Nasal fractures due to blunt trauma are a common occurrence.
Fights, auto accidents, and sports accidents account for most fractures
in an urban setting. Work, farm, sports, or leisure activity accidents
account for most of these injuries in rural areas.1 Males
aged 15 to 25 years old make up the majority of the population,
with fights being their major etiology.2–5 These
fractures are often missed on initial evaluation, especially
when there are many more urgent trauma concerns. Perform closed
or open reduction of these fractures within the first 2 weeks, when
it is easiest to avoid the need for more elaborate operations later
to correct the disfigurement and nasal airway obstruction.
Perform the reduction in children within 3 to 7 days, as fracture
fixation occurs faster than in adults.6
The clinical indications of a nasal fracture include a history
of epistaxis, new onset nasal blockage, or a change in nasal appearance.
Determine whether the patient has a prior history of a nasal bone
fracture, as repeat nasal bone fractures will be more difficult
to reduce. An old photograph of the patient may aid this determination.
One study revealed that 30 percent of injured noses had a preexisting
nasal deformity.7 At least 48 percent of the general population
has a nasal septal deviation.8 Physical examination may
demonstrate skin lacerations, nasal tenderness and mobility, internal mucoperichondrial
tears, ecchymosis, or a septal hematoma. A septal hematoma must
be drained to avoid cartilage necrosis and a resulting saddle nose
deformity. Refer to Chapter 147 regarding the complete details of
nasal septal hematoma management.
The mechanism of injury, force of impact, direction of impact,
and the history of any prior nasal deformity must be ascertained
from the patient in order to understand the potential magnitude
of the fracture. Photographic documentation is crucial before one
attempts any nasal manipulation. Obtain radiographs, Waters and
lateral nasal, to support the physical findings of a nasal fracture (Figure
146-1). Many surgeons recommend radiographs as part of medical legal
documentation, although all Otolaryngologists do not agree. Radiographs
can have a high false-negative rate due to the lack of fine resolution
or a high false-positive rate from the misinterpretation of the
normal bony sutures.9,10
Radiographs demonstrating a nasal fracture. A. Waters view of a deviated nasal
septum and right nasal bone fracture. B. Lateral
view of a fracture from a frontal and inferior force having driven
the lower aspect of the nasal bones in.
The direction of the force to fracture the nasal bone is variable.
There are several lateral and frontal force injury classifications,
but no consensus exists.5,11,12 One study demonstrated
that 66 percent of nasal fractures were due to lateral ...