Fractured nose

Question 1

A 21 year old man presents with a suspected fractured nose sustained during a football game. Can you outline your management?

Answer 1

Introductory
Nasal bone fractures are common injuries, and require close reduction within 2 weeks of the injury being sustained. Important to assess for any airway compromise before proceeding with assessment. Key complications of nasal trauma such as nasal septum haematoma, mucosal trauma, and additional facial trauma/traumatic head injury should be assessed for and rule out.

Goals of management

• thorough Hx/Ex/Ix to characterise injury and screen for any significant complications or co-existing injuries
• call for senior help in instance of airway compromise,
• definitive management of any complications of nasal trauma emergently, and ultimate closed reduction of fracture within 2 weeks of the initial injury
• immediate referral to ENT/senior colleagues for any acute complications

Question 2

Fractured nose - History

Answer 2

History

• PC: When trauma, MOI, blood loss? eye pain/blurred vision etc, pain (SOCRATES)
• HPI: previous injuries, previous facial surgeries, alcohol?

Question 3

Fracture nose - Examination

Answer 3

Examination:
MSK
- C-spine assessment
- all other bony facial prominences
- Slit lamp assessment in setting of eye complaints (dislocated Lens, retinal tear/detachments)
- cranial nerves: eye movements, pupillary size and reactivity, any focal neurology

Nose:
Examination is often complicated by oedema. If no other injuries are evident on assessment, reasonable to discharge with pain meds and re-assess in 3-5 days.
- Inspection (?CSF leakage), septal haematoma, mucosal lacs, obvious bony deformity

Can utilise adrenaline + local anaesthetic preparations can be used for vasoconstriction and pain relief during internal examination.

Question 4

Fractured nose - Investigations

Answer 4

Investigations
Uncomplicated nasal bone fractures rarely require further imaging.

If suspected additional bony injury, would order CT facial bones.

Question 5

Fractured nose - Management

Answer 5

Management
Key points/supportive
- rule out key complications
- treat any open lacerations
- tetanus status adressed
- involvement of senior colleagues.
- RICE in the days post-injury

Septal haematoma

• requires immediate drainage to prevent septal necrosis.
• incision to release bleeding, then nasal packing to prevent re-accumulation of blood.

Nasal bone fracture

• close reduction should be performed within 5-10 days of the injury before re-fixation of the nasal bones occurs.
• May require referral to MaxFacs/ENT/Plastics for procedure
• mild unilateral fractures may be reduced acutely in the clinical setting