Nasal-Septal Fracture
Francis B. Quinn, M.D.
Herve’ J. LeBoeuf, M.D.
Nasal fracture is the most common facial fracture, and the third most
common fracture of the skeleton overall. However, because many fractures are
subclinical and many others are associated with multiple trauma, a high
percentage are not diagnosed or treated at the time of injury. These often lead
to chronic nasal obstruction and account for many of the septoplasty procedures
performed for obstruction and septal deviation. Most facial fractures can be
restored to their preoperative state with proper early intervention. The following
synopsis is a look at the early diagnosis and treatment of nasal fractures with the
goal being the prevention of these late complications.
Anatomy
The external nose is a triangular pyramid composed of cartilaginous and
osseous structures that support the skin, musculature, mucosa, nerves, and
vascular structures. The upper third of the nose is supported by bone, and the
lower two-thirds gains its support from a complicated interrelationship of the
upper and lower lateral cartilage’s and the nasal septum. The skin in the upper
portion of the nose is freely movable and thin; in the lower portion the skin is
thick and has prominent sebaceous glands. In the distal nose the attachment of
the skin to the underlying cartilaginous structures is more intimate. The entire
nose has an excellent blood supply, which permits extensive dissection with
safety and results in early, rapid healing. The supporting framework of the nose
is made up of semirigid cartilaginous structures that are attached to the solid and
inflexible bone structure of the nose. The cartilaginous tissues include the lateral
nasal cartilages, the alar cartilages, and the septal cartilage. There are several
sesamoid cartilages in the lateral portions of the ala and in the base of the
columella. The cartilaginous structures support the overlying subcutaneous
tissue, skin, mucosa, and lining of the nose. The cartilages are intimately
attached to the bony structures, which consist of the frontal process of the
maxilla, the nasal spine of the frontal bone, the pair of nasal bones, and the
bones of the septum, the vomer, and the perpendicular plate of the ethmoid.
The paired nasal bones articulate in the midline with each other, and are
supported laterally by the frontal processes of the maxilla and superiorly by the
“nasal spine” of the frontal bone. The lower third of the nasal bone is thin and
broad. In the proximal position the nasal bones are thicker and narrow in their
articulation with the frontal bone. The thin portion of the nasal bones is subject
to fracture, whereas the thicker portions are more difficult to injure. The nasal
bones seldom fracture in the upper portions, but fractures often occur in the
lower half. In the upper portions the bones are also firmly supported by an
intimate articulation with the frontal bone and frontal process of the maxilla. 1
Pathogenesis
Many different and often complex methods of classifying nasal-septal
fracture have been proposed. However, the most clinically pertinent
understanding of a given nasal fracture lies in each individual patients history.
When predicting the amount of damage a patient may have sustained, attention
should be given to the patient's age, the instrument they were struck with and the
force and direction of the instrument. The fracture patterns seen vary distinctly
with the application of frontal and lateral forces.
Stranc and Robertson found that lateral forces account for most nasal
fractures. They proposed a classification system based on direction and
intensity of the blow to the nose in order to estimate structures which may be
injured (Appendix I).2 They also found that younger patients tend to have
fracture-dislocation of larger segments, whereas older patients (with brittle dense
bone) tend to have comminuted fractures.
Because of the intimate associations of the bony and cartilaginous
portions of the nose with the nasal septum it is unusual to observe fractures to
either structure without damage to the other. A common mistake in reduction of
nasal fractures is to reduce the bony fracture without attention to the septum,
which leads to progressive nasal obstruction as the septum heals with fibrous
scar tissue. Septal fractures tend to activate interlocked stresses, and during the
process of healing by fibrosis they may produce septal twisting of various
configurations (C-shaped, S-shaped, or spurs). Fracture lines are commonly
vertical when located anteriorly and horizontal when located posteriorly.3 Septal
fractures also are frequently associated with a “telescoping” of the fractured
edges causing a retruded appearance of the cartilaginous portions of the nose.
