As long as they are aware of certain pitfalls, primary care providers can manage nasal fractures, including reduction of selected displaced fractures. Fractures of other facial bones and the skull are rarely seen in primary care settings but are commonly encountered in rural, emergency department, and urgent care settings. In these instances, primary care clinicians will be called on to evaluate the patient for other serious associated injuries, stabilize the patient, provide initial care of the fracture, and arrange appropriate specialty evaluation and treatment. This chapter focuses on the management of nasal fractures and on the recognition of other facial and skull fractures and the potentially serious injuries that often accompany them.
In adults, nasal fractures are the most common fracture of the face and skull and rank third in incidence of any fracture (only clavicle and wrist fractures are more common). The mandible and zygoma are also frequently fractured. Facial fractures are encountered fairly frequently in primary care and sports medicine settings. Sports-related facial fractures account for 10% to 42% of all facial fractures. Other common etiologies include motor vehicle accidents (MVAs), altercations and assaults, and falls. Facial fractures are two to three times more common in males than in females, and the incidence of each type of fracture is related to each bone’s anatomic location and strength. The force required to cause fractures of the face and skull increases as follows: nasal bones, zygoma, mandible (angle), frontal bone, maxilla and mandible (midline), and supraorbital rim.
Facial and skull fractures are less common in children than in adults and follow a different pattern. In the age group 0 to 18 years, mandible fractures are most common (32.7%), followed by nasal (30.2%) and maxillary or zygoma (28.6%) fractures. The likelihood of these fractures increases with age. In adolescents, these fractures are more common, and mandible fractures predominate. In toddlers and infants, cranial and central facial injuries are more common. Unless the cause of injury is obvious (e.g., MVAs), one must always consider the possibility of child abuse when evaluating such fractures. As with adults, boys experience more facial fractures than girls (5 : 3 ratio).
Many fractures in adults and children can be prevented. It is estimated that more than 250,000 people per year in the United States (many of whom are children) have sports-related facial trauma because of inadequate safety equipment such as improper seat belt or helmet use.
The paired nasal bones lie at the top of the nose ( Figures 17-1 to 17-3 ), encompassing approximately one-third of the nose’s length. Each nasal bone attaches superiorly to the frontal bone and inferiorly to an upper lateral cartilage, a curved triangular cartilage that articulates in the midline. The paired upper lateral cartilages are critical in defining nasal appearance, and fractures involving these can lead to significant cosmetic deformity. They also articulate with the paired lower lateral cartilages at a complex fibrous joint that functions as a nasal valve, a critical region that affects nasal airflow (see Figure 17-2 ). Fracture involving the nasal valve can cause problems with nasal obstruction (chronic nasal congestion). The external cartilage structure of the nose (upper and lower lateral cartilages) encompasses approximately two-thirds of the length of the nose. The medial canthal ligament of the eye attaches near the base of the upper nose (see Figure 17-1 ). After significant trauma to this area, this ligament may rupture or be displaced, which causes the globe to move laterally. This produces an abnormally wide spacing of the eyes, referred to as telecanthus.
Nasal Septum and Surrounding Structures
The nasal septum is composed of cartilage and bone, similar to the external nose. The cartilaginous septum is the primary structure separating the right and left nasal passages and is composed of the quandrangular cartilage (which is quandrangular shaped, as the name implies). This is the structure that you first see when you look at the septum during an internal nasal examination. This is also the structure that typically causes congenital septal deviation. Thus, when fractured or dislocated, it causes nasal obstruction (chronic nasal congestion). The quadrangular cartilage is supported by the anterior nasal spine of the maxilla inferiorly and by the bony septum (perpendicular plate of the ethmoid posteriorly and the vomer inferiorly) (see Figures 17-1, 17-3, and 17-4 ). The cartilaginous and bony septum is lined by mucoperichondrial and mucoperiosteal soft tissue, respectively, that has a robust vascular supply. This is responsible for epistaxis at the time of injury. This can also cause a septal hematoma, which if not immediately treated can lead to necrosis of the cartilaginous septum with resulting severe cosmetic deformity and functional impairment.
