Nasal Fracture 

Updated: Dec 06, 2018
Author: Samuel J Haraldson, MD; Chief Editor: Craig C Young, MD 

Overview

Practice Essentials

Nasal fractures seen in participants of athletic activities occur as a result of direct blows in contact sports and as a result of falls. The nasal bones are the most commonly fractured bony structures of the maxillofacial complex.[1, 2, 3, 4, 5, 6]  See the images below.

Lateral radiographic view of a displaced nasal bon 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 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.

The nasal bone's protruding position coupled with its relative lack of support predisposes it to fracture. Prompt appropriate treatment prevents functional and cosmetic changes. Because of the nose's central location and proximity to important structures, the clinician should carefully search for other facial injuries in the presence of facial fractures.

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education articles, Facial Fracture and Broken Nose.

Epidemiology

Frequency

United States

Nasal fractures occur nearly twice as often in males as in females. Athletic injuries and interpersonal altercations account for the greatest proportion of causes. Less common causes include falls and motor vehicle accidents.[7, 8]

In a retrospective study, Erdmann et al investigated the medical records of 437 patients with 929 facial fractures.[3] These authors noted that the most common etiology of facial trauma was assault (36%), followed by motor vehicle collision (MVC, 32%), falls (18%), sports (11%), occupations (3%), and gunshot wounds (2%). Of the facial fractures sustained, the most common fracture type was nasal bone fracture.[3]

A study by Hanba et al found that risk factors for facial fracture included being white, Asian, female, or ≥ 60 years of age.[9]

A study by Plawecki et al evaluated the incidence of 20,519 patients, 55 years of age or older, who went to the ED for recreational activity-associated facial fractures. The study reported that the annual incidence of facial fractures increased by 45.3% from 2011 through 2015. Nasal fractures were the most common site of fracture (65.4%) and cycling (26.6%) was the most common cause in this cohort of older patients.[10]

 

International

In a retrospective study of Brazilian children aged 5-17 years, Cavalcanti and Melo found that facial injuries were most frequent in males (78.1%; 3-fold more common than in females) aged 13-17 years (60.9%), and the most common causes of these injuries were falls (37.9%) and traffic accidents (21.1%).[1] Of the facial injuries, nasal fractures were also most common (51.3%), followed by the zygomatic-orbital complex (25.4%).

In another retrospective study, Hwang et al reviewed and analyzed the medical records of 236 patients with facial bone fractures from various sports who were treated at one hospital between 1996 and 2007.[11] The investigators noted the age group with the highest frequency of such injuries was 11-20 years (40.3%), with a significant male predominance across all age groups (13.75:1). There were 128 isolated nasal fractures, with soccer accounting for 39% of these; baseball, 18%; basketball, 12.5%; martial arts, 5%; and skiing or snowboarding, 5%.[11]

Functional Anatomy

The lay term nose consists of bone and cartilage. The nasal septum, a commonly injured structure, consists of the vomer, the perpendicular plate of the ethmoid, and the quadrangular cartilage. Paired protrusions from the frontal bones and the ascending processes of the maxilla complete the bony component. The upper lateral and lower lateral cartilages, as well as the cartilaginous septum, compose the nonbony portion.

The blood supply occurs via branches of the ophthalmic artery, the ethmoidal and dorsal arteries, the facial artery, the nasopalatine, the sphenopalatine, and the greater palatine arteries. Sensation results from many small nerve branches; the external surface superiorly receives sensation from the supratrochlear and infratrochlear nerves, and the inferior portion receives sensation from branches of the infraorbital and anterior ethmoidal nerves. Internally, sensation is supplied by branches of the anterior ethmoidal ganglion and the sphenopalatine ganglion.

Sport-Specific Biomechanics

Any force directed to the mid face, either frontally or laterally, can disrupt the nasal anatomy, causing bony or cartilaginous injury. Frontally directed forces must be greater than normal to cause bony injury because the upper and lower lateral cartilages absorb a great deal of impact.

Children are more likely to sustain cartilaginous injury for a variety of reasons. This is mainly because children have a greater proportion of cartilage to bone, and the cartilage provides increased protection from fracture. Children's bones are also more elastic than adults' bones. This explains the increased incidence of greenstick fractures in children (fracture without displacement).

 

Presentation

History

Any history of a fall or force directed toward the mid face should alert the clinician of a possible nasal fracture.

The clinician should obtain details of the injury, including the mechanism and location of injury as well as the direction of force. These details allow estimation of its severity.[4, 5, 12, 13, 25]

Physical

In cases of nasal fracture, there is evidence of trauma to the mid face. Often, deformity of the nose provides the greatest clue. Other signs include swelling, skin laceration, ecchymosis, epistaxis (bleeding from within the nose), and cerebrospinal fluid (CSF) rhinorrhea. Epistaxis implies mucosal disruption; this should increase the clinician's suspicion for a nasal fracture, including possible nasal septum fracture.