Diagnosis
With any trauma to the midface, the clinician should be suspicious of the
possibility of a nasal fracture. A careful history should be taken of the nature of
the incident, whether or not there was any bleeding from the nose, and if the
patient notes any external deformity. A nasal fracture is almost certain under
these circumstances . The clinician should also inquire about prior nasal
obstruction and fracture so as not to confuse pre-existing deformities with an
acute injury.
A thorough physical exam by an experienced practitioner will reveal most
nasal-septal fractures, although patients presenting after 3-6 hours may have
significant edema which obscures the fracture. Signs of a fracture include
deformity, deviation, abnormal contour, lacerations, mucosal rents, ecchymosis,
and hematoma. Signs of more severe fractures include lid edema, scleral
chemosis, periorbital ecchymosis, subconjunctival hemorrhage and
subcutaneous emphysema.3
2
The exam should begin with topical decongestion of the nasal mucosal
after careful debridment of intramucosal blood. Palpation of the bony and
cartilaginous structures should be performed both externally and internally for
crepitance and dislocation. The tip should be pressed posteriorly and
cephalically to ascertain the degree of loss of cartilaginous support.
Sharp has found that use of routine x-rays to be financially inefficient and
unnecessary.4 Previous studies have shown that nasal films fail to reveal nearly
50% of clinically evident fractures. Furthermore, old fracture lines cannot be
differentiated from acute minimally displaced fracture lines. It is noteworthy that
some authors continue to advocate nasal films for legal documentation purposes
in the absence of an emergency room evaluation by an otolaryngologist. For
more severe trauma, such as naso-orbital fractures, nasofrontal ethmoid
fractures, or possible cribform plate fractures, axial and coronal computed
tomography scans should be obtained.
Photographic documentation of the injury should be considered an
essential part of the evaluation. Pre injury photographs should also be obtained
to understand the patients baseline anatomy. Mayell has noted that
approximately 30% of patients with a nasal fracture have pre-existing nasal
deformities. Also of note is the high incidence of patient dissatisfaction (25-50%
in some studies) with their postreduction outcome. The acute injury phase
photographs are helpful to remind the patient of the extent of their deformity prior
to surgical intervention.
Intervention
There are three major considerations in the plan for reduction of a nasal
fracture. The first is whether to perform open reduction or closed reduction.
Some authors advocate the attempted closed reduction of all but the most
severely comminuted nasal fracture if seen within the first two to three weeks
post-injury. Even if the patient will need subsequent rhinoplasty, closed
reduction assists in both minimizing the extent of rhinoplasty needed, and in the
patient's comfort while awaiting rhinoplasty. Bailey lists his recommendation for
open and closed reduction in his text. He states the indications for closed
reduction as: 1) unilateral or bilateral fracture of the nasal bone; 2) fracture of the
nasal-septal complex with nasal deviation less than one half the width of the
nasal bridge. The indications for open reduction are stated as: 1) Extensive
fracture-dislocation of the nasal bones and septum; 2) nasal pyramid deviation
exceeding one half the width of the nasal bridge; 3) fracture dislocation of the
caudal septum; 4) open septal fractures; 5) persistent deformity after closed
reduction.3 One could also add nasal-septal fractures seen three weeks or more
post-injury to this list.
The second consideration is the issue of the use of local or general
anesthetic. There are a number of articles from England (where OR time is
precious) comparing the two techniques.5,6 Various endpoints of reduction were
compared, including cosmesis and residual nasal obstruction. The consensus is
that both the patient and the physician perceived outcome is statistically
insignificant between the two methods. Also of note is that >90% of the patients
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compared the pain under anesthesia as being equivalent to having dental work
done. In this era of cost-containment this is significant, and perhaps more
reductions should be performed under local anesthesia.
The third major consideration is that of the timing of reduction. If the
patient presents in the first 3 to 6 hours (prior to significant distorting edema) ,
the closed reduction should be performed immediately. After this, most authors
advocate delaying the procedure 3-7 days to allow for recession of the edema so
that proper realignment may be attained. Most patients do not heal significantly
before three weeks and therefore closed reduction may be attempted any time in
the first 2-3 weeks. After 3 weeks the fracture has healed such that it cannot be
reduced easily and open reduction must be performed. Because of the maturing
scar tissue and fibrosing cartilage, rhinoplasty must be delayed 3-6 months to
obtain optimal results.
