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Nasal Fracture
Aka: Nasal Fracture, Nasal Bone Fracture, Fractured Nasal Bones, Fractured Nose, Broken Nose, Nasal Trauma- See Also
- Epidemiology
- Nasal Fractures account for 40% of bone injuries in facial Trauma
- Pathophysiology
- See Nasal Anatomy
- Often results from minor Nasal Trauma
- History
- See Trauma History
- Epistaxis associated with injury
- Mechanism of injury
- Strength of blow to nose
- Object that inflicted injury
- Direction of force
- Symptoms
- Epistaxis (may be only presenting symptom and sign)
- Signs
- Observe for associated injuries
- Eye Trauma
- Epistaxis
- Cervical Spine Injury
- Mandibular Fracture
- Facial Fracture
- Zygomatic arch Fracture
- Maxillary SinusFracture
- Orbital Fracture
- Evaluate eyes for symmetry
- Evaluate Extraocular Movement
- Examination most helpful in first 3 hours after injury (before significant swelling)
- Observe for complications (see below)
- External exam: Clinical diagnosis (not radiographic)
- Localized Edema and Ecchymosis of nose
- Nasal deformity: Birds Eye View
- Look from head of stretcher for deviation
- Palpate nose for crepitation or step-offs
- Compare to photo before injury (best available)
- Use driver's license if others not available
- Internal exam
- Apply Anesthesia and vasconstrictor to mucosa
- Oxymetazoline (Afrin) and Lidocaine 4% liquid 1:1
- Phenylephrine (Neo-Synephrine) and Lidocaine 4%
- Cocaine 5-10% solution
- Clear blood clots and debris
- Warm saline gentle irrigation and suction
- Use small cotton tipped applicators to dab areas
- Examine with head lamp and nasal speculum
- Assess Nasal Airway patency
- Assess for continuing Epistaxis
- Assess turbinates
- Evaluate for Septal Hematoma
- Evaluate for clear Rhinorrhea (possible CSF)
- Apply Anesthesia and vasconstrictor to mucosa
- Observe for associated injuries
- Complications: Evaluate for in all cases
- Septal Hematoma
- Observe for white or purple swelling on septum
- Depress septal mucosa to check for fluctuant area
- Failed diagnosis may result in saddle deformity
- CSF Rhinorrhea
- Presents as clear Rhinorrhea
- Double Ring Sign (variable efficacy)
- Place bloody Nasal Discharge on filter paper
- May form double ring on paper if CSF present
- Septal Hematoma
- Indications: Immediate Consultation
- Cerebrospinal fluid leak suspected
- Limited Extraocular Movement (Orbital Fracture)
- New malocclusion of teeth
- Altered Mental Status
- Imaging
- Nasal XRay is not recommended
- Low Test Sensitivity and Test Specificity
- Coronal CT of facial bones Indications
- Suspected Facial Fracture
- Clear Rhinorrhea consistent with CSF leak
- Extraocular Movement abnormality
- Malocclusion
- Subcutaneous Emphysema
- Mental status changes (also obtain CT Head, CT Cervical Spine)
- Nasal XRay is not recommended
- Management: General Measures
- Critical Management: Ensure adequate airway
- Manage other facial injuries
- Irrigate open wounds
- Use caution if debriding tissue
- Medications
- Tetanus Prophylaxis
- Prophylactic antibiotics if indicated
- Consider if suspect contaminated wound
- Management: Fracture Reduction
- Emergency Department
- See Closed Reduction of Nasal Fracture
- Simple digital pressure may be used to align small displacements (less than 50% of nasal bridge width)
- Otolaryngology open reduction (within 10 days of injury)
- Emergency Department
- Management: Complications
- Septal Hematoma
- See Septal Hematoma for management
- Requires Incision and Drainage
- Cerebrospinal fluid leak
- Neurosurgical Consultation
- Septal Hematoma
- Management: Home Instructions
- Apply ice to nose
- Keep head elevated
- Follow-up otolarygology if need for further Nasal Fracture Reduction and rhinoplasty
- Athletes may return to play with protective facemask in uncomplicated cases
- Course
- Swelling and Ecchymosis decreases after 3-5 days
- References
- Dreis (2020) Crit Dec Emerg Med 34(7):3-21
- Del Vecchio (1994) Emergency Medicine p. 637-8
- Kucik (2004) Am Fam Physician 70(7):1315-20 [PubMed]