Mechanism of Injury
Nasal fractures result from direct blows. The direction and force of the blow determine the injury pattern. Lateral blows of moderate force result in a depressed, inward fracture of the ipsilateral nasal bone. With greater forces, the contralateral nasal bone may outfracture or the septum may fracture. Inferior blows commonly result in isolated septal fractures as the quandrangular cartilage is torn from its inferior attachment to the anterior nasal spine of the maxilla, vomer, or both. Frontal blows, if sufficiently forceful, may produce a septal fracture with splaying of the nasal bones. These fractures have a higher likelihood of being comminuted. If the injury was caused by very high force, it is important to consider the possibility of concomitant serious injuries to the neck, face, or skull.
The primary goal of the initial visit is to assess the patient adequately. Clots and dried blood (both internal and external) should be removed to allow adequate visualization. Topical decongestants can be used to control epistaxis and should be used to improve visualization during internal nasal examination (anterior rhinoscopy). Examination of the cranial nerves is advisable, with particular attention paid to cranial nerves II to VIII (vision, extraocular movements, facial sensation, facial movement, and hearing and balance). Associated injuries may include septal hematoma, fractures of other facial bones, dental fractures or injuries, and cerebrospinal fluid (CSF) leakage. CSF leakage sometimes is not evident until several days after acute injury. If evident on initial presentation, the patient needs careful evaluation and management to decrease the risk of associated complications.
Typical symptoms of a nasal fracture include localized pain and edema. Visual inspection and palpation should be performed systematically to evaluate for nasal bone depression, displacement, or mobility. These findings confirm nasal bone fracture in the majority of cases. A major pitfall is not doing this portion of the examination adequately in the presence of edema, which can mask a fracture during an inadequate examination. One must also visually inspect and palpate the nasal cartilage (upper and lower lateral cartilages) and septal cartilage (quadrangular cartilage) for fracture or dislocation from their fibrous attachments. Both epistaxis and ecchymosis around the nose or eyes suggest the presence of a nasal fracture, although one can have a nasal fracture without these. Overlying abrasions or lacerations may also be noted. Patients generally report difficulty breathing through the affected side(s) of the nose. The patient (or a companion if present) commonly reports that the shape of the nose has changed. Visual changes, telecanthus (abnormally wide spacing of the eyes), paresthesias, or altered sensorium strongly suggests other potentially serious injuries.
Hematomas of the nasal septum are relatively common. They require drainage as soon as possible to prevent necrosis of the cartilaginous septum and a saddle deformity that is difficult to correct surgically. After draining the septal hematoma, packing or nasal splints should be used to compress the septum on both sides to prevent reaccumulation of the hematoma (see below for more details). An early septal hematoma may be mistaken for a deviated septum. Palpating the septum can help distinguish between the two: an acute hematoma will feel soft, fluctuant, and raised. If a hematoma cannot be excluded, otolaryngology consultation is recommended.
Radiographs are not required in the assessment of nasal fractures. History and physical examination is more accurate for the detection of a clinically significant fracture. In fact, some clinicians report that radiographs fail to show 47% to 60% of clinically detectable fractures. Furthermore, radiographs of the nose are often misleading and difficult to interpret. After studying the time and expense of radiographs, many surgeons have concluded that radiographs are not justified in the evaluation of nasal fractures. The primary role of imaging in patients with suspected nasal fractures is to evaluate for fractures of other facial bones. Computed tomography (CT) scans are superior to plain radiographs for this purpose, especially when assessing patients with more serious injuries or concerning signs or symptoms such as visual complaints or facial paresthesia.