Closed Reduction
The nose is anesthetized using 4% cocaine as an intranasal solution
(maximum adult dose 8ml) with 1:100,000 epinephrine soaked pledgets. This
shrinks the nasal mucosa sufficiently to allow adequate intranasal examination.
This is supplemented with external nasal field blocks using 2% lidocaine with
1:100,000 epinephrine along the nasal dorsum, lateral to the nasal pyramid, and
at the base of the anterior septum. The patient may also be given oral or
intravenous sedation to enhance the anesthesia. Although the anesthesia is
effective almost immediately, fifteen minutes should be given to maximize the
vasoconstrictive property of the medication. The use of EMLA cream has been
proposed, but this increases the patient's preoperative preparation time by an
hour, and may not be as effective as the previously mentioned regimen.
Few instruments need be at hand for fracture reduction. These include
Asch and Walsham forceps, a large Kelly clamp with protective rubber tubing
over the blades, Boies or Ballenger elevators, intranasal specula and a head
light. Almost all nasal fractures can be reduced by upward and outward forces
with an instrument placed in the nose under the nasal bone. The instrument is
inserted intranasally to a point 1cm caudal to the nasofrontal angle. The
depressed fragment is elevated by exerting force in the direction opposite to the
fracturing force, usually anterolaterally. If the opposite nasal bone is displaced
laterally, that bone is moved medially to its normal position. The Asch or
Walsham forceps may be used by inserting one blade in each nostril or by
placing one blade in the nose under the nasal bone and the other on the
overlying skin. Pressure should not be exerted too high in the nose (under the
thick nasal bone near the nasofrontal suture) as this area is rarely fractured and
mucosal tears and bleeding can be produced. Reduction can usually be
accomplished with the fragments remaining in position, but digital molding may
be necessary in some patients. Inadequate reduction of the nasal septum
prevents satisfactory repositioning of the external nose in the case of bilateral
pyramid fracture-dislocation. Reducing the nasal bone fragments first often
reduces the septum simultaneously; if not, the Asch or Walsham forceps usually
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permit gentle elevation of the nasal pyramid while pressure is applied over the
displaced septal region.3
If a septal fracture-dislocation does not reduce easily, the perichondrium
may be elevated unilaterally to expose an overriding cartilage fracture that
requires sequential resection. If the nasal bones are comminuted or loose, they
may be supported with an intranasal antibiotic soaked gauze packing. The
septum may by stabilized with silastic splints but the routine use of nasal packing
for stable fractures is debatable. A small catheter may be placed along the floor
of the nasal vault prior to packing to enhance patient comfort permitting
equalization of pressure in the nasopharynx during swallowing, and preventing
discomfort of negative pressure in the middle ear. An external splint of placed,
consisting of steristrips and mastisol, followed by a heat activated thermal
polymer to conform to the patient's nose and an other layer of steristrip. The
packing may be removed in 2-3 days, and the splints in 10 days. Fracture
stability is checked at the 10 day postoperative visit and if there is instability the
external splint should be replaced for another week, otherwise it may be
discarded.
Because incomplete greenstick fractures of the septum and nasal bones
can account for later deviations, Manson recommends that fracture lines be
completed prior to reduction. Some authors perform submucous resection on
C-shaped septal fractures, but this may cause a loss of nasal height. Dorsal
nasal humps can result from this slight loss of dorsal height. A safer method is
to attempt closed reduction and warn the patient of possible need for future
rhinoplasty.1 If the fracture cannot be reduced by closed reduction, the operation
should be immediately converted to an open reduction. For this reason many
authors advocate the use of the operating room for all closed reductions.
