Nasal Septal Fractures have been associated with nasal bone fractures in 42% to 96% of patients. Nasal bone and septal fractures have an impact not only on cosmetic appearance but also on functional nasal breathing as well.[rx][rx]
The structural support of the nose is comprised mainly of cartilage, bone, and skin. The paired nasal bones are attached to the frontal bone superiorly and the frontal process of the maxilla on either side laterally. They are attached to the nasofrontal and nasomaxillary suture lines, respectively. The nasal bones tend to be thicker above the level of the medial canthus.[rx]
The nasal septum is comprised posteriorly of bone and anteriorly of cartilage. The perpendicular plate of the ethmoid bone superiorly and the vomer inferiorly, make up the bony septum. These fuse with the quadrangular cartilage, which makes up the anterior portion of the nasal septum. The quadrangular cartilage provides support for the nasal dorsum from the keystone area to the supratip of the nose.[rx] This keystone area is a major structural support of the middle one-third of the nose. The upper lateral cartilages fuse to the cartilaginous septum, which is firmly attached to the perpendicular plate of the ethmoid bone. The final element of the keystone area is the attachment of the upper lateral cartilages to the nasal bony vault. The septum is attached to the nasal floor anteriorly at the nasal spine and posteriorly at the nasal crest of the maxilla and palatine bones.
Causes of Nasal Septal Fractures
Nasal bones are fractured with a variety of trauma to the maxillofacial skeleton.
- The most common causes of nasal bone fractures globally are interpersonal violence, motor vehicle accidents, sporting accidents, and falls. In North America, traffic accidents account for more nasal bone fractures than interpersonal violence.[rx]
- In children, the most common cause tends to be sporting accidents or motor vehicle accidents, depending on the source.[rx][rx] Interestingly, ball-related sports such as soccer, basketball, baseball, and rugby have a higher incidence of nasal bone fractures compared to fighting-related sports.[rx]
Symptoms Of Nasal Septal Fractures
Symptoms of a broken nose septum fracture include bruising, swelling, tenderness, pain, deformity, and/or bleeding of the nose and nasal region of the face.
- Pain or tenderness, especially when touching your nose
- Swelling of your nose and surrounding areas
- Bleeding from your nose
- Bruising around your nose or eyes
- Bruising, swelling and tenderness around the nose
- A deformed, twisted or crooked nose
- Blockage of one or both nostrils
- A deviated septum
- A bruise-like discoloration under the eyes
- Crooked or misshapen nose
- Difficulty breathing through your nose
- Discharge of mucus from your nose
- Feeling that one or both of your nasal passages are blocked
Diagnosis of Nasal Septal Fractures
History
Your doctor in the emergency department may ask the following questions
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How – How was the fracture created, and, if chronic, why is it still open? (underlying etiology)
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When – How long has this fracture been present? (e.g., chronic less than 1 month or acute, more than 6 months)
- Where – Where on the body parts is it located? Is it in an area that is difficult to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery?
- What is your Past – Has your previous medical history of fracture? Are you suffering from any chronic disease, such as hypertension, blood pressure, diabetes mellitus, previous major surgery? What kind of medicine did you take? What is your food habits, geographic location, Alcohol, tea, coffee consumption habit, anabolic steroid uses for athletes, etc?
Physical Examination
Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, swelling. If the fracture is in the dept of a joint, the joint motion, normal movement will aggravate the pain.
- Inspection – Your doctor also check superficial tissue, skin color, involving or not only the epidermal layer or Partial-thickness affects the epidermis and extend into the dermis, but full-thickness also extends through the dermis and into the adipose tissues or full-thickness extends through the dermis, and adipose exposes muscle, bone, evaluate and measure the depth, length, and width of the fracture. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached and evaluate for signs and symptoms of infect warm, pain, delayed healing.
- Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, microtrauma, and ecchymosis at the site of fracture.
- Motor function – Your doctor may ask the patient to move the injured area to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means only that the muscles and tendons work properly, and does not guarantee bone integrity or stability. The concept that “it can’t be fractured because you can move it” is not correct. The jerk test and manual test are also performed to investigate the motor function.
- Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, numbness, and pinprick sensations, in its fracture side.
