Fracture of Nose

Introduction

The most common facial fracture, a fractured nose usually results from blunt injury and is commonly associated with other facial fractures. The severity of the fracture depends on the direction, force, and type of the blow.
A severe, comminuted fracture may cause extreme swelling or bleeding that may jeopardize the airway and require tracheotomy during early treatment. Inadequate or delayed treatment may cause permanent nasal displacement, septal deviation, and obstruction.

Causes
With low-energy injuries, noncomminuted nasal bone fragments are caused by low-velocity trauma. Such injuries could occur in the following situations:

• injuries created during fistfights (hand or fist blows only, no blunt instruments)
• uncomplicated falls such as tripping
• low-velocity motor vehicle collision.

With high-energy injuries, a higher amount of energy is absorbed by the nasal and facial bones, with comminution of bone fragments and associated injuries to the soft tissue and orbitonasal skeleton. These injuries would include:

• injuries sustained from a leveraged blow to the nose using an object such as a stick, pipe, or other blunt object
• falls from heights
• sport injuries with fast-moving projectiles, such as a ball or puck
• high-velocity motor vehicle collisions.

Clinical Features
Immediately after the injury, a nosebleed may occur, and soft-tissue swelling may quickly obscure the break. After several hours, pain, periorbital ecchymoses, and nasal displacement and deformity are prominent. A possible complication is septal hematoma, which may lead to abscess formation, resulting in vascular septic necrosis and saddle nose deformity.

Diagnosis
Palpation, X-rays, and signs and symptoms, such as a deviated septum, confirm a nasal fracture. The diagnosis also requires a full patient history, including the cause of the injury and the amount of nasal bleeding. Watch for clear fluid drainage, which may suggest a cerebrospinal fluid (CSF) leak and a basilar skull fracture. A computed tomography (CT) scan may be necessary.

Management
Treatment restores normal facial appearance and reestablishes bilateral nasal passage after swelling subsides. Reduction of the fracture corrects alignment; immobilization (intranasal packing and an external splint shaped to the nose and taped) maintains it. Reduction is best accomplished in the operating room under local anesthesia for adults and general anesthesia for children.
CSF leakage calls for close observation, a CT scan of the basilar skull, and antibiotic therapy; septal hematoma requires incision and drainage to prevent necrosis.

Special considerations

• Start treatment immediately. While waiting for X-rays, apply ice packs to the nose to minimize swelling. Wrap the ice packs in a light towel to prevent ice from directly contacting the skin.
• To control anterior bleeding, gently apply local pressure. Posterior bleeding is rare and requires an internal tamponade applied in the emergency department.
• Because the patient will find breathing more difficult as the swelling increases, instruct him to breathe slowly through his mouth.
• To warm the inhaled air during cold weather, tell the patient to cover his mouth with a handkerchief or scarf.
• To prevent subcutaneous emphysema or intracranial air penetration (and potential meningitis), warn the patient not to blow his nose.
• After packing and splinting, apply ice in a plastic bag.
• Before discharge, tell the patient that ecchymoses should fade after about 2 weeks.