Jubilee Hospital. Trivandrum.
Fractures of the Nasal bone fractures are among the most common facial bone fractures- comprise up to 50% of all facial fractures.
Most nasal fractures are diagnosed by history and physical examination. History usually includes a preexisting trauma, which may be followed by epistaxis. Typically, the epistaxis has resolved by the time the patient presents for intervention.
Physical examination findings include swelling over the nasal bridge, grossly apparent deviation of the nasal bones, and periorbital ecchymosis. Plain radiographs are not helpful in the diagnosis or management of nasal fractures in isolated nasal injury. CTscan is helpful if the patient has associated facial fractures. Be sure to ask the patient how the external shape of the nose has changed since the fracture. This helps determine what corrective maneuvers should be taken to restore the patient’s appearance through reduction of the nasal fracture.
Nasal pyramid fractures should be reduced first, followed by nasal septum reduction once the edema and swelling settles down, say 7 days to 10 days. It can be done under local or General Anesthesia.
Reduce depressed side of nose first. Using Ash and Walsham forceps elevator into the nose under the depressed fragment. Apply steady outward pressure on the posterior aspect of the nasal bone. Control outward pressure with counter pressure exteriorly with the other thumb. Fragments may need to be molded into the proper position.
If unable to reduce with elevators, use Walsham forceps to directly grasp the nasal bone. Insert one blade beneath the bone as the other blade is opposed on the outer skin surface. Manipulate the bone into position.
Check for septal reduction. If not adequately reduced, use Asch forceps to elevate the nasal pyramid while applying direct pressure to the displaced portion of the septum until it is moved back into the proper position.
Check for septal hematoma and drain it if present.
Stabilize reduction with internal packing (Merocel) and an external splint (e.g. Thermaplast). These external splints require intense heat for activation and molding, so the nasal dorsal skin should be protected with Steri-Strip bandage application prior to placement of the splint.
Remove packing in 5 days and remove nasal splint in 7 days. While the nasal packing is in place, the patient should be on an oral antibiotic and anti inflammatory drugs.