Internal examination

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

  • Adequate lighting must be available, and the patient should be placed in a comfortable, slightly reclined position. Bleeding can be controlled with topical cotton pledgets soaked in vasoconstrictors, such as 0.25% phenylephrine (Neo-Synephrine [Bayer HealthCare, Morristown, NJ] is also available as a spray) or 4% cocaine, which also provides anesthesia. Retained blood clots should be removed with suctioning or swabbing.

  • The clinician should search for any deformity or septal hematoma; however, septal deviation does not automatically determine fracture. An estimated 33-50% of the population normally has a septal defect.

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

Causes

See History, above.

 

DDx

Differential Diagnoses

 

Workup

Laboratory Studies

In cases with a significant amount of bleeding or where a patient may require operative intervention, the following blood tests should be obtained:

  • Complete blood cell (CBC) count – To check baseline level of hemoglobin and platelet count

  • Coagulation studies (prothrombin time [PT] / activated partial thromboplastin time [aPTT])

  • Blood typing and cross-matching for packed red blood cells – In the event transfusion should be required

Imaging Studies

See the list below:

  • Nearly 50% of nasal fractures are likely to be missed on plain film nasal radiographs. A high incidence of false-positive studies secondary to the complex anatomy of the developmental suture lines exists. Cartilaginous injury is not detected by radiographs; therefore, it is not considered routine to order nasal radiographs only when an isolated nasal fracture is suspected.

  • Facial x-ray series: If suspicion for other facial injury exists, then a complete facial radiographic series should be obtained.

  • Computed tomography (CT) scanning provides the best information regarding the extent of bony injury in nasal and facial fractures, particularly digital volume tomography (DVT).[14] Again, cartilaginous injury is likely to be missed.

Procedures

Closed reduction

  • Closed reduction of nasal fractures, including nasal septal fractures, should be performed by an otolaryngologist, plastic surgeon, or maxillofacial surgeon.

  • The repair technique requires specialized instruments and involves a reversal of forces that caused the injury.

  • An attempt at closed reduction of an obvious nasal deformity may be made in the acute setting by medical personnel who are trained in this procedure, in which only a gloved hand is used.

  • A study investigated the minimal and optimal duration of the nasal packing following reduction surgery of nasal bone fracture. The study demonstrated that 1-day packing had comparable postoperative outcome with reducing the patients' discomfort. A longer packing duration was not needed to achieve stable results and the study concluded that 1-day is a reasonable packing time for most nasal bone fractures.[15]

 

Treatment

Acute Phase

Medical Issues/Complications

High-force midfacial injuries may involve structures other than the nose itself.

  • Septal hematoma

    • This is a common and serious complication of nasal trauma. Septal hematomas are collections of blood in the subperichondrial space. This places pressure on the underlying cartilage, resulting in irreversible necrosis of the septum. The patient also becomes predisposed to infection. A saddle deformity may develop from loss of tissue.

    • Drainage procedure: Septal hematomas must be drained immediately upon their being found. Cotton pledgets soaked in 4% cocaine are used for topical anesthesia. A scalpel incision must be made to allow drainage. A small Penrose-type drain is placed to prevent reaccumulation. Finally, nasal packing is placed. The patient should be started on oral antibiotics with anti-staphylococcal coverage.

  • Blowout fractures

    • Orbital wall and orbital floor blowout fractures may occur.[16]

    • Any abnormality of ocular anatomy or function should alert the clinician of the possibility of these injuries.

    • A common finding is extraocular muscle dysfunction, commonly characterized by the inability to look up on the affected side, suggesting entrapment of a nerve or muscle.

    • The presenting complaint may be diplopia.

  • Nasolacrimal duct injury

    • The nasolacrimal complex lies in close proximity to the nasal bones.

    • High-force midfacial injuries or those resulting in comminuted fractures require a consultation with an ophthalmologist.

  • Infection: Although rare, infections resulting from nasal fractures can cause serious complications. For this reason, patients should be placed on antibiotics with coverage for staphylococcal pathogens.

  • Fracture of the cribriform plate

    • This type of injury may predispose to leakage of CSF, allowing rare but extremely serious complications such as meningitis, encephalitis, or brain abscess to follow.

    • Drainage of clear rhinorrhea immediately after trauma to the mid face and up to several days later should alert the clinician to the possibility of this associated fracture of the cribriform plate.

