March 7, 2021
nasal injuries in athletes cover

Nasal Fractures

For physicians covering hockey and wrestling, evaluation of facial injuries are commonplace. Facial fractures are common injuries and account for 400,000 annual visits to the ER annually in the US (5). Due to severe side effects of a septal hematoma, having a strong working knowledge of these injuries is a must.

Case Introduction

You are covering a wrestling tournament and one of the athletes is brought to the tent after being elbowed in the nose by an opposing player. Which of the following complications of a nasal fracture can lead to septal necrosis?

A) Septal hematoma
B) Superficial laceration
C) Comminuted nasal bone fracture
D) Nasal deviation

Anatomy

In order to make the diagnosis of a nasal fracture, it is important to be aware of the anatomy that make up the nasal complex. The bony anatomy involves bones from the maxilla, ethmoid bone, frontal bone, vomer, and nasal bones (2). The nasal bones are paired bones that join each other at the midline (6). Fractures will most commonly occur at the distal end of the nasal bones (2). As seen in Figure 1, the nasal bone becomes thinner below the intercanthal line, which makes fractures below this line more common (4). The nasal cartilage consists of the upper and lower lateral cartilages and the midline septum (2). It is less common to fracture the nasal cartilage than the nasal bone and septum (2).

nasal anatomy illustration
nasal anatomy illustration

Figure 1 and 2: Illustration of nasal bone anatomy (4)

Physical Exam

Symptoms suggestive of a nasal bone fracture are epistaxis, swelling, and bruising (1). The physical exam starts with examination of the external structures (2). Providers should evaluate for nasal malposition, lacerations, and periorbital swelling (2). The physical exam also involves palpation for crepitus, tenderness, and depression of the nasal bones (2). The nasal tip should be evaluated first to assess for loss of septal support (3). A nasal speculum exam is required to assess the septum and intranasal structures (3). The use of a nasal vasoconstrictor can be used to help stop bleeding (6). Typically, damage occurs to both the nasal bones and cartilaginous structures with trauma (9).

Nasal fractures can be diagnosed with standard radiographs with a sensitivity of 88% and specificity of 95% (1). One of the challenges of radiographs is that old fractures of the nasal bones do not heal by ossification so it can be difficult to determine if a fracture is new or old (4). CT scans can also be done at the cost of increased radiation to the patient (1). There are multiple classification methods for nasal fractures, but none are considered the gold standard (8).

nasal bone fracture

Image 1: Radiograph demonstrating nasal bone fracture (courtesy of radiopaedia.org)

Treatment

Treatment of nasal fractures first begins with assessing the airway, cervical spine, breathing, and circulation of the patient (4). Once life threatening emergencies have been ruled out, the provider can continue with treatment.  A common complication of a nasal fracture is a septal hematoma. This is why a nasal speculum is necessary when evaluating for nasal fracture. These need to be drained promptly in order to prevent a septal abscess or cartilage necrosis (3, 11).

A nasal fracture that is well aligned and does not affect the nasal airway can be managed with observation alone (3).  The patient should be advised to keep their head and nose elevated to decrease swelling (5). For those covering games in which an athlete develops epistaxis that will not stop, treatment will require nasal packing (7).

A displaced or comminuted nasal fracture with mild septal deviation can be treated with closed reduction (3).  Some physicians choose to wait a couple of days after injury once swelling has improved prior to performing any reduction (9). The rule of thumb is to reduce a nasal fracture within 14 days in adults (10). Those fractures that require surgery should be repaired within the first week from the injury (6).

Conclusion

Nasal fractures are commonly seen in contact sports, so sports medicine physicians must be aware of the signs and symptoms of a nasal fracture and appropriate treatment options. A nasal speculum exam must be done to avoid missing a septal hematoma. Ultimately, some nasal fractures will require the care of a plastic surgeon or ENT physician.

Case Conclusion

Answer: A. The correct answer is a septal hematoma. A patient with a nasal fracture requires a nasal speculum exam to rule out a septal hematoma. An untreated septal hematoma can lead to septal abscess and cartilage necrosis. The other complications can occur as a result of the nasal fracture but are unlikely to cause septal necrosis.

Hoffmann, John F. “An Algorithm for the Initial Management of Nasal Trauma.” Facial Plastic Surgery: FPS, vol. 31, no. 3, June 2015, pp. 183–93. PubMed, doi:10.1055/s-0035-1555618.

Author

Gregory Rubin, DO @ Rubinsportsmed.com

References

1)      Pérez-Guisado, Joaquín. “Clinical Evaluation of the Nose: A Cheap and Effective Tool for the Nasal Fracture Diagnosis.” Eplasty, vol. 12, Jan. 2012. PubMed Central, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3266122/.

2)      Kelley, Brian P., et al. “Evaluation and Reduction of Nasal Trauma.” Seminars in Plastic Surgery, vol. 24, no. 4, Nov. 2010, pp. 339–47. PubMed, doi:10.1055/s-0030-1269763.

3)      Hoffmann, John F. “An Algorithm for the Initial Management of Nasal Trauma.” Facial Plastic Surgery: FPS, vol. 31, no. 3, June 2015, pp. 183–93. PubMed, doi:10.1055/s-0035-1555618.

4)      Chegar, Burke. “Nasal Fracture.” CUMMINGS OTOLARYNGOLOGY–HEAD AND NECK SURGERY, SEVENTH EDITION, Elsevier.

5)      Chukwulebe, Steve, and Christopher Hogrefe. “The Diagnosis and Management of Facial Bone Fractures.” Emergency Medicine Clinics of North America, vol. 37, no. 1, Feb. 2019, pp. 137–51. DOI.org (Crossref), doi:10.1016/j.emc.2018.09.012.

6)      Aronovich, Sharon. “Nasal Fractures: Evaluation and Management .” ORAL AND MAXILLOFACIAL TRAUMA, Elsevier Saunders.

7)      Christophel, John. “Facial, Eye, Nasal, and Dental Injuries.” DeLee, Drez, & Miller’s Orthopaedic Sports Medicine, Fifth Edition, Elsevier.

8)      Fattahi, Tirbod, and Salam Salman. “Management of Nasal Fractures.” Atlas of the Oral and Maxillofacial Surgery Clinics of North America, vol. 27, no. 2, Sept. 2019, pp. 93–98. PubMed, doi:10.1016/j.cxom.2019.04.002.

9)      Ziccardi, Vincent B., and Hani Braidy. “Management of Nasal Fractures.” Oral and Maxillofacial Surgery Clinics of North America, vol. 21, no. 2, May 2009, pp. 203–08, vi. PubMed, doi:10.1016/j.coms.2008.12.011.

10)   Chan, James, and Sam P. Most. “Diagnosis and Management of Nasal Fractures.” Operative Techniques in Otolaryngology-Head and Neck Surgery, vol. 19, no. 4, Dec. 2008, pp. 263–66. www.optecoto.com, doi:10.1016/j.otot.2008.07.003.

11)   Scott, Neil, et al. “Elite and Professional Sports Facial Injuries Management – a Consensus Report.” The British Journal of Oral & Maxillofacial Surgery, vol. 58, no. 10, Dec. 2020, pp. e254–59. PubMed, doi:10.1016/j.bjoms.2020.08.046.

Leave a Reply

Your email address will not be published. Required fields are marked *