Nasal Fracture

Nasal Fracture

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Nasal fractures seen in participants of athletic activities occur as a result of direct blows in contact sports and as a result of falls. The nasal bones are the most commonly fractured bony structures of the maxillofacial complex. [1, 2, 3, 4, 5, 6]  See the images below.

The nasal bone’s protruding position coupled with its relative lack of support predisposes it to fracture. Prompt appropriate treatment prevents functional and cosmetic changes. Because of the nose’s central location and proximity to important structures, the clinician should carefully search for other facial injuries in the presence of facial fractures.

For excellent patient education resources, visit eMedicineHealth’s First Aid and Injuries Center. Also, see eMedicineHealth’s patient education articles, Facial Fracture and Broken Nose.

United States

Nasal fractures occur nearly twice as often in males as in females. Athletic injuries and interpersonal altercations account for the greatest proportion of causes. Less common causes include falls and motor vehicle accidents. [7, 8]

In a retrospective study, Erdmann et al investigated the medical records of 437 patients with 929 facial fractures. [3] These authors noted that the most common etiology of facial trauma was assault (36%), followed by motor vehicle collision (MVC, 32%), falls (18%), sports (11%), occupations (3%), and gunshot wounds (2%). Of the facial fractures sustained, the most common fracture type was nasal bone fracture. [3]

A study by Hanba et al found that risk factors for facial fracture included being white, Asian, female, or ≥ 60 years of age. [9]

A study by Plawecki et al evaluated the incidence of 20,519 patients, 55 years of age or older, who went to the ED for recreational activity-associated facial fractures. The study reported that the annual incidence of facial fractures increased by 45.3% from 2011 through 2015. Nasal fractures were the most common site of fracture (65.4%) and cycling (26.6%) was the most common cause in this cohort of older patients. [10]

 

International

In a retrospective study of Brazilian children aged 5-17 years, Cavalcanti and Melo found that facial injuries were most frequent in males (78.1%; 3-fold more common than in females) aged 13-17 years (60.9%), and the most common causes of these injuries were falls (37.9%) and traffic accidents (21.1%). [1] Of the facial injuries, nasal fractures were also most common (51.3%), followed by the zygomatic-orbital complex (25.4%).

In another retrospective study, Hwang et al reviewed and analyzed the medical records of 236 patients with facial bone fractures from various sports who were treated at one hospital between 1996 and 2007. [11] The investigators noted the age group with the highest frequency of such injuries was 11-20 years (40.3%), with a significant male predominance across all age groups (13.75:1). There were 128 isolated nasal fractures, with soccer accounting for 39% of these; baseball, 18%; basketball, 12.5%; martial arts, 5%; and skiing or snowboarding, 5%. [11]

The lay term nose consists of bone and cartilage. The nasal septum, a commonly injured structure, consists of the vomer, the perpendicular plate of the ethmoid, and the quadrangular cartilage. Paired protrusions from the frontal bones and the ascending processes of the maxilla complete the bony component. The upper lateral and lower lateral cartilages, as well as the cartilaginous septum, compose the nonbony portion.

The blood supply occurs via branches of the ophthalmic artery, the ethmoidal and dorsal arteries, the facial artery, the nasopalatine, the sphenopalatine, and the greater palatine arteries. Sensation results from many small nerve branches; the external surface superiorly receives sensation from the supratrochlear and infratrochlear nerves, and the inferior portion receives sensation from branches of the infraorbital and anterior ethmoidal nerves. Internally, sensation is supplied by branches of the anterior ethmoidal ganglion and the sphenopalatine ganglion.

Any force directed to the mid face, either frontally or laterally, can disrupt the nasal anatomy, causing bony or cartilaginous injury. Frontally directed forces must be greater than normal to cause bony injury because the upper and lower lateral cartilages absorb a great deal of impact.

Children are more likely to sustain cartilaginous injury for a variety of reasons. This is mainly because children have a greater proportion of cartilage to bone, and the cartilage provides increased protection from fracture. Children’s bones are also more elastic than adults’ bones. This explains the increased incidence of greenstick fractures in children (fracture without displacement).

Cavalcanti AL, Melo TR. Facial and oral injuries in Brazilian children aged 5-17 years: 5-year review. Eur Arch Paediatr Dent. 2008 Jun. 9(2):102-4. [Medline].

Kim MG, Kim BK, Park JL, et al. The use of bioabsorbable plate fixation for nasal fractures under local anaesthesia through open lacerations. J Plast Reconstr Aesthet Surg. 2008 Jun. 61(6):696-9. [Medline].

Erdmann D, Follmar KE, Debruijn M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg. 2008 Apr. 60(4):398-403. [Medline].

Cantrill SV. Facial trauma. Rosen P, ed. Emergency Medicine: Concepts in Clinical Practice. 4th ed. St. Louis, Mo: Mosby-Year Book; 1998. Vol 1: 459.

