A Comparison Between K-Wire Splinting and Intranasal Gauze Packing in Nasal Bone Fracture. J Craniofac Surg. 2015 Jul. 26 (5):1624-7. [Medline].

  7. Illum P. Long-term results after treatment of nasal fractures. J Laryngol Otol. 1986 Mar. 100(3):273-7. [Medline].

  8. Rohrich RJ, Adams WP Jr. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg. 2000 Aug. 106(2):266-73. [Medline].

  9. Bailey BJ. Nasal fractures. Bailey BJ. Head and Neck Surgery - Otolaryngology. Philadelphia, Pa: JB Lippincott; 1993. Vol 1: 991-1007.

  10. Pollock RA. Nasal trauma. Pathomechanics and surgical management of acute injuries. Clin Plast Surg. 1992 Jan. 19(1):133-47. [Medline].

 
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Lateral radiographic view of a displaced nasal bone fracture in a patient who sustained this injury because of a punch to the face during a hockey game.
Lateral radiographic view of a nasal bone fracture in an elderly patient who fell forward on her face as a result of syncope. Marked comminution is present.
Lateral radiographic view of a minimally displaced nasal bone fracture.
 
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