Indications for Referral
Emergent Referral (Within 30 to 60 Minutes)
Blows to the face that fracture the nose may cause other more serious injuries. A history of loss of consciousness or neck pain necessitates appropriate workup, referral, or both. Fractures of other facial bones and any neurologic or cranial nerve deficit also require emergency consultation. The most common cranial nerve-related signs and symptoms are visual impairment, diplopia, facial paresthesia or numbness, facial paresis, and hearing or balance problems). Telecanthus should be suspected whenever the distance between the eyes (from the medial canthus of the right eye to the medial canthus of the left) exceeds the distance from the medial canthus to the lateral canthus of each eye. This condition should also prompt emergency consultation. Patients with septal hematomas should immediately be referred to an otolaryngologist for drainage if one is uncomfortable doing this procedure. If adequate drainage has been performed (as described below), close follow-up should be scheduled as a nonemergent referral.
Nonemergent Referral (Within Several Days)
Patients with complex nasal fractures should be referred to an otolaryngologist or plastic surgeon for consideration of open reduction or repair. These include septal fractures and dislocations, the presence of a septal hematoma, and nasal bone fractures with external nasal deviation greater than half of the width of the nasal bridge (the nasal bridge is the widest part of the top third of the nose). In these cases, open reduction or repair is recommended. A fractured or dislocated septum can interlock with the nasal bones when twisted, which makes successful closed reduction improbable. Furthermore, if the septum is fractured or dislocated, open reduction is necessary to avoid further damage to the septum. If the nasal bones are laterally deviated by more than half the width of the nasal bridge, successful closed reduction is also unlikely. Open fractures (lacerations that communicate with the fracture site) generally do well with vigorous irrigation, repair of the laceration, and a course of oral antibiotics, but telephone consultation in such cases is recommended, at a minimum. Otolaryngology or plastic surgery consultation is also advisable for lacerations involving the nasal cartilage. If a septal hematoma has been drained or packed by a primary care provider, prophylactic oral antibiotics for staphylococci and streptococci is recommended with close otolaryngology follow-up, both to reevaluate the septum and consider open reduction or repair.
In the majority of cases, epistaxis is well controlled with topical decongestant sprays with or without direct pressure. Short-term, liberal use of these sprays is safe in the absence of hypertensive urgency or emergency. If epistaxis is persistent, one may reapply topical decongestant and hold direct pressure for 5 to 10 minutes (the patient or a staff member can assist with direct pressure). Direct pressure should be applied by squeezing at the lower third of the nose (at the junction of the upper and lower lateral cartilages, applying firm pressure unto the septum). This area is compressible and often helps reduce bleeding while minimizing discomfort for the patient (as opposed to the upper third of the nose, which is not compressible and more likely to be painful). Both for safety and to reduce epistaxis, it is important to ensure the patient does not have uncontrolled hypertension (treat hypertension if systolic blood pressure >160 mm Hg or diastolic blood pressure >110 mm Hg).
If the patient has brisk epistaxis not responding to the above measures, nasal packing may be required. If nasal packing is used, prophylactic oral antibiotics to cover staphylococci and streptococci should be considered (while nonabsorbable packing is in place) given the potential risk of toxic shock syndrome. Although no large trials have addressed the prevalence of toxic shock syndrome with nonabsorbable nasal packing, case reports have been published in the adult and pediatric literature, and information has been extrapolated from similar cases with tampon use. Given the potential to prevent a life-threatening complication and medicolegal concerns, prophylactic antibiotics are suggested. If packing is required, other factors must also be considered. If the patient is taking an antiplatelet agent or anticoagulant, one should assess the risks and benefits in that particular patient and consider holding the medication. Nasal packing should not performed if one suspects a LeFort fracture (dissociation of the maxilla from the skull). A LeFort fracture can be recognized clinically by forward motion of the maxilla when one stabilizes the skull and gently pulls the upper teeth forward. This fracture (discussed below under Fractures of Other Facial Bones: Clinical Presentation) must be stabilized before nasal packing.
