3.10 Nasal Fracture
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agk's Library of Common Simple Emergencies

Presentation
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After a direct blow to the nose the patient 
usually arives at the emergency department with 
minimal continued hemorrhage. There is usually 
tender ecchymotic swelling over the nasal bones 
or the anterior maxillary spine; inspection and 
palpation may (or may not) disclose a nasal 
deformity.

What to do:
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- Examine for any associated injuries (i.e., 
   blowout fractures, zygoma fractures).
- With minor injuries, explain that x-rays are 
   not routinely used or useful, because all 
   therapeutic decisions are made on the basis 
   of the physical examination. If there is a 
   fracture, but it is stable and in good 
   position clinically, it need not be reset. 
   Conversely, a broken and displaced cartilage 
   may obstruct breathing and require 
   operation, but never show up on the film. 
   Send the patient for x-rays of the nasal 
   bones only if there is a good reason.
- If bleeding continues, instill cotton 
   pledgets soaked in 4% cocaine or 2% 
   tetracaine (Pontocaine) mixed 1:1 with 1% 
   Neo-Synephrine or epinephrine 1:1000 into 
   both nasal cavities.

- After removing the cotton pledgets, inspect 
   the nasal mucosa for large lacerations or a 
   septal hematoma.
- Patients with nondisplaced fractures without 
   deformity should be sent home with 
   analgesics, cold packs, and instructions to 
   avoid contact sports and related activities 
   for six weeks.
- Patients with displaced fractures and/or 
   nasal deformity should have otolaryngologic 
   or plastic surgery consultation for 
   immediate or delayed reduction. Patients can 
   be instructed that reduction is more 
   accurate after the swelling subsides and 
   there is no greater difficulty if it is done 
   within six days of the injury.
- Septal hematomas should be drained to prevent 
   septal necrosis and the development of a 
   saddle nose deformity. Otolaryngologic 
   consultation is advisable.
- An isolated fracture of the anterior nasal 
   spine (in the columella of the nose), does 
   not necessitate restricting activities. It 
   only hurts when you smile.

What not to do:
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- Do not automatically x-ray every injured 
   nose. Patients may expect this, because it 
   is the old practice, but routine films have 
   turned out not to help.
- Do not assume a negative x-ray means no 
   fracture when a deformity is apparent. X-
   rays can often be inaccurate in determining 
   the presence and nature of a nasal fracture. 
   Rely on your clinical assessment. When there 
   is swelling, arrange for re-examination in 
   3-4 days when the swelling subsides, to look 
   for subtle deformities.
- Do not pack an injured nose that does not 
   continue to bleed. Packing is generally 
   unnecessary and will only add to the 
   patient's discomfort.

Discussion
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The two most common indications for reducing a 
nasal fracture are an unacceptable appearance 
and inability of the patient to breathe through 
the nose. Regardless of x-ray findings, if 
neither breathing nor cosmesis is a concern, it 
is not necessary to reduce the fracture. Nasal 
fractures are uncommon in young children, 
because their noses are mostly pliable 
cartilage. Suspect septal hematoma when a 
patient's nasal airway is completely occluded. 
Within 48 to 72 hours a hematoma can compromise 
the blood supply to the cartilage and cause 
irreversable damage.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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