Nasal fracture

Nasal fracture is a common occurence in adults. Of all the human facial bones, the nasal bones are most frequently broken. Partly because of the relative delicacy of the nasal bones as opposed to other bony parts of the face, and partly due to the prominance of the nose, when the face receives a forceful impact it is the nose that generally absorbs the blow. The ease with which the nose is broken may help protect the integrity of the neck, eyes, and brain.

In children, trauma is less likely to actually sharply break the nasal bones. Particularly in young children and toddlers, the paired nasal bones are quite flexible . Even with a large amount of force, these immature bones tend to bend, or fracture only partially into what is called a "green stick fracture" (reminiscent of the way a young green twig will bend, and rather than snap like a woody twig of the same caliber).

At any age, a break in the nasal bone may be of little consequence. Unlike the arm or rib, where muscles insert onto the bone and will pull at each side of the break, distracting the fracture- the nasal bones are structural features that give shape to the nasal airway and face rather than function as a moving part. If the bones are not pushed out of position (displaced), then the fracture is likely to heal without causing a change in the shape of the nose. In that situation, care is needed for two or three weeks until the bones have begun to heal firmly. Until then, even rather slight trauma might push the bones out of position and mar the straightness of the nose.

When a nasal fracture is displaced, and the shape of the nose is obviously different after a break, that initial period when the bones are moveable can be taken advantage of by a specialist. The bones can often be pushed back into place in the operating room or office so that the break heals with less cosmetic deformity. That's one reason it is important to have a careful examination when a nasal fracture is supected.

Another reason that medical attention is wise when there are signs of a nasal fracture has to do with overall health rather than the nose itself. A blow to the head sufficient to cause a nasal fracture may well have caused other conditions that are more significant. In young children, for example, who sustain broken noses in car accidents and other trauma, there is a high incidence of skull fracture. Generally, whereas the nasal fracture is obvious, the skull fracture is not. In sports injuries, and other trauma, in both children and adults, the swelling and bruising that can rapidly distort the face may be assumed to all be from an obviously broken nose, but mask more severe facial fractures- like that of the zygoma (cheekbone) or orbit (eye socket). These bones, like the nasal bones, are more amenable to being brought back into place within the first days or weeks after the trauma.

Recognition

Many physicians make a diagnosis of a nasal fracture by clinical history and physical examination rather than by x-ray or other imaging study. The picture to the right shows many of the details that doctors look for and ask about. (1) Bleeding. Bleeding from the nose has a technical name: epistaxis. The lining of the nose has a very rich blood supply, and even a small tear in the mucosa can cause an alarming amount of bleeding. A bloody nose often occurs with a broken nose, but even if there is bleeding, it's not always so obvious. This rugby player has fresh blood marking his face in a trail from the front of his nose- but he also has blood staining his lips. Sometimes there is bleeding inside the nose from a broken nose, but all, or most all, of the blood exits the back of the nose, and is swallowed, rather than appears at the front of the nose. Bleeding from a broken nose can also cause blood to pool in the sinuses, where it will eventually disapate. (2) External nasal deformity. The distinct C shape of the rugby player's nose is new. In first week or so after the injury, the soft tissues and bone fragments of the displaced external nasal pyramid can be manually repositioned by an expert. Once the fractured bone has healed, the nose will assume the geometry of this underlying skeleton.

Associated conditions

When the face has been struck forcibly enough to cause a nasal fracture, a careful examination of the other bones of the face, and the skull, is often indicated.

Immediate Treatment

Examination of the inside of the nose is important, because of the possibility of a septal hematoma. X-rays of the nose are not usually indicated, but x-rays, and CT scans, of the face and head may be if either other facial fractures are suspected, or loss of consciousness has occured, and the possibility of brain hemmorhage must be ruled out. (references: Fermin S. Godinez, DO, & Susan J. Letterle, MD. Chapter 23. Maxillofacial & Neck Trauma. in C. Keith Stone, Roger L. Humphries Current Emergency Diagnosis & Treatment, 5th Edition, Copyright © 2004 by The McGraw-Hill Companies, Inc)

Ice.

Reduction of displaced fracture.

Nasal fracture in children

Since the nasal bones in young children are so resilient, when there is clinical evidence of a fracture then there was likely a significant blow to the head or face.