These need to be drained immediately. The technique for this drainage is similar to an incision and drainage of an abscess, a skill possessed by most primary care providers. One important difference is that the mucoperichondrial lining overlying the quadrangular cartilage is very thin. Thus, after local anesthesia is given (described below under Indications and Technique for Closed Reduction), the incision is made superficially through this thin mucoperichondrium to avoid scoring the underlying cartilage. Injection of adequate local anesthetic between the mucoperichondrium and underlying cartilage helps separate the two anatomic layers. After the hematoma is drained, Silastic splints or packing must be placed bilaterally to firmly support both sides of the cartilaginous septum to prevent reaccumulation of the hematoma (described below under Indications and Technique for Closed Reduction). If drainage of a septal hematoma is performed, referral to an otolaryngologist for close follow-up and consideration of open reduction or repair of the fracture is needed. At the time of drainage, a minimum of telephone consultation is recommended. Oral antibiotics are recommended for staphylococci and streptococci coverage while the nonabsorbable packing is in place.
Isolated, Simple Nasal Bone Fractures
Nasal fractures are considered simple if external nasal deviation is less than half the width of the nasal bridge, the nasal septum is not fractured or dislocated, septal hematoma is not present, the fracture is closed, and no other facial fractures are present. Simple fractures may be either unilateral or bilateral. Nondisplaced simple fractures require no specific treatment other than control of epistaxis (if present) and ice or analgesia because these patients do not have nasal obstruction or cosmetic deformity. Closed reduction is recommended for displaced simple fractures. The best time for successful reduction is within 3 hours of injury before the onset of significant edema. If this is not possible, reduction should be delayed 3 to 7 days to allow edema to improve and facilitate improved reduction. If reduction is delayed, closed reduction within 2 weeks of injury yields the best results. After associated injuries have been excluded and epistaxis is controlled, the patient may be discharged with instructions. Go to Expert Consult for the electronic version of a patient instruction sheet for nasal fractures.
Informed Consent Before Closed Reduction
Patients should be counseled that they may have persistent cosmetic deformity or nasal obstruction (chronic nasal congestion) after closed reduction but that it is being offered to give them a chance at improved cosmesis or function without requiring an open procedure. These are the main points of patient dissatisfaction and must not be underemphasized. If the patient is dissatisfied after closed reduction, he or she still has the option to have an open septorhinoplasty procedure in the future by an otolaryngologist or plastic surgeon. Patients should also be counseled on other risks, including unsuccessful closed reduction necessitating open reduction, increased epistaxis, infection, and allergic reaction to medication.
Indications and Technique for Closed Reduction of Isolated, Simple Nasal Fractures
Closed reduction is indicated if significant cosmetic deformity or significant functional impairment (obstruction of the nasal passage) is present. Closed reduction provides good results in approximately three-fourths of these patients, provided the reduction is timed as described above. Injuries that are more complex or older may require open reduction under general anesthesia. Open reduction may also be necessary if closed reduction does not produce acceptable results.
Although the operating room with short-term anesthesia may seem like the optimal setting for closed reduction of simple nasal fractures, this is rarely done unless other surgeries are needed simultaneously. Data do not demonstrate better outcomes for closed reduction performed in the operating room under sedation compared with other settings with local anesthesia. If feasible, premedication should be done with an oral or intravenous benzodiazepine 30 minutes before reduction. Topical lidocaine, cocaine, benzocaine, or tetracaine should be obtained to obtain intranasal anesthesia. Using bayonet forceps, the practitioner should layer thin gauze packing soaked with the anesthetic in the nose and remove the packing after 5 minutes. The anesthetic must extend far enough into the nose to reach the mucosa underlying the nasal bones because this area must be anesthetized. Some also advocate supplementing topical anesthesia with injection of 1% lidocaine with 1 : 100,000 epinephrine along the dorsum of the nose (externally) lateral to the midline bilaterally and at the base of the anterior septum (internally). This optional, additional anesthesia can further block the infratrochlear, infraorbital, greater palatine, and superior alveolar nerves. If these injections are performed, the practitioner should wait 10 to 20 minutes before reduction. After removing the anesthetic-soaked gauze, the practitioner should measure the distance from the external nostril rim to the top of the nasal bone, where the nasal bone articulates with the frontal bone (may be measured externally using the instrument). A blunt instrument such as an elevator (if available) or the rigid steel handle of a scalpel is inserted into the nasal cavity to a point that is 1 cm less than the previously measured distance (nasal fracture rarely involves the strong nasofrontal suture and manipulation of this area produces unnecessary mucosal damage or bleeding). The depressed nasal bone fragment is elevated by applying a moderate amount of force in the direction opposite the fracturing force (almost always anterolaterally). At the same time the instrument is being moved laterally, if the contralateral nasal bone is displaced laterally, it should also be pushed medially into proper alignment by the contralateral hand with the fingers placed gently over the fracture site to feel when the bone is adequately reduced. If not adequately reduced, a repeat attempt should be made (through whichever nostril will best facilitate reduction, which is often the nostril ipsilateral to the worst fracture).
