Nasal Fracture ?>

Nasal Fracture

Nasal Fracture

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

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 eMedicine’s Breaks, Fractures, and Dislocations Center, Sports Injury Center, and Back, Neck, and Head Injury Center. Also, see eMedicine’s patient education articles, Facial Fracture and Broken Nose.

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Initial Evaluation and Management of Maxillofacial Injuries
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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.

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

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%).
Functional Anatomy

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.

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Sport-Specific Biomechanics

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).

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Any history of a fall or force directed toward the mid face should alert the clinician of a possible nasal fracture.
The clinician should obtain details of the injury, including the mechanism and location of injury as well as the direction of force. These details allow estimation of its severity.4, 5, 6, 7

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Initial Evaluation of the Trauma Patient
In cases of nasal fracture, there is evidence of trauma to the mid face. Often, deformity of the nose provides the greatest clue. Other signs include swelling, skin laceration, ecchymosis, epistaxis (bleeding from within the nose), and cerebrospinal fluid (CSF) rhinorrhea. Epistaxis implies mucosal disruption; this should increase the clinician’s suspicion for a nasal fracture, including possible nasal septum fracture.
Internal examination
Acute edema may hide deformities; however, a careful search for intranasal injury must take place.
Adequate lighting must be available, and the patient should be placed in a comfortable, slightly reclined position. Bleeding can be controlled with topical cotton pledgets soaked in vasoconstrictors, such as 0.25% phenylephrine (Neo-Synephrine [Bayer HealthCare, Morristown, NJ] is also available as a spray) or 4% cocaine, which also provides anesthesia. Retained blood clots should be removed with suctioning or swabbing.
The clinician should search for any deformity or septal hematoma; however, septal deviation does not automatically determine fracture. An estimated 33-50% of the population normally has a septal defect.
Manipulation: A cotton-tipped swab should be placed in each naris up to the septum to check for deformity and mobility.

See History, above.

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