Open Reduction
The nose is anesthetized and prepared in the same manner as for closed
reduction. The operative procedure chosen is dictated by the patient's type of
fracture-dislocation. Most cases needing open reduction are due to an
interlocked segment of cartilage and/or bone. The septum is approached though
a hemitransfixion incision on the side of dislocation (complete transfixion
incisions predispose to lower tip height and introduce additional structural
instability). Further access to the fracture line is gained through lateral
intercartilaginous incisions. The dorsal skin is elevated off the upper lateral
cartilage’s and the periosteum is elevated from the nasal bones. Piriform
aperture incisions provide access to the lateral fracture lines. Common findings
are dislocation of the quadrangular cartilage off the maxillary crest, or a Cshaped fracture of septal cartilage and bone, as described by Murray and
associates.3
The cartilaginous segments are exposed and reduced. Sometimes a
segment of cartilage must be resected adjacent to the fracture. A Cottle elevator
is used to excise small strips of cartilage, allowing the septum to swing like a
"trapdoor" back into its normal position. A small chromic stay suture may be
placed through the periosteum near the anterior nasal spine and the inferior
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portion of the cartilaginous septum to maintain its reduction. Often a displaced
maxillary crest must be removed entirely. Radical resection of cartilage or bone
is avoided to preserve support and limit fibrosis and contracture. After septal
surgery of this type, satisfactory reduction can almost always be accomplished.3
Depressed comminuted fractures should be exposed by judicious
periosteal elevation. Overaggressive elevation of the periosteum may cause
devitalization of the bone with subsequent necrosis and/or malunion. The
fragments may be elevated into position and maintained with fine wires (28
gauze) and a minidrill. There has been some use of miniplates with these
fractures, but extrusion of the plate, wound breakdown, and unsightly
appearance of the dorsal nasal skin over the plates have limited their utility thus
far. The wound is closed in 3 layers- periosteum, subcutaneous tissue, and skin.
Packing is rarely necessary to support the fixation. Properly placed wires should
not be palpable through the skin, as the ends of the wire may be twisted through
a hole or between fragments. Prophylactic antibiotics are administered for five
days.1 Mathog also describes an older method of external lead plate fixation of
these types of fractures.
Septoplasty and rhinoplasty techniques for delayed repair is a broad topic
covered in previous grand rounds.
Nasal Fracture in Children
It is thought that many septal deformities in adults are due to minor
trauma as a child or neonate that went unrecognized. As the slight deviation
matures, progressive nasal obstruction and deformity occurs. A child’s nose
differs from that of an adult in several ways. Specifically, the underdeveloped
nose has less frontal projection, is largely composed of cartilage, and possesses
several growth centers. As a result, pediatric nasal trauma often presents a
unique diagnostic and therapeutic dilemma. The immature nose is more likely to
be associated with other fractures of the face because the nasal projection is
much less prominent. A blow to the face is, in general, distributed to the
adjacent maxilla. Since the child’s nose is more cartilaginous than its adult
counterpart, it is easily compressible and absorbs little of the energy from the
striking force as it passes across the face. The resultant edema spreads over
the face and tends to disguise the extent of the nasal involvement in the pediatric
age group.
Palpation at the onset of the injury should be attempted; however, the
pediatric patient is usually apprehensive, especially shortly after trauma. As a
result, the immature patient is likely to be uncooperative and an exacting
examination may not be possible. In addition, the large amount of attendant
edema with facial trauma, and the lack of rigidity of the nasal skeleton tend to
produce a less than optimal situation for evaluation, even in the cooperative
patient. An external and intranasal examination should always be performed.
The cartilaginous structures of the nose tend to buckle and twist with the trauma
rather than to fracture.
Operative intervention is indicated for a displaced nasal fracture that
results in either a cosmetic deformity or noticeable airway obstruction.
6
Management of nasal fractures in children differs from that in adults in that
general anesthesia is usually required. The prevailing method of managing
pediatric nasal fractures is closed reduction. The nose with splayed nasal bones
and no impactions can be reduced with bilateral digital compression on the
dorsum for ten to 15 minutes. Often, nasal deviation to one side can also be
reduced by digital compression on the side of the deviation. A difficulty with
closed reduction in children is that clear cut end point is difficult to appreciate.