The cosmetic result should be assessed by the physician and patient. The nose should be examined internally to be sure the nasal passages are adequately patent and the septum is not significantly deviated. If the septum is found to be deviated after reduction, it should be relocated in the maxillary groove. Bleeding is likely to occur after reduction, but this can generally be controlled with a topical decongestant spray (see Epistaxis above).
After reduction, an external nasal splint should be applied. If prefabricated nasal splints are not available, a splint may be made as follows: The practitioner cuts several layers of plaster cast material into a triangular shape 2 inches in length. He or she covers the surface of the nose with tape (applying it in left-to-right direction), wets the splint material, gently molds the splint over the nose (paying particular attention to the upper third of the nose where the nasal bones have been reduced), and holds it in place with tape (applied in a left-to-right direction). The splint should be removed in 1 to 2 weeks. If there is concern that the reduction of the nasal bones is unstable or that the septum may be unstable, one may place Silastic septal splints covered in antibiotic ointment for 3 to 7 days or pack the nose with antibiotic ointment-soaked gauze strip packing for 2 to 3 days to support the reduction. This may be challenging because the packing must be inserted high into the nose to support the nasal bones. Referral may be preferable if instability is anticipated.
Patients will need follow-up to have the external nasal splint or nasal packing removed at the time intervals noted above. At that time, one can start gentle normal saline nasal irrigations twice daily, as tolerated, to decrease nasal obstruction from blood clots or debris. The final cosmetic and functional result should be assessed approximately 1 month after reduction, at which time a repeat external and internal nasal examination should be performed. If the patient is not satisfied with the cosmetic result or a nasal passage is significantly obstructed, the patient should be referred for consideration of operative repair. As already discussed, patients accept this referral much better if the possibility was explicitly discussed before the initial reduction.
Return to Work or Sports
Most individuals with an isolated, simple nasal fracture can return to work in 1 to 2 weeks after the acute healing period and to noncontact sports in 2 weeks. It takes approximately 3 weeks for initial healing of a nasal fracture in a healthy adult. Nasal fractures are relatively common in contact sports. Athletes who are anxious to return to contact sports before a nasal fracture is fully healed should ensure they have adequate head and face protection. They may benefit from use of a facial brace that covers the nose. Ready-made braces are available and work well if a good fit can be found. If an athlete is unable to find a commercial brace that fits well, an orthotist can make custom facial protection. After a patient has a nasal fracture, he or she is more prone to having a recurrent fracture in the setting of nasal trauma. The risk for recurrent fractures increases if open surgery was required.
The most common complication is a lingering unsatisfactory result (cosmetic or functional), which may necessitate open reduction. Another typical complication is persistent epistaxis (managed as discussed above). Necrosis of the septum after septal hematoma and complications resulting from unrecognized associated injuries may also occur. If the patient has evidence of new, clear rhinorrhea after a nasal fracture, one must consider a CSF leak. This often results from a fracture of the cribriform plate of the ethmoid or anterior cranial fossa (see Figure 17-5 ). If not recognized and managed properly, this injury can lead to potentially fatal meningitis or pneumocephalus. A salty taste or new anosmia may also be found in patients with CSF leaks, but these are often not present.