Fracture Nasal Bone

By

Dr. T. Balasubramanian M.S. D.L.O.

Synonyms:  Fracture nasal bone, Broken nose,  Nose fracture, Facial fracture.

Introduction:  Nose is the most prominent part of the face, hence it is likely to be the most common structure to be injured in the face.  Although fractures involving the nasal bones are very common, it is often ignored by the patient. 
Patients with fractures of nasal bone will have deformity, tenderness, hemorrhage, edema, ecchymosis, instability, and crepitation.  These features may be present in varying combinations. 

Pathophysiology:

1.  Nasal bones and underlying cartilage are susceptible for fracture because of their more prominent and central position in the face.
2.  These structures are also pretty brittle and poorly withstands force of impact.
3. The ease with which the nose is broken may help protect the integrity of the neck, eyes, and brain.  Thus it acts as a protective mechanism.  
4. Nasal fractures occur in one of two main patterns- from a lateral impact or from a head-on impact.  In lateral trauma, the nose is displaced away from the midline on the side of the injury, in head-on trauma, the nasal bones are pushed up and splayed so that the upper nose (bridge) appears broad, but the height of the nose is collapsed (saddle-nose deformity). In both cases, the septum is often fractured and displaced.
5. The nasal bone is composed of two parts: A thick superior portion and a thin inferior portion.  The intercanthal line demarcates these two portions.  Fractures commonly occur below this line.

Types of nasal bone fractures:  Fractures involving nasal bones are divided into three categories depending on the degree of damage, and its management.

Class I fractures: Very little force is sufficient to cause a fracture of nasal bone.  It has been estimated to be as little as 25-75 pounds / sq inch.  Class I fractures are mostly depressed fractures of nasal bones.  The fracture line runs parallel to the dorsum of the nose and naso maxillary suture and joins at a point where the nasal bone becomes thicker.  This point is about 2/3 of the way  along its length.  The fractured segement usually regains its position because of its attachement along its lower border to the upper lateral cartilage.  The nasal septum is not involved in this particular injury.  Class I fractures donot cause gross lateral displacement of nasal bones, though a persistent depressed fragment may give it the appearance.  In children these fractures could be of green stick variety and a significant nasal deformity may develop subsequently during puberty when nasal growth accelerates. 
     Clinically this fracture will present as a depression over the nasal bone area.  There may be tenderness and crepitus over the affected nasal bone.  Radiological evidence may or may not be present.  Infact class I fracture of nasal bone is purely a clinical diagnosis.


















Clinical photograph of a patient with class I fracture of nasal bone.


Class II fractures:  These fractures cause a significant amount of cosmetic deformity.  In this group not only the nasal bones are fractured, the underlying frontonasal process of the maxilla is also fractured.  The fracture line also involves the nasal septum.  This condition must be recognised clinically because for a successful result both the nasal bones as well as the septum will have to be reduced.  Since both the nasal bones and the fronto nasal process of maxilla would have absorbed a considerable amount of force, the ethmoidal labyrinth and the adjacent orbit should be intact.
     The precise nature of the deformity depends on the direction of the blow sustained.  A frontal impact may cause comminated fracture of nasal bones causing gross flattening and widening of the dorsum of the nose.  A lateral blow of similar magnitude is likely to produce a high deviation of the nasal skeleton.  The perpendicular plate of ethmoid is invariably involved in these fractures, and is characteristically C shaped (Jarjaway fracture of nasal septum). 


















 Diagramatic representation of class II fracture of nasal bone and nasal septum



Class III fractures:  Are the most severe nasal injuries encountered.  This is caused by high velocity trauma.  It is also known as naso orbital fracture / naso ethmoidal fracture.  Recent term to describe this class (Naso orbito ethmoid fracture) indicates the clinical importance of orbital component in these injuries.  These fractures are always associated with Le Fort fracture of the upper face involving the maxilla also.  In these fractures the nasal bone along with the buttressing fronto nasal process of maxilla fractures, telescoping into the ethmoidal labyrinth.  Two types of naso ethmoidal fractures have been recognised:

Type I:  In this group the anterior skull base, posterior wall of the frontal sinus and optic canal remain intact.  The perpendicular plate of ethmoid is rotated and the quadrilateral cartilage is rotated backwards causing a pig snout defromity of the nose.  The nose appears foreshortened with anterior facing nostrils.  The space between the eyes increase (Telecanthus), the medial canthal ligament may be disrupted from the lacrimal crest.

