Nasal fractures due to blunt trauma are a common occurrence (Figure 203-1). Fights, auto accidents, and sports accidents account for most fractures in an urban setting.1-4 Work, farm, sports, or leisure activity accidents account for most of these injuries in rural areas.5 The majority of nasal fractures occur in males aged 15 to 25 years old, with fights being the major etiology.6-9 Nasal fractures are often missed on initial evaluation, especially when there are many more urgent trauma concerns. It is best to perform closed or open reduction of a nasal fracture within the first 2 weeks when it is easiest to avoid 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.10
A photograph of a patient with a nasal fracture. (Used with permission from Shah BR, et al: The Atlas of Pediatric Emergency Medicine, 2nd ed. New York: McGraw-Hill; 2013.)
Suspect a nasal fracture in the blunt trauma patient with 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% of injured noses had a preexisting nasal deformity.11 At least 48% of the general population has a deviated nasal septum.12 Physical examination of the blunt trauma patient 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 the subsequent saddle nose deformity. Refer to Chapter 204 regarding the complete details of managing a nasal septal hematoma.
ANATOMY AND PATHOPHYSIOLOGY
The mechanism of injury, force of impact, direction of impact, and history of any prior nasal deformity must be ascertained from the patient in order to understand the potential magnitude of the fracture. If possible, obtain photographic documentation before any attempts at nasal manipulation. The Waters and lateral nasal radiographs will often support the physical findings of a nasal fracture (Figure 203-2). Many Surgeons recommend radiographs as part of the medical legal documentation, although many do not agree. Plain 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.13,14 A computed tomography (CT) scan is more sensitive and specific to identify a nasal bone fracture. Unfortunately, its cost and the radiation exposure are significant. A nasal fracture can often be diagnosed based upon the history and the physical examination. Reserve the CT scan for ...