- Range of motion – A range of motion examination of the fracture associate joint and it’s surrounding joint may be helpful in assessing the muscle, tendon, ligament, cartilage stability. Active assisted, actively resisted exercises are performed around the injured area joint.
- Blood pressure and pulse check – Blood pressure is the term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, blood pressure, and assessing how quickly blood returns to the tip of a toe to heart and it is pressed the toe turns white (capillary refill).
Evaluation
Imaging is generally not warranted for simple nasal bone fractures. Plain film X-rays are not typically useful. A computed tomography (CT) scan without intravenous contrast of the facial bones is the gold standard for evaluation of bony trauma of the maxillofacial area if there is a concern for more extensive facial injuries.[rx] Concerning symptoms, as previously noted, should prompt providers to order imaging. More recently, ultrasonography has been explored to help aid in the diagnosis of nasal bone fractures but proved inferior to CT.[rx]
Laboratory evaluation is generally not required in a simple nasal bone fracture or septal hematoma. A complete blood count and coagulation studies may be considered in patients with epistaxis who have lost a considerable amount of blood or who take anticoagulant medication. Patients with persistent clear rhinorrhea can have this collected and sent for beta-2-transferrin, which can be used to help confirm a CSF leak.
Treatment of Nasal Septal Fractures
Initial management should include control of epistaxis and closure of any lacerations of the external skin or internal nasal lining whenever possible. Epistaxis may be conservatively controlled with digital pressure, pushing the nasal alae against the septum. More serious epistaxis may require cauterization or nasal packing.
Observation without surgical intervention is recommended in patients who do not have an obvious cosmetic deformity or nasal obstruction. Conservative measures such as elevating the head and icing the area are recommended until local edema subsides. Patients should be closely followed within three to five days for reexamination, as nasal deviation can be unmasked with the resolution of edema.[rx]
Closed reduction of the nasal bone and septal fractures is generally recommended for fractures that cause nasal deviation or airway obstruction. It may be performed under local anesthetic or minimal sedation, but general anesthesia is most often preferred due to improved airway protection and overall patient comfort.[rx] Timing of closed reduction is varied in the literature, with some sources advocating early intervention within five to seven days, while others state that edema should completely resolve, and closed reduction should be performed within one to two weeks of injury.[rx][rx] After two weeks, patient satisfaction with cosmetic outcomes significantly decrease.[rx] Later intervention risks callus formation and difficulty reducing nasal bones into their premorbid location. In this case, an endonasal or percutaneous open reduction can be performed using osteotomies.[rx] In a typically closed reduction, a flat, broad instrument such as a Boies elevator is used endonasal to reduce fractures with a postoperative splint applied to the nasal dorsum.
Closed reduction may also be performed on the nasal septum using a Boies elevator or Asch forceps. If adequate reduction of the nasal septum cannot be performed in a closed fashion, some have advocated for an open septoplasty in the acute setting, showing that patients have significant improvement in nasal obstruction postoperatively.[rx] Intranasal splints or packing may also be used to help keep the septum reduced, but this is typically not used unless a septoplasty has been performed. Septoplasty is avoided if there is significant mucosal disruption along the septum due to the risk of postoperative septal perforation.[rx]
An open septorhinoplasty is generally avoided in the acute setting as there are frequently nasal lacerations or cartilage disruptions. Further dissecting these cartilage structures can revascularize them in the acute setting, and any cartilage grafts may be more susceptible to infection and rejection. It is therefore often recommended septorhinoplasty be delayed 3 to 6 months post-injury.[rx]
Do no HARM for 72 hours after injury
- Heat—hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
- Alcohol stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
- Running, and walking may cause further damage, and causes healing delay.
- Massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.
Medication
The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment
- Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen.
- Muscle Relaxants – These medications provide relief from spinal muscle spasms, spasticity. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture.
- Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, osteoarthritis.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx]
- Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, tenderness through the skin. If the fracture is closed and not open fracture then you can use this item.
- Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
- Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints.
- Dietary supplement – To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses & improved health.
- Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, post-surgical breathing problem, then advice you to take bronchodilator cough syrup.
What To Eat and What to avoid
Eat Nutritiously During Your Recovery
All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.
- Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.
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