Nasal fractures

In cases of facial trauma, nasal fractures

account for approximately 40 percent of
bone injuries

{
is a fracture of one of the bones
 ROWE & KILEY (1968)
Described fractures of the nasal bones & or nasal
septum according to the impact only:
 1. Lateral nasal injuries

 2. Anterior nasal injuries

Drawback : only included the impact factor &

nothing else (not the force or bone involved)

Classification
  Various weights were dropped on cadavers
noses & the resultant fractured nasal pyramid
was dissected out.
 The fracture lines are described & particular
reference is directed to the involvement of the
septum in grossly deviated noses.

MURRAYS PATHOLOGICAL
CLASSIFICATION
Fractures can be classified
as open or closed,
depending on the integrity
of the mucosa.
Confirming that septal
hematoma is not present is
crucial to avoid further
compressive damage to
native tissue and dangerous
infectious complications. 
Nasal bone fractures 
were classified into six
types:
Type I) Simple without
displacement;
Type II) Simple with
displacement/without
telescoping; IIA; Unilateral;
IIAs) Unilateral with
septal fracture;
IIB) Bilateral;
IIBs) Bilateral with
septal fracture;
Type III) Comminuted with
telescoping or depression.
 MARKOWITZ ET AL CLASSIFICATION


Markowitz type I fractures include a single-segment central fragment in which the

medial canthal ligament is attached to a relatively large segment of fractured
bone. Markowitz type II fractures include the comminuted central fragment with
the medial canthal tendon still attached. Markowitz type III fractures are
conditions in which the insertion of the medial canthal ligament is comminuted
 Nasal fractures are caused by physical traumas to
the face. Common sources of nasal fractures
include sports injuries, fighting, falls, and car
accidents in the younger age groups, and falls
from syncope or impaired balance in the elderly

Cause
  The direction of force to the nose during injury
determines the pattern of the fracture.
 Frontal force causes damage ranging from simple
fracture of the nasal bones to flattening of the entire nose.
 Lateral force may depress only one nasal bone; however,
with sufficient force, both bones may be displaced.
Lateral force can cause severe septal displacement, which
can twist or buckle the nose. Septal fragments may
interlock, creating further difficulty in reduction.
 Superior-directed force (from below) rarely occurs. It
may cause severe septal fractures and dislocation of the
quadrangular cartilage.

Patophysiology
 Clinical findings in patients
with a history of trauma to the
nose or face may include the
following:
 Epistaxis, which is common in
nasal fractures due to mucosal
disruption
 Change in nasal appearance
 Nasal airway obstruction
 Infraorbital ecchymosis
periorbital ecchymosis is
a sign of basal skull
fracture or subgaleal
hematoma
 PHYSICAL EXAMINATION
 Adequate lighting
 Acute edema may hide deformities; however, a careful search for
intranasal injury must take place
 Patient should be placed in a comfortable, slightly reclined position
 Nose should be externally observed from all angles
 Bleeding can be controlled with topical cotton pledgets soaked in
vasoconstrictors – 0.25%
 phenylephrine – 4% cocaine, which also provides anesthesia.
• Other signs: –
 Any open wound (a) Oedema
 Nasal airway evaluation : (b)Skin laceration
 (a) Obstruction (c)Periorbital ecchymosis
(d)cerebrospinal fluid (CSF) rhinorrhoea
 (b) Hematoma (e) Olfactory disorders
 (c) Septal deviation  Palpation : Evidence of nasal fracture
Mobility : of the nasal bones is assessed by
grasping the dorsum btw two fingers and
firmly rocking the
pyramid back & forth
Crepitations can also be felt
Reduction should be accomplished
between the fifth and 10th day after the
injury, and before the nasal bones start to
fixate.5 However, before releasing a patient
with any type of nasal trauma, it is critical
to rule out septal hematomas.

A septal hematoma is blood that collects in

the space between the septal cartilage and
the overlying perichondrium (a cross
section of the cartilaginous portion of the
nasal septum). A hematoma  may deprive
the septal cartilage of its blood supply
from the overlying mucosa and can lead to
permanent sequelae
 The initial internal inspection usually will reveal the presence of large
blood clots, which should be removed with warm saline irrigation,
suction, and cotton-tipped applicators.
Internal examination
 Assessment of nasal cavity using speculum via direct
visualization or using endoscopy ( use of 0 or
 30 degree 4mm rod telescope)

 Not entirely necessary

However may provide additional information and rule out the

following: –
 (a)Mucosal tears

 (b) Lacerations

 (c)Ecchymosis

 (d)Hematoma

 Push the tip of the nose upward to check for integrity of the

septal support system.

