Nasal Fractures

Pediatric Nasal FractureWe can all agree that the nose is a very useful part of the body. It allows us to stop and smell the flowers. It offers us an amazing way to administer medications (ex, intranasal fentanyl). For some, it is a storage container, which can be problematic (ex, button batteries and other nasal FBs). Unfortunately, it is often the first thing to impact the ground, a fist, or projectiles. With this in mind, let us take a moment to review pediatric Nasal Fractures:

 

Nasal Fractures: Basics

  • One of the most commonly encountered facial fractures. [Hoffman, 2015; Desrosiers, 2011; Wright, 2011]
  • May be unilateral and simple or comminuted, dislocated, and complex. [Hoffman, 2015]
    • Low-energy impacts may lead to isolated, unilateral fractures with mild displacement.
    • High-energy impacts may lead to comminuted, bilateral fractures.
      • A displaced nasal dorsum is suggestive of a nasal septal dislocation/fracture.

 

Nasal Fractures: Pediatric Differences

  • Pediatric anatomy is different than adults! [Hoffman, 2015]
    • Less prominent nasal dorsum
      • More protected by prominent supraorbital rim and forehead
      • Less likely to take the brunt of the impact.
    • More cartilaginous
      • More flexible
      • Less likely to become comminuted.
    • Nasal septum is more at risk of injury
      • More prone to dislocation and/or distortion.
      • Septal hematomas are more common.
    • Heal more quickly
      • Which is good… but needs contemplation with respect to follow-up…
      • Children should follow-up within 7-10 days (adults – 2 weeks).
    • Development influences the midface growth
      • Prior to adolescence, the nasal septum is the growth center for the midface
      • Conservative therapies (ex, closed reduction) are the main treatment option to help minimize risk of altering growth.

 

Nasal Fractures: Evaluation

  • The diagnosis of a nasal fracture is predominantly based on H+P!
  • Imaging is rarely useful!
    • Plain xrays: over-estimate AND under-estimate injury.[Hoffman, 2015]
    • Ultrasound: can help image the nasal bones. [Dogan, 2017]
    • CT Scans: neither necessary nor warranted for the evaluation of nasal fractures [Hoffman, 2015]
      • Surgical indications are based on appearance and functional status of the nose, not imaging results.
      • Medical radiation is not trivial.
  • Other facial fractures may be present concurrently.
    • Raccoon eyes, battle sign, or hemotympanum? – consider basilar skull fracture
    • Midface mobility? – consider LeFort fractures
    • Facial numbness? – consider maxillary or orbital fracture
    • Double vision or change in vision? – consider orbital fracture
    • Dental occlusion? – consider maxillary or mandibular fracture
    • Significant watery rhinorrhea? – consider CSF leak and basilar skull fracture
  • Don’t just feel the outside, look up the nose!
    • Septal hematoma is more likely to occur in children than adults.
      • Septal hematoma must be decompressed and managed expeditiously.
      • Untreated septal hematoma can develop into abscess and can lead to collapse of the cartilage and subsequent deformity.
    • Watery rhinorrhea?
      • CSF vs snot is challenging to discern.
      • The “halo test” (fluid placed on filter paper; halo of CSF around blood) is not reliable enough.
      • The glucose test (CSF having glucose while snot shouldn’t) is also not perfectly reliable.
      • Snot often stops… CSF leak may persist… so re-examination is reasonable.
  • Don’t forget the eyes!
    • Injury to the nose may also impact injury to the eye(s).
    • Check visual acuity and pupillary response and symmetry.
    • Check globe position and movement.

 

Nasal Fracture: Management

  • Treat the pain! These hurt!
  • Not all nasal fractures require specific treatment. [Hoffman, 2015]
    • Treatment is based on appearance and nasal function.
    • This can be difficult to determine immediately after the injury due to swelling, etc.
  • Re-evaluation after swelling improves, but before bones become fused, is an integral aspect of nasal fracture management.
    • Children should be re-assessed within 7-10 days from injury.
    • Adolescents and adults heal more slowly and can be seen in ~14 days.
  • Most children will have closed reduction attempted first, unless other complicating facial fractures are present.

 

Moral of the Morsel

  • Nasal fractures can look awful, but rarely require specific intervention themselves acutely.
  • Look for the septal hematoma! The fractured nasal bones aren’t the acute problem… the hematoma will be though!
  • CT isn’t for nasal fractures. CT those who you are concerned about other facial injuries, not just broken noses.
  • Anticipate the follow-up plan. 7-10 days for kids is what a plastic surgeon is going to recommend.

 

References

Dogan S1, Kalafat UM2, Yüksel B2, Karaboğa T2, Basturk M2, Ocak T2. Use of radiography and ultrasonography for nasal fracture identification in children under 18 years of age presenting to the ED. Am J Emerg Med. 2017 Mar;35(3):465-468. PMID: 28043725. [PubMed] [Read by QxMD]

Hoffmann JF1. An Algorithm for the Initial Management of Nasal Trauma. Facial Plast Surg. 2015 Jun;31(3):183-93. PMID: 26126215. [PubMed] [Read by QxMD]

Allred LJ1, Crantford JC, Reynolds MF, David LR. Analysis of Pediatric Maxillofacial Fractures Requiring Operative Treatment: Characteristics, Management, and Outcomes. J Craniofac Surg. 2015 Nov;26(8):2368-74. PMID: 26517461. [PubMed] [Read by QxMD]

Desrosiers AE 3rd1, Thaller SR. Pediatric nasal fractures: evaluation and management. J Craniofac Surg. 2011 Jul;22(4):1327-9. PMID: 21772190. [PubMed] [Read by QxMD]

Wright RJ1, Murakami CS, Ambro BT. Pediatric nasal injuries and management. Facial Plast Surg. 2011 Oct;27(5):483-90. PMID: 22028012. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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