Smith JA. Nasal emergencies and sinusitis. Tintinalli JE, Ruiz E, Krome RL, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York, NY: McGraw-Hill Publishing; 1996. 1087-91.

Coto NP, Meira JB, E Dias RB, Driemeier L, de Oliveira Roveri G, Noritomi PY. Assessment of nose protector for sport activities: finite element analysis. Dent Traumatol. 2011 Jul 26. [Medline].

Shirani G, Kalantar Motamedi MH, Ashuri A, Eshkevari PS. Prevalence and patterns of combat sport related maxillofacial injuries. J Emerg Trauma Shock. 2010 Oct. 3(4):314-7. [Medline]. [Full Text].

Swenson DM, Yard EE, Collins CL, Fields SK, Comstock RD. Epidemiology of US high school sports-related fractures, 2005-2009. Clin J Sport Med. 2010 Jul. 20(4):293-9. [Medline].

Hanba C, Svider PF, Chen FS, Carron MA, Folbe AJ, Eloy JA, et al. Race and Sex Differences in Adult Facial Fracture Risk. JAMA Facial Plast Surg. 2016 Dec 1. 18 (6):441-448. [Medline].

Plawecki A, Bobian M, Kandinov A, Svider PF, Folbe AJ, Eloy JA, et al. Recreational Activity and Facial Trauma Among Older Adults. JAMA Facial Plast Surg. 2017 Jun 15. [Medline].

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

Colton JJ, Beekhuis GJ. Management of nasal fractures. Otolaryngol Clin North Am. 1986 Feb. 19(1):73-85. [Medline].

Rohrich RJ, Adams WP Jr. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg. 2000 Aug. 106(2):266-73. [Medline].

Bremke M, Wiegand S, Sesterhenn AM, et al. Digital volume tomography in the diagnosis of nasal bone fractures. Rhinology. 2009 Jun. 47(2):126-31. [Medline].

Choi DS, Lee JW, Yang JD, Chung HY, Cho BC, Choi KY. Minimal packing duration in close reduction for nasal bone fracture treatment. J Plast Surg Hand Surg. 2015 Apr 15. 1-5. [Medline].

Shin JW, Lim JS, Yoo G, Byeon JH. An analysis of pure blowout fractures and associated ocular symptoms. J Craniofac Surg. 2013 May. 24(3):703-7. [Medline].

Wong CH, Daniel RK. Immediate functional and cosmetic open rhinoplasty following acute nasal fractures: our experience with asian noses. Aesthet Surg J. 2013 May 1. 33(4):505-15. [Medline].

Ardeshirpour F, Ladner KM, Shores CG, Shockley WW. A preliminary study of the use of ultrasound in defining nasal fractures: criteria for a confident diagnosis. Ear Nose Throat J. 2013 Oct-Nov. 92(10-11):508-12. [Medline].

Atighechi S, Baradaranfar MH, Karimi G, et al. Diagnostic value of ultrasonography in the diagnosis of nasal fractures. J Craniofac Surg. 2014 Jan. 25(1):e51-3. [Medline].

Bianco M, Sanna N, Bucari S, et al. Female boxing in Italy: 2002-2007 report. Br J Sports Med. 2009 Aug 19. epub ahead of print. [Medline].

Gharehdaghi J, Samadi Rad B, Ghatreh Samani V, Kolahi F, Khatami Zonoozian A, Marashian SM. Comparison of physical examination and conventional radiography in diagnosis of nasal fracture. Indian J Otolaryngol Head Neck Surg. 2013 Aug. 65:304-7. [Medline]. [Full Text].

Peterson BE, Doerr TD. Utility of computed tomography scans in predicting need for surgery in nasal injuries. Craniomaxillofac Trauma Reconstr. 2013 Dec. 6(4):221-4. [Medline]. [Full Text].

Procacci P, Ferrari F, Bettini G, et al. Soccer-related facial fractures: postoperative management with facial protective shields. J Craniofac Surg. 2009 Jan. 20(1):15-20. [Medline].

We J, Kim Y, Jung T, et al. Modified technique for endoscopic endonasal reduction of medial orbital wall fracture using a resorbable panel. Ophthal Plast Reconstr Surg. 2009 Jul-Aug. 25(4):303-5. [Medline].

Chukwulebe S, Hogrefe C. The Diagnosis and Management of Facial Bone Fractures. Emerg Med Clin North Am. 2019 Feb. 37 (1):137-151. [Medline].

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 Dec 1. 20 (6):460-467. [Medline].

Samuel J Haraldson, MD 

Samuel J Haraldson, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Society for Sports Medicine, Texas Medical Association

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.

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Andrew L Sherman, MD, MS Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, University of Miami, Leonard A Miller School of Medicine

Andrew L Sherman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, Florida Society of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Russell L. Reinbolt, MD and Robert D. Welch, MD, to the development and writing of this article.

Nasal Fracture

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