Nasal Fracture

Aka: Nasal Fracture, Nasal Bone Fracture, Fractured Nasal Bone, Fractured Nose, Broken Nose, Nasal Trauma

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II. Epidemiology

  1. Nasal Fractures account for 40% of bone injuries in facial Trauma

III. Pathophysiology

  1. See Nasal Anatomy
  2. Often results from minor Nasal Trauma

IV. History

  1. See Trauma History
  2. Epistaxis associated with injury
  3. Mechanism of injury
    1. Strength of blow to nose
    2. Object that inflicted injury
    3. Direction of force

V. Symptoms

  1. Epistaxis (may be only presenting symptom and sign)
  2. Nasal or facial pain

VI. Signs

  1. Observe for associated injuries
    1. Eye Trauma
    2. Epistaxis
    3. Cervical Spine Injury
    4. Mandibular Fracture
    5. Facial Fracture
      1. Zygomatic arch Fracture
      2. Maxillary SinusFracture
      3. Orbital Fracture
        1. Evaluate eyes for symmetry
        2. Evaluate Extraocular Movement
  2. Examination most helpful in first 3 hours after injury (before significant swelling)
  3. Observe for complications (see below)
  4. External exam: Clinical diagnosis (not radiographic)
    1. Localized Edema and Ecchymosis of nose
    2. Nasal deformity: Birds Eye View
      1. Look from head of stretcher for deviation
    3. Palpate nose for crepitation or step-offs
    4. Compare to photo before injury (best available)
      1. Use driver's license if others not available
  5. Internal exam
    1. Apply Anesthesia and vasconstrictor to mucosa
      1. Oxymetazoline (Afrin) and Lidocaine 4% liquid 1:1
      2. Phenylephrine (Neo-Synephrine) and Lidocaine 4%
      3. Cocaine 5-10% solution
    2. Clear blood clots and debris
      1. Warm saline gentle irrigation and suction
      2. Use small cotton tipped applicators to dab areas
    3. Examine with head lamp and nasal speculum
      1. Assess Nasal Airway patency
      2. Assess for continuing Epistaxis
      3. Assess turbinates
      4. Evaluate for Septal Hematoma
      5. Evaluate for clear Rhinorrhea (possible CSF)

VII. Complications: Evaluate for in all cases

  1. Septal Hematoma
    1. Observe for white or purple swelling on septum
    2. Depress septal mucosa to check for fluctuant area
    3. Failed diagnosis may result in saddle deformity
  2. CSF Rhinorrhea
    1. Presents as clear Rhinorrhea
    2. Double Ring Sign (variable efficacy)
      1. Place bloody Nasal Discharge on filter paper
      2. May form double ring on paper if CSF present

VIII. Indications: Immediate Consultation

  1. Cerebrospinal Fluid Leak suspected
  2. Limited Extraocular Movement (Orbital Fracture)
  3. New malocclusion of teeth
  4. Altered Mental Status

IX. Imaging

  1. Approach
    1. In the absence of acute facial bone CT indications, consider deferring facial bone imaging to ENT follow-up
    2. Plain film XRay lacks efficacy to add diagnostically to a clinically suspected isolated Nasal Fracture
    3. Baek (2013) Iran J Radiol 10(3):140-7 +PMID: 24348599 [PubMed]
  2. Nasal XRay is not recommended (adds little to management)
    1. Low Test Sensitivity for Nasal Fracture: 60 to 70%
    2. Low Test Specificity
  3. Coronal CT of facial bones Indications
    1. Suspected Facial Fracture
    2. Clear Rhinorrhea consistent with CSF Leak
    3. Extraocular Movement abnormality
    4. Malocclusion
    5. Subcutaneous Emphysema
    6. Mental status changes (also obtain CT Head, CT Cervical Spine)

X. Management: General Measures

  1. Critical Management: Ensure adequate airway
    1. See ABC Management
    2. See Trauma Evaluation
    3. See Secondary Trauma Evaluation
  2. Manage other facial injuries
    1. Irrigate open wounds
    2. Use caution if debriding tissue
  3. Medications
    1. Tetanus Prophylaxis
    2. Prophylactic Antibiotics if indicated
      1. Consider if suspect contaminated wound

XI. Management: Fracture Reduction

  1. Emergency Department
    1. See Closed Reduction of Nasal Fracture
    2. Simple digital pressure may be used to align small displacements (less than 50% of Nasal Bridge width)
  2. Otolaryngology open reduction (within 10 days of injury)
    1. Nasal deviation more than half the width of the Nasal Bridge
    2. Open septal Fracture
    3. Caudal septum (anterior septum) Fracture dislocation (nasal obstruction)

XII. Management: Complications

  1. Septal Hematoma
    1. See Septal Hematoma for management
    2. Requires Incision and Drainage
  2. Cerebrospinal Fluid Leak
    1. Neurosurgical Consultation

XIII. Management: Home Instructions

  1. Apply ice to nose
  2. Keep head elevated
  3. Follow-up otolarygology if need for further Nasal Fracture Reduction and rhinoplasty
  4. Athletes may return to play with protective facemask in uncomplicated cases

XIV. Course

  1. Swelling and Ecchymosis decreases after 3-5 days

XV. References

  1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
  2. Del Vecchio (1994) Emergency Medicine p. 637-8
  3. Kucik (2004) Am Fam Physician 70(7):1315-20 [PubMed]

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