The cartilaginous elements do not move into place as readily, and when they are
mobilized, they do into ”snap” into place as do adult dislocations. The bony
elements frequently are involved in a greenstick fracture and may be resistant to
maintenance of the desired postion.
Although many nasal surgeons have advocated immediate repair of all
septal deviations secondary to birth trauma, correction is necessary only in the
case of nasal airway obstruction, as newborns are obligate nasal breathers. 7,8
In one study, nasal fracture was noted to be associated with nasofacial
disproportion, especially a long nose, in 21% of the patients who were followed
long-term. A long nose deformity was observed to develop during puberty,
normally a time of rapid growth for the nose. These findings correlate closely
with the observations of Grymer and colleagues,9 who described three periods of
nasal development: age 1 to 6 years (rapid growth), 6 to11 years (slow growth),
and 12 to 16 years (rapid growth). They recommended that nasal surgery be
performed between the ages of 6 to 11 years when practical.3
Early Complications
Septal hematoma may develop either as a result of the injury or of the
repair and is often bilateral. The fracture allows blood to pass into both
mucoperichondrial planes, undrained. This may lead to fibrosis or to
organization as a thick obstructive section of septal cartilage. If the hematoma is
under excessive pressure, necrosis and perforation are likely results. Loss of
septal support will cause collapse of the cartilaginous dorsum with a resultant
saddle-nose deformity. If a hematoma is suspect, palpation for fluctuance may
be done with cotton-tipped swabs followed by needle aspiration. Treatment is by
horizontal incision at the base of the septum so as to produce dependent
drainage. Bilateral hematomas are treated with a unilateral offset incisions with
preservation of the septum. Silastic splints, light packing, or mattress sutures for
2-3 days will prevent reaccummulation.
Edema, ecchymosis, and epistaxis usually resolve spontaneously.
Persistent epistaxis should be dealt with in the usual fashion. Infection is a rare
complication, but antibiotic prophylactics should be used in immunocompromised
patients and those who have hematoma. CSF rhinorrhea is associated with
more severe trauma and indicates fracture of the posterior frontal sinus table or
the cribriform plate. Diagnosis is easily made by glucose measurements of the
rhinorrhea and serum. Neurosurgery should be consulted and the patient
observed closely for 6 weeks. Occasionally a lumbar drain or bone grafting may
be necessary. Emphysema of the face and neck may also occur and usually
resolves spontaneously with avoidance of increases in upper airway pressure.
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Late Complications
Untreated hematomas of the nasal septum may become organized,
resulting in subperichondrial fibrosis and thickening with partial nasal airway
obstruction. The septum may be as thick as 1cm, and in cases of repeated
trauma the cartilaginous septum may be largely replaced with calcified or
chondrified material. Submucous resection of the thickened portion of the nasal
septum may be required, and in some patients a partial turmbinectomy may be
advisable.
Synechiae may form between the septum and the turbinate in areas
where soft tissue lacerations occur and the tissues are in contact. If
bothersome, these may be treated by division followed by the placement of
nonadherent, petrolatum-impregnated material between the cut surfaces for a
period of five days. During this time, epithelization occurs.
Obstruction of the nasal vestibule may occur as a result of malunited
fractures of the piriform margin or scar tissue contracture from loss of vestibular
lining. Osteotomy of the bone fragments corrects the former; however, the
contracture due to loss of soft tissue or scar contraction may require excision of
scar, and replacement with skin or composite grafts within the nasal vestibule.
Residual osteitis is seen occasionally in compound fractures of the nose
or in fractures associated with infected hematomas. Rarely a portion of the bony
nasal framework may be lost as a result of infection and may require late
replacement with bone grafts. In these cases, appropriate debridement and
antibiotics constitute the preferred regimen of treatment.
Slight malunion of nasal fractures is common after closed reduction, since
the exact anatomic position of the fragments can be difficult to detect by
palpation alone, especially in the presence of edema. Residual deviation also
occurs owing to release of “interlocked stresses” following fracture of the
cartilage. If troublesome, the resulting external deformities may require
reconstructive rhinoplasty.1
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