 Retained blood clots should be removed with suctioning or

swabbing using a frazier suction

 procedure.
Ragiology
When an uncomplicated
nasal fracture is suspected,
plain radiography rarely is
indicated. In fact, because
of poor sensitivity and
specificity, plain
radiography may serve
only to confuse the clinical
picture. Plain radiography
will not allow identification
of cartilaginous
disruptions, and physicians
may misinterpret normal
suture lines as
nondisplaced fractures
However, when findings such as CSF rhinorrhea, extraocular movement
abnormalities, or malocclusion are present, radiologic imaging by CT is
indicated to assess for facial and mandibular fractures.
Complications

 Lacerations
 Epistaxis
 Septal hematoma or abscess
 Cerebrospical fluid rhinorrhoea
Medical Therapy
Elevation of the head and use of cold compresses
in the periorbital and nasal region can be helpful
while waiting for edema to subside. Even in the
presence of significant edema, a nasal deformity
often may be obvious. In a patient with no
apparent abnormality at the initial visit,
reassessment of the nose after the edema subsides
may reveal findings necessitating repair. Surgical
intervention may then be undertaken.
 Surgical Therapy
 Treatment begins with management of external soft tissue injuries.
If an open wound is present and appears to be contaminated with
foreign matter, copious irrigation will be required. Some
debridement also may be necessary. However, debridement should
be done judiciously because tissue will be needed to cover any
exposed cartilage.
 Reduction of acute nasal fractures in the primary care setting is
confined largely to the closed reduction of mild unilateral fractures.
However, on rare occasions, open reduction in an operating room is
necessary.
Bleeding
Most nasal fractures cause significant bleeding.
Proper techniques for hemostasis should be
applied prior to any diagnostic procedure and
any definitive treatment of nasal fractures.
 The goal of closed reduction is to realign cartilaginous and bony structures
to their locations before the injury to decrease discomfort and maximize
airway patency. The aesthetic outcomes of closed reduction techniques are
often less than optimal, and patients should be counseled that nasal
reconstruction might eventually be necessary. Given the obvious anxiety
and pain associated with reduction, pretreatment with anxiolytic and pain
medications should be considered.

In laterally displaced
fractures
 Two instruments, the Asch and the Walsham forceps, are
designed to reduce the displaced septum and impacted nasal
bones, respectively, although these instruments often are used
interchangeably. An important drawback with these instruments
is the possibility of mucosal crushing injuries and resulting
hematomas that may occur between their tines.

Reduction instruments. (Left) Asch
forceps, (center) Walsham forceps,
and (right) Boies elevator.
When used correctly, the Boies elevator is inserted
into the nostril deeply to an internally or externally
displaced fracture. The blade of the elevator
opposes the physician’s thumb on the outside of the
nose. The physician then gently attempts to raise or
depress the misaligned bones to their original
configuration. The reduction may be felt as the
fractured bone returns to its proper alignment.
Pearl: correct instrument placement
Prior to the endonasal placement of the elevator, it is placed against the
outside of the nose to the level of the medial canthus. The index finger is
then placed against the edge of the elevator and is used as a stop when
the elevator is placed intranasally to ensure that it can not be advanced
too far superiorly.
Carefully position the instrument under the depressed
nasal bone.
 In centrally depressed fractures

Sometimes the frontal processes of the maxillae are displaced laterally with
the nasal bones impacted inside them.
Reduction requires elevation of the nasal bones anteriorly and repositioning
of the frontal processes medially.
The elevator must not be inserted too far into the nasal cavity.
In this case the elevator is placed in the nose and lifts the nasal dorsal
pyramid anteriorly, while simultaneously the thumb and index finger put
medial pressure on the displaced frontal processes of the maxillae.
 Alternative technique
Centrally depressed fractures
require posterior to anterior
elevation which can often be
achieved by reducing the nasal
septum.

In some cases, Asch or Walsham forceps can be used to elevate the

dorsum and disimpact the displaced septum.
Closed reduction requires indirect elevation of the nasal bones to
restore the architecture of the nasal pyramid.
 Reduction of the nasal
septum

The Asch or Walsham septum-straightening forceps are used to straighten the

nasal septum.
Grasp the nasal septum with the blades of the instrument and gently manipulate
the septum into proper alignment.
External splint providing pressure and
support.
 Splinting

Nasal septum
The nasal septum can be stabilized with splints or packs.
Removal of packings and splints
Hemostatic packs are removed after 24 hours. Packs that are supporting the nasal
bones are left in place as long as the external splint is in place. (Various surgeons leave
these in place from anywhere between 5-10 days).
The patient should be prescribed antibiotic treatment for as long as the nasal packs are
in place.
Management of septal hematoma. (A) Cross-sectional view of a septal
hematoma, showing blood accumulation between the septum and
perichondrium. Treatment involves anesthesia, followed by (B) incision
using a hemostat, (C) drainage of the hematoma, and (D) insertion of
sterile gauze to prevent the reaccumulation of blood.
Aftercare following
management of nasal
fractures Postoperative positioning
Keeping the patient’s head
in a raised position both
preoperatively and
postoperatively may
significantly improve
edema and pain.
Furuncle of the nose
Nasal furunculosis is a localized infection of the
hair-bearing nasal vestibule. It is usually caused
by the bacteria S aureus. It can occur as a primary
infection or secondary to chronic rhinorrhea,
upper respiratory infections, and nose picking.
Clinical features:
 Pain on touching the nose

especially the tip/ala;

 Pus pointing or swelling

over the nose or in the

vestibule;
 Purulent discharge if it

ruptures;
 Tenderness of the nasal

tip/ala
Management
 Not to squeeze the lesion;
 Dangerous area of the face – infection can
spread along the angular and ophtalmic veins
to cavernous sinus;
 Systemic antibiotics and analgesics;
 Drainage if it becomes an abscess;
 Management of underlying diabetes if present