Nasal Fracture

Aka: Nasal Fracture, Nasal Bone Fracture, Fractured Nasal Bones

1. See Also
   1. Septal Hematoma
2. Epidemiology
   1. Account for 40% of bone injuries in facial Trauma
3. Pathophysiology
   1. See Nasal Anatomy
   2. Often results from minor nasal Trauma
4. 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
5. Symptoms
   1. Epistaxis (may be only presenting symptom and sign)
6. Signs
   1. Observe for associated injuries
      1. Cervical Spine Injury
      2. Mandibular Fracture
      3. Facial Fracture
         1. Zygomatic arch Fracture
         2. Maxillary SinusFracture
         3. Orbital Fracture
            1. Evaluate eyes for symmetry
            2. Evaluate Extraocular Movement
   2. Examination easiest in first 3 hours after injury
   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)
7. 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
8. Indications: Immediate Consultation
   1. Cerebrospinal fluid leak suspected
   2. Limited Extraocular Movement (orbital Fracture)
   3. New malocclusion of teeth
   4. Altered Mental Status
9. Imaging
   1. Nasal XRay is not recommended
      1. Low Test Sensitivity and Test Specificity
   2. Coronal CT of facial bones Indications
      1. Suspected Facial Fracture
      2. Clear Rhinorrhea consistent with CSF leak
      3. Extraocular Movement abnormality
      4. Malocclusion
10. 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
11. Management: Closed Reduction
    1. See Closed Reduction of Nasal Fracture
12. Management: Complications
    1. Septal Hematoma
       1. See Septal Hematoma for management
       2. Requires Incision and Drainage
    2. Cerebrospinal fluid leak
       1. Neurosurgical Consultation
13. Course
    1. Swelling and Ecchymosis decreases after 3-5 days
14. Home Instructions
    1. Apply ice to nose
    2. Keep head elevated
15. References
    1. Del Vecchio (1994) Emergency Medicine p. 637-8
    2. Kucik (2004) Am Fam Physician 70(7):1315-20 [PubMed]