Nasal Fractures:
This injury is common in contact sports and fights. If the blow is from the front the nasal bones may be depressed. The blow often comes from the side(usually the right) so that the nasal bones are deviated to one side. If a nose has been broken a motor vehicle accident, one should look for other facial fractures. The diagnosis of nasal fractures is largely clinical. Simple fractures are easily reduced using local anaesthesia. If, however, a fracture is present in the cartilaginous septum(middle of nose), the nose tends to redeviate following simple manipulation.
Symptoms of nasal injury
The patient presents complaining of pain, nasal deformity, difficulty breathing through the nose as well as bleeding from the nose
Examination
The nose is defined by the shadows that it causes. Alteration in shadowing on either side of the nose leads to a perception of deviation. Two imaginary curved lines running from the superciliary ridges (eyebrows) running through the radix to the tip defining points of the alar cartilages(tip of nose) are useful in evaluating the nose. This line is illustrated in the associated picture. When these smooth lines are disrupted the observer's eye may notice a deformity. The best time to assess nasal injury is immediately after the injury, before temporary swelling masks a minor deviation. If this is not possible review 7 - 14 days after the injury when the swelling has diminished is also appropriate. If there is any doubt about a fracture being present, pain on palpation of the use is useful. If the nasal bones are non tender 14 days after the injury it is highly unlikely that there is a significant nasal bone injury.
Subtle deformities such as depression of a nasal bone or an upper lateral cartilage(underlying nasal support) is more easily recognisable if one covers one side of the nose and then compares it to the other. This is illustrated in the associated pictures.
Radiology or X-rays:
The value of simple nasal X-rays in the diagnosis of nasal fractures is extremely limited. They continue to be routinely done by many accident and emergency clinics and patients often feel that their treatment is not adequate unless they have had an X-ray. In reality they are are a poor diagnostic aid. Previous fractures may be seen, vascular markings are easily confused with a fracture and they fail to document any cartilaginous injury. Effectively they are a waste of time unless one is also looking for other facial bone injuries.
Grade
II Fractures(on right)
With
greater force, lateral displacement of the nasal bones occurs. The
fracture lines run parallel to the dorsum. The ipsilateral nasal
bone to the force fractures to and immediately above the nasal maxillary
suture running up to the thick part of the nasal bone. The contralateral
nasal bone fractures parallel to and immediately below the dorsum.
A fracture line connects the two decribe fractures across the midline
where the bone changes from thick to thin. A fracture occurs in
the perpendicular plate of the ethmoid bone.
Grade III Fractures (above)
Lateral displacement of the bones occurs. The fracture lines run parallel to the dorsm. The ipsilateral nasal bone to the force fractures to and immediately above the nasal maxillary suture running up to the thick part of the nasal bone. The contralateral nasal bone fractures to but some distance below the dorsum. A fracture line connects the fractures across the midline where the bone changes from thick to thin. This is demonstrated in the picture on the left. A reverse C shaped fracture involving the perpendicualr plate, the vomer and the cartilaginous septum occurs.
Grade III Fractures and Treatment
The nasal septum influences the position of the dorsum. This fracture is common on the fracture prone individual involved in contact sports. Simple manipulation of this type of fracture obtains an adequate result in 60% of cases. The middle picture illustrates the result of simple manipulation. To obtain an optimal result correction and and reconstruction of the fractured septum is obligatory.This has been done in the picture on the right side.
Cartilaginous Trauma
Trauma does not necessarily involve the bony part of the nose - isolated septal fractures and disruption of the attachemnt of the upper lateral cartilage to the nasal bones may also occur. Often these injuries are missed in the acute situation and only recognised when a patient presents later complaining of nasal obstruction.
Treatment of Nasal Fractures
Objective morphology and function do not always correlate with patient satisfaction. The wish of the patient should be the first consideration. A model wishes perfection whereas a rugby player is less critical. If there is a high risk of further injury and treatment is requested, simple manipulation is the most cost effective option. Open reduction of an associated fracture septum improves the final result but may weaken the septum should further injury occur.
These risks need to be discussed with the patient. In adults, a nasal fracture may be manipulated into position at any time up to three weeks after the accident. Nasal fractures in children need manipulation as early as 4 days because they heal quickly.
Results of Simple Manipulation
Type I fractures are rare; the bone fragment tends to drift back with time. Type II and Type III fractures are common. Type II fractures tend to do well with simple manipulation. If there is a septal injury as in Type III fractures there is an 80% chance of the reduction being successful.
How to manipulate nasal fractures under local anaesthetic
I have reduced over 800 fractured noses under local anaesthetic. I suspect that this is one of the largest experiences in Auckland. I have reduced nasal fractures in a 10 year old and up to 4 weeks after the original injury.
Firstly it is important to define the original injury. Most nasal fractures are Type II and Type III fractures. Local anaesthetic is injected into the presumed nasal bone fracture sites directly through the skin. I initially do this by a single injection into the top of the nose where the skin is more pliable. This is the most uncomfortable part. It is usually very well tolerated and I have developed a number of techniques over the last decade which help me to distract the patient. Further injections are then placed where the local anaesthetic is placed previously. I then apply a force in an opposite direction of the original force.
There is no further bruising and the patients is able to drive home afterwards.
Nasal casts
Although many people still use a cast on the nose for a week after simple manipulation there is no evidence that they work! It takes 6-8 weeks for the bones to heal and they can still be displaced over this time. If you break an arm or a leg a cast is put on for longer than a week!