Nasal and Septal Fractures

Nasal and Septal Fractures

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Nasal fractures are the most common types of facial fractures; however, they are often unrecognized and untreated at the time of injury. Its central position and anterior projection on the face predisposes the nose to traumatic injury. Studies have shown that most nasal fractures involve the septum, which can be an obstacle to successful reduction.

Fractures can be classified as open or closed, depending on the integrity of the mucosa. Prompt identification and management of the injury in the early postinjury period is imperative to avoid the potential complications of nasal and septal fractures. Confirming that septal hematoma is not present is crucial to avoid further compressive damage to native tissue and dangerous infectious complications. Longer-term follow-up allows the surgeon to assess for both early and late sequelae of injuries to the nasal complex. Surgical intervention may be appropriate in the early postfracture period or much later, after the fracture has healed. [1]

For excellent patient education resources, see eMedicineHealth’s patient education article Broken Nose.

An oblique view of nasal fractures is depicted below.

Nasal fractures are the third most common types of fractures, behind fractures of the clavicle and wrist. Nasal fractures are often cited as the most common type of facial fracture, accounting for approximately half of all facial fractures in several studies. Zygomatic (22%), blowout (12%), mandibular bone (8%), and maxillary bone (9%) fractures follow in frequency.

Most commonly, nasal bone fractures are sustained in fights (34%), accidents (28%), and sports (23%). A 2009 study of 236 patients with facial fractures incurred while playing sports determined that fractures of the nasal bone were most common. [2]

With increasing use of air bags in automobiles, a shift in the mechanism of injury and the type of nasal fractures has occurred; therefore, the incidence of septal injury in nasal fractures, without concurrent nasal bone fracture, has increased.

In a study of 2023 adults with facial fracture, including 209 patients over age 64 years, Atisha et al determined that nasal fractures were more common in elderly persons than in nonelderly ones (54.1% vs 45.3%, respectively). [3]

In children, nasal fractures are most commonly due to falls. In a study of 100 children with traumatic nasal deformity, Liu et al determined that such injuries were most often the result of sports-related trauma (28%), with accidental trauma (21%), interpersonal violence (10%), motor vehicle collisions (6%), and alcohol-related trauma (2%) being the next most common reasons for injury. [4] The possibility of child abuse should be considered in every child presenting with a nasal fracture.

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.

Clinical findings in patients with a history of trauma to the nose or face may include the following [5] :

Epistaxis, which is common in nasal fractures due to mucosal disruption

Change in nasal appearance

Nasal airway obstruction

Infraorbital ecchymosis

Indications for repair of nasal fractures include abnormal nasal function, abnormal appearance, and presence of early postinjury complications. Several methods of reduction and repair can be performed to achieve good cosmetic and functional results.

Closed reduction may be performed under local anesthesia or local anesthesia with mild sedation. Indications include the following [6] :

Simple fracture of nasal bones

Simple fracture of nasal-septal complex

Open reduction requires deeper sedation or a general anesthetic. Indications include the following:

Extensive fracture-dislocation of nasal bones and septum

Fracture dislocation of caudal septum

Open septal fractures

Persistent deformity after closed reduction

Relative indications, eg, septal hematoma, inadequate bony reduction due to septal deformity, cartilaginous deformities, displaced nasal spine, and recent intranasal surgery

See the list below:

Nasal skin has an abundant blood supply and tends to be thinner over the rhinion and thicker over the nasion. Nasal skin thickness varies among individuals.

The nasal pyramid is composed of 2 nasal bones and the frontal process of the maxilla. The thickness of the bones decreases toward the tip of the nose; as a result, most fractures occur in the lower half.

Upper lateral cartilages form the middle nasal vault. Upper lateral cartilages are attached to the nasal bones superiorly, the quadrangular cartilage of the septum medially, and the lower lateral cartilages (ie, tip cartilages) inferiorly.

The images below depict the oblique and lateral view of the nasal anatomy.

Sesamoid cartilages are less important and lie in the fat pad between lower lateral cartilages and the piriform aperture.

The nasal septum (as seen in the image below) has a cartilaginous and bony component that is lined with mucoperichondrium and mucoperiosteum, from which the cartilage and bone receive their blood supply. Interruption of the opposition of perichondrium to cartilage (as with septal hematoma) may interrupt the blood supply and lead to resorption of septal cartilage and possibly subsequent saddle-nose deformity.

Some fractures do not need correction, providing the patient is satisfied with the appearance and function of the nose. In more severe injuries, one must entertain the option of deferring a nasal procedure until the patient has become stabilized.

Kuhnel TS, Reichert TE. Trauma of the midface. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2015. 14:Doc06. [Medline]. [Full Text].

Hwang K, You SH, Lee HS. Outcome analysis of sports-related multiple facial fractures. J Craniofac Surg. 2009 May. 20(3):825-9. [Medline].

Atisha DM, Burr Tv, Allori AC, Puscas L, Erdmann D, Marcus JR. Facial Fractures in the Aging Population. Plast Reconstr Surg. 2016 Feb. 137 (2):587-93. [Medline].

Liu C, Legocki AT, Mader NS, Scott AR. Nasal fractures in children and adolescents: Mechanisms of injury and efficacy of closed reduction. Int J Pediatr Otorhinolaryngol. 2015 Dec. 79 (12):2238-42. [Medline].

Pérez-Guisado J, Maclennan P. Clinical evaluation of the nose: a cheap and effective tool for the nasal fracture diagnosis. Eplasty. 2012. 12:e3. [Medline]. [Full Text].

Han DS, Han YS, Park JH. A new approach to the treatment of nasal bone fracture: the clinical usefulness of closed reduction using a C-arm. J Plast Reconstr Aesthet Surg. 2011 Jul. 64(7):937-43. [Medline].

Han DS, Han YS, Park JH. A new approach to the treatment of nasal bone fracture: radiologic classification of nasal bone fractures and its clinical application. J Oral Maxillofac Surg. 2011 Nov. 69(11):2841-7. [Medline].

Hung T, Chang W, Vlantis AC, Tong MC, van Hasselt CA. Patient satisfaction after closed reduction of nasal fractures. Arch Facial Plast Surg. 2007 Jan-Feb. 9(1):40-3. [Medline].

Yi CR, Kim YJ, Kim H, et al. Comparison study of the use of absorbable and nonabsorbable materials as internal splints after closed reduction for nasal bone fracture. Arch Plast Surg. 2014 Jul. 41(4):350-4. [Medline]. [Full Text].

Li K, Moubayed SP, Spataro E, Most SP. Risk Factors for Corrective Septorhinoplasty Associated With Initial Treatment of Isolated Nasal Fracture. JAMA Facial Plast Surg. 2018 Jun 14. [Medline].

Daniel G Becker, MD Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of Pennsylvania School of Medicine

Daniel G Becker, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American Medical Association, Colorado Medical Society

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;The Physicians Edge;Sync-n-Scale;mCharts<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; .

Hassan H Ramadan, MD, MSc Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University School of Medicine

Hassan H Ramadan, MD, MSc is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Rhinologic Society

Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Adam T Ross, MD, to the development and writing of this article.

Nasal and Septal Fractures

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