External nasal fractures: classification, symptoms, diagnosis, and treatment

Nasal bone fracture is a violation of the structural integrity of the nasal osteocartilaginous framework due to mechanical impact.

Etiology

This condition is the most common among all types of injuries, especially among injuries to the facial area. The causes of fractures are home and traffic accidents, falls in the street, and sports injuries.

Classification of nasal fractures

Nasal bone fractures do not have a universally approved classification. We have attempted to compile the most common ones used in clinical practice.

This type of injury affects the nasal bones, the frontal processes of maxilla, and the nasal septum.

Nasal bone fracture

• Displaced closed nasal bone fracture;
• Non-displaced closed nasal bone fracture;
• Displaced open nasal bone fracture;
• Non-displaced open nasal bone fracture;
• Nasal septal injury.

Nasal bone fracture (Johnson, 2013)

• Type 1: simple fracture without displacement;
• Type 2: simple fracture with distortion;
• Type 3: comminuted nasal fracture;
• Type 4: fractures with significant displacement and deformation of the nose;
• Type 5: combined fractures.

Anatomy

Mechanism of nasal fractures

The extent and nature of the damage depend on the strength and direction of the damaging factor, as described below.

• With a weak force applied, a fracture line or crack appears, and no displacement of bone fragments is observed.
• As well, there is typically no displacement of bone fragments when the lateral nasal wall of the nose is hit. This damages the quadrangular cartilage of the nasal septum, causing a horizontal fracture or dislocation. However, if a significant force was applied, the cartilaginous part of the nose wings may fall behind the frontal processes of the maxilla, forming a saddle-shaped deformation. It is associated with a fracture of the nasal septum in the projection of the perpendicular plate of the ethmoid bone.
• When force is applied from the lateral side, a shift in the opposite direction occurs, usually to the right. In addition to breaking both nasal bones, this may also harm the perpendicular plate and the frontal process of the maxilla on the side opposite the impact.

• In case of lateral impacts localized closer to the nasal tip, a dislocation of the quadrangular cartilage of the nasal septum and marginal fractures of the nasal bones without their displacement occur.

Open and closed nasal fractures

The division of fractures into open and closed still remains ambiguous.

Some authors believe that open fractures can be considered those in the event of a violation of the skin integrity, but without communication between the bone part and the skin wound via a wound channel.

Other authors, on the contrary, agree that fractures should be considered open if the bone is in contact with the external environment.

The nasal mucosa may remain intact, or it may be also injured. In this case, ruptures occur, associated with moderate bleeding; as well, subcutaneous emphysema may develop.

When using the Johnson’s classification of nasal bone fractures, which is quite common in European countries, the following features should be noted:

• Type 1 fracture is characterized by a violation of the integrity of any bone of the nasal pyramid without displacement, which does not lead to deformation of the external nose.
• Type 2 is characterized by a unilateral or bilateral fracture of the nasal pyramid bones with their displacement and nasal deformity as a result.
• Type 3 is characterized by bilateral fragmentation of the nasal bones, while the nasal septum may remain intact or damage to varying extent.
• Type 4 is characterized by a massive injury; in addition to the nasal bones and frontal processes of the maxilla, the nasal septum is damaged. The external nose is also deformed.
• Type 5 is characterized by a combined injury in which the integrity of soft tissues is compromised. There may be a nasal pyramid impaction with resulting saddle-shaped deformity, a fracture of the base of the skull or orbit.

Clinical presentation

The following symptoms are typical for the external nose fractures:

• facial and nasal pain, particularly at the time of injury;
• difficulty nasal breathing, bleeding, impaired sense of smell;
• severe swelling of the nasal and adjacent soft tissues; hematomas (including periorbital);
• complaints of aesthetic dissatisfaction with the external nose shape (due to displacement of bone fragments);
• wound accompanied by bleeding (in case of open fractures).

Nasal fracture diagnosis

1. History taking

A thorough medical history is collected, and the circumstances of the injury are clarified.

2. Physical examination and rhinoscopy

Typical findings on rhinoscopy in the nasal cavity:

• blood clots;
• continuous bleeding (less commonly);
• severe swelling of mucosa;
• mucosal tears;
• dislocation of the quadrangular cartilage;
• nasal septum deviation.

Fracture-specific signs:

• In case of a septal hematoma: a pillow-shaped mucosa protrusion of a crimson color is found.
• Open fractures are characterized by the presence of a wound on the skin and external bleeding.

Palpation and external examination:

Palpation reveals severe tenderness, bony crepitus and pathological mobility.

If possible, the shape of the external nose, the presence of hematoma, and subcutaneous emphysema should be assessed. However, due to the severe swelling of the soft tissues, it is often not possible to objectively assess whether there is a nasal deformity.

3. Instrumental diagnosis

All patients with suspected nasal bone fractures should be referred to lateral nasal bone radiography.

If X-ray shows controversial result, or to determine the location and nature of the injury more precisely, a CT scan of the facial skull is performed.

Treatment for nasal fractures

For non-displaced closed fractures

Conservative therapy is used, aiming to maintain breathing function.

Local vasoconstrictors, regular nasal irrigation with saline solutions, and systemic analgesics are prescribed.

It is recommended to limit physical exertion and avoid mechanical impact on the external nose.

For open fractures

Initial surgical debridement for the wound is provided. Tetanus preventive vaccination is mandatory.

For displaced nasal bone fractures

Surgical treatment is performed, aiming to reposition and fix bone fragments, restore breathing function, and eliminate acquired deformities of the external nose.

There are three options of surgical treatment: early (up to 7–10 days), delayed (10–14 days), and elective.

Repositioning of the nasal bones can be performed using external (manually by fingers) or endonasal (using elevators) methods.

Then, a tight nasal packing is performed with gauze turundas, and, if necessary, external fixation with a plaster cast.

Elective surgery

No earlier than 6 months after the injury, septo- or rhinoseptoplasty is performed to restore the shape of the external nose and the breathing function.