Surgical Intervention

High-force nasal trauma resulting in deformity from displaced fractures or dislocations or from comminuted fractures may require open reduction and/or fixation by a surgeon.

Consultations

If specialists were not consulted for the initial patient visit, appropriate referral to an otolaryngologist, maxillofacial surgeon, or plastic surgeon for outpatient management is warranted.

Other Treatment

In the acute phase, the patient should apply ice to the nose and elevate the head to aid in reduction of any swelling present. Nasal decongestants are prescribed to help reduce swelling and mucosal congestion.

 

Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications and infections.

Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Amoxicillin and clavulanate (Augmentin)

Drug combination that treats bacteria resistant to beta-lactam antibiotics.

Penicillin VK (Pfizerpen)

Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached and most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects.

Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft-tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking the dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. DOC in penicillin-allergic patients.

Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.

Decongestants

Class Summary

Decongestants reduce mucosal edema.

Phenylephrine nasal (Neo-Synephrine)

Applied directly to nasal mucous membranes where it stimulates alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.

Analgesics

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort and promote pulmonary toilet.

Acetaminophen (Tylenol, Feverall, aspirin-free Anacin)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants. Effective in relieving mild to moderate acute pain; however, it has no peripheral anti-inflammatory effects. May be preferred in elderly patients because of fewer GI and renal side effects.

Hydrocodone/acetaminophen

Drug combination indicated for moderate to severe pain.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Class Summary

NSAIDs have analgesic and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions. Treatment of pain tends to be patient specific.

Ibuprofen (Advil, Excedrin IB, Ibuprin, Motrin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Anesthetics

Class Summary

Anesthetic agents are used to produce local anesthesia.

Cocaine

Decreases membrane permeability to sodium ions, which, in turn, inhibits depolarization and blocks conduction of nerve impulses.

Use the lowest dose necessary to produce anesthesia. The 4% solution is available as a 4-mL unit-dose vial (total of 16 mg of cocaine) or 10-mL multidose vial (total of 40 mg cocaine).

 

Follow-up

Return to Play

Uncomplicated nondisplaced fractures should not prevent a patient who participates in noncontact sports from returning to play in 2 weeks. In healthy adults, fracture healing occurs in approximately 3 weeks. Athletes involved in contact sports should have adequate head and face protection for several weeks when returning to play.

Complications

See Treatment, Acute Phase, Medical Issues/Complications.

Prevention

Nasal fractures in sports can be prevented with the use of helmets that have adequate face protection.

Prognosis

Most nondisplaced nasal fractures heal without cosmetic or functional deformity. Both open and closed reduction techniques produce a high rate of refractory cosmetic deformity, manifested by septal deviations. Many patients eventually require nasal-septal rhinoplasty.17{ref26}

See also the Cosmetic Surgery section in Medscape Reference's Otolaryngology & Facial Plastic Surgery book.

 

Questions & Answers

Overview

What are nasal fractures?

What is the prevalence of nasal fractures in the US?

What is the global prevalence of nasal fractures?

What is the functional anatomy relevant to nasal fractures?

What are the biomechanics of nasal fractures?

Presentation

Which clinical history findings are characteristic of nasal fractures?

What are the signs and symptoms of nasal fractures?

Which internal nasal exam findings are characteristic of nasal fractures?

DDX

What are the differential diagnoses for Nasal Fracture?

Workup

What is the role of blood tests in the workup of nasal fractures?

What is the role of imaging studies in the workup of nasal fractures?

What is the role of closed reduction in the treatment of nasal fractures?

Treatment

How is septal hematoma treated in patients with nasal fractures?

What are the signs and symptoms of blowout fractures in patients with nasal fractures?

How is a nasolacrimal duct injury treated in patients with nasal fractures?

How are infections treated in nasal fractures?

What are the signs and symptoms of fracture of the cribriform plate in patients with nasal fractures?

What is the role of surgery in the treatment of nasal fractures?

Which specialist consultations are beneficial to patients with nasal fractures?

How is swelling managed in the initial treatment of nasal fractures?

Medications

What are the goals of drug treatment for nasal fractures?

Which medications in the drug class Anesthetics are used in the treatment of Nasal Fracture?

Which medications in the drug class Nonsteroidal Anti-inflammatory Drugs (NSAIDs) are used in the treatment of Nasal Fracture?

Which medications in the drug class Analgesics are used in the treatment of Nasal Fracture?

Which medications in the drug class Decongestants are used in the treatment of Nasal Fracture?

Which medications in the drug class Antibiotics are used in the treatment of Nasal Fracture?

Follow-up

When can patients with nasal fractures return to play?

How are nasal fractures prevented?

What is the prognosis of nasal fractures?