1. INTRODUCTION

• Epidemiology: #1 most common facial fracture
• Mechanism: Any blunt injury to the face
• Pathoanatomy
  • Frequent area of injury due to anterior position and thin bones
• Associated injuries
  • Epistaxis
  • Septal hematoma = blood accumulation separating the septal cartilage from the perichondrial blood supply
  • Intracranial injuries

2. Presentation

• Symptoms
  • Pain, epistaxis
• Physical Exam
  • Inspect
    • Swelling, deformity
    • Evaluate for septal hematoma
  • Palpate
    • Crepitus, tenderness, step-offs, mobility

3. Imaging

• Nasal fracture is a clinical diagnosis
  • Contusion or tenderness over the bridge of the nose may be assumed to have fracture of the nasal bones
• Radiographs: Insensitive
  • Although often used, generally no clinical utility
• CT: Often unnecessary
  • No advantage in diagnosing septal fractures
  • Reserve for patients in which suspected of having other, more complex fractures

4. Treatment

• Ice for swelling
• Epistaxis
  • Generally controllable by pinching the cartilaginous anterior closed with two fingers x 10 min
  • May require TXA, cautery or anterior packing
  • Consider need for prophylactic antibiotics with nasal packing
• No further management necessary if:
  • 1) Acceptable alignment
  • 2) Epistaxis controlled
  • 3) No septal hematoma
  • 4) If patient breathing out of each individual nares
• Closed Reduction
  • If markedly displaced, can attempt reduction using scalpel handles in each nare with anterior and midline pressure
  • But, often NOT done in ED due to ++swelling.
  • Majority of fractures will be reduced with specialist when patient follows up 3-5 days after initial injury when swelling improved
  • See Procedural Skill: Nasal Fracture Reduction
• Operative
  • May be necessary pending Plastics/OMFS/ENT assessment
    • If uncertain due to swelling, refer for reassessment after swelling improves in 3-5 days
• Follow-up
  • Swelling over the bridge obscures ability to assess acceptability of the appearance at the time of injury
  • Referral to Plastics/OMFS/ENT in 3-5 days. May require further reduction if alignment unacceptable once swelling decreases

5. Complications

• Septal hematoma
  • Appears as dark purple/blue mass coming off of septum
  • If left untreated, septal hematomas can lead to infection, abscess, cartilage necrosis, saddle nose deformity, or septal perforation
  • See Procedure: Septal Hematoma Drainage

6. Pediatrics

• May have premature closure of sutures and unevem growth
• No imaging studies indicated, but referral to specialist
• Referral to Plastics/ENT/OMFS preferably within 4 days of the injury