Describe nasal trauma and the fractures of the nose and face.

Nasal Fractures

• The nasal bones are the most commonly fractured bones of the face, because the nose projects and its upper third is bone with a thin, unsupported lower part.
• Assessment is clinical rather than radiological.
• Mechanism determines the deformity — a lateral blow (the commonest) causes deviation to the opposite side, often with depression of the near side; a frontal blow causes flattening and splaying of the nasal bones, and if severe telescoping with a saddle deformity and telecanthus

Other Nasal and Facial Trauma

• Septal fracture and dislocation frequently accompany a nasal fracture and are the commonest reason a manipulated nose remains obstructed — the bones are straightened but the septum is not.
• Soft tissue injuries — irrigate, debride minimally given the excellent blood supply, and close in layers ensuring cartilage is covered; give tetanus prophylaxis and antibiotics for contaminated wounds
• Maxillofacial fractures classified by LE FORT — I: a horizontal fracture above the teeth, giving a mobile upper dental arch ("floating palate"); II: a pyramidal fracture through the nasal bones, orbital floors and maxilla, giving a mobile midface with the nose; and III: craniofacial dysjunction, separating the facial skeleton from the skull base — all of which may be associated with CSF leak and airway compromise
• Naso-orbito-ethmoid (NOE) fractures are the serious ones for the nose: they cause telecanthus (an increased intercanthal distance from disruption of the medial canthal tendon), a flattened nasal bridge, and frequently CSF leak and lacrimal injury; and require open reduction and canthal fixation
• Orbital blow-out fracture — giving diplopia on upgaze, enophthalmos and infraorbital numbness; the white-eyed trapdoor fracture in a child is a surgical emergency because the trapped muscle becomes ischaemic
• Warn against nose-blowing after any midfacial fracture.
• Late deformities — a saddle nose (from septal cartilage loss after haematoma, abscess or over-resection); a deviated external nose; persistent obstruction; and synechiae. These are corrected by septorhinoplasty with cartilage or bone grafting, ideally deferred at least 6 months and, in children, until facial growth is complete
• Consider non-accidental injury in a child, and domestic violence in an adult with recurrent or inconsistent facial injury — and ask
• Do not order plain nasal radiographs; they are frequently wrong in both directions and change nothing
• The decision to manipulate rests on appearance and airway, judged clinically rather than radiologically
• Palpate the septum in every broken nose; a haematoma is soft and bilateral and is missed by inspection alone
• Assess within hours or wait a week; a grossly swollen nose at forty-eight hours cannot be judged at all
• Manipulate within ten to fourteen days in an adult and seven to ten in a child, before the fracture unites
• A lateral blow deviates and a frontal blow flattens, which is why the mechanism predicts the deformity
• The septum is why a manipulated nose stays blocked, so it must be assessed and addressed separately from the bones
• Exclude CSF rhinorrhoea after any midfacial injury, and confirm with beta-2 transferrin rather than a glucose stick
• Assess the eye and conscious level first; the associated injuries matter more than the nasal fracture
• Warn against nose-blowing after a midfacial fracture, which forces air and organisms into the orbit and cranial cavity
• Telecanthus indicates a naso-orbito-ethmoid fracture, from disruption of the medial canthal tendon, and needs open fixation
• A white-eyed trapdoor fracture in a child is a surgical emergency despite the unimpressive appearance
• Photograph the injury and document the mechanism; assault is a common cause and litigation frequently follows
• Warn that a perfect result is not guaranteed before manipulating; a proportion need later septorhinoplasty
• Defer septorhinoplasty at least six months, and until facial growth is complete in a child
• Ask about domestic violence and non-accidental injury where facial injuries are recurrent or the history is inconsistent