Type II:  Here the posterior wall of the frontal sinus is disrupted with multiple fractures involving the roof of ethmoid and orbit.  Sphenoid and parasellar regions may sometimes be involved.  Since the dura is adherent to the roof of ethmoid fractures in this region causes tear in the dura causing csf rhinorrhoea.  Pneumocranium and cerebral herniation may complicate this type of injury. 

Management:

If fractures of nasal bones are left uncorrected it could lead to loss of structural integrity and the soft tissue changes that follow may lead to both unfavorable appearance and function.  The management of nasal fractures is based solely on the clinical assessment of function and appearance; therefore, a thorough physical examination of a decongested nose is paramount.
     Patients with fractures involving nose will have intense bleeding from nose making assessment a little difficult.  Bleeding must first be controlled by nasal packing.  These patients also have considerable amount of swelling involving the dorsum of the nose, making assessment difficult.  These patients must be conservatively managed for atleast 3 weeks for the oedema to subside to enable precise assessment of bony injury.   According to Cummins Fracture reduction should be accomplished when accurate evaluation and manipulation of the mobile nasal bones can be performed; this is usually within 5-10 days in adults and 3-7 days in children. 

Radiological investigations:

1. Plain xray nasal bones
2. Xray paranasal sinuses water's view
3. CT scan paranasal sinuses - This is a must in all cases of class II and class III fractures of nasal bones for precise estimation of damage.

Most class I fractures can be managed by closed reduction and imobilisation by application of POP.  Digital pressure alone commonly does the job. 

















Photo showing digital pressure being applied to reduce nasal bone fracture



If the fractured fragments are impacted then a Welsham's forceps will have to be used to disimpact and reduce the fractured nasal bone.


















Photo showing Welsham forceps being used to disimpact the nasal bone



In the event of using Welsham's forceps to disimpact the nasal bone, there will be extensive trauma to the nasal mucosa causing epistaxis.  The nasal cavity of these patients must be packed with roller gauze, with application of an external splint to stabilise the bone.

Class II septal fractures:

Closed reduction in these cases donot give optimal results because the septal fracture is not corrected.  Since the fractured fragments of the perpendicular plate of ethmoid and the septal cartilage fragments are not repositioned the results of closed reduction are not satisfactory.  In these patients closed manipulation of nasal bones should always be accompanied by open correction of septal deformity. 

Class III fractures: Must be treated with open reduction and internal fixation.  The problem here is eventhough the nasal bones can be reduced the adjacent supporting bones (components of the ethmoidal labyrinth) donot support the nasal bones because of their brittleness.  It is always better to reconstruct and stabilise the anterior table of the frontal bone so that other parts of nasal skeleton can derive support from it.  Formerly transnasal wires were used to fix the nasal bones, but with the advent of plates and screws the whole scenario has undergone a dramatic change.

Ellis procedure of management of Class III fractures:

Aims of the procedure include:

1. Provision of adequate surgical exposure to provide an unobstructed view of all components of the fracture.

2. The medial canthal ligament should be identified.  This is rarely avulsed and is usually attached to a large fragment of bone.  Once identified the ligament should be reattached and secured to the lacrimal crest.  This step will avoid the future development of telecanthus.

3. Reduction and reconstruction of medial orbital rim.  This can be achieved by use of transnasal 26 gauge wires.  If plates are used they should be very thin otherwise they will become conspicous once the wound has healed.

4. Reconstruction of medial orbital wall and floor with bone grafts

5. Realignment of nasal septum

6. Augmentation of dorsum of the nose by the use of bone grafts

7.  Accurate soft tissue readaptation should be encouraged by placing splints.

Complications of nasal bone fracture:

1. Cosmetic deformity  (saddle nose, pig snout deformity)
2. Persistent septal deviation
3. CSF leak
4. Orbital oedema / complications
5. Nasal block / compromise of nasal functions