Technique and timing for closed reduction of isolated nasal fractures: A retrospective study. (Original Article).

Abstract

Isolated fractures of the nasal pyramid are among tile most common facial injuries. Nevertheless, studies of therapeutic results following closed reduction of nasal fractures are rare. We conducted a retrospective clinical review of 187 patients who were evaluated for nasal trauma (including nondislocated fractures, dislocated fractures, and contusions) at our otolaryngology department during 1997 and 1998. Of this group, 96 fractures were treated with closed reduction--either under local anesthesia (n = 68), under general anesthesia (n 21), or with con concomitant septoplasty under general anesthesia (n = 7). At follow-up, which ranged from 1 to 2 years, 91 of the 96 patients (94.8%) expressed satisfaction with their results. Prior to deciding on a course of action, the surgeon must conduct a careful physical examination because the decision as to whether treatment is required, which technique to use (open vs closed reduction), and which type of anesthesia is appropriate (local vs general) all depend on the clinical findings, such as the degree of deviation and airflow obstruction. We also suggest that all patients receive both a Waters' view and a lateral view x-ray. In our opinion, closed reduction is a safe procedure for isolated nasal fractures and can be performed with local anesthesia in most adult patients. Morbidity is minimal in tile hands of an experienced ENT surgeon.

Introduction

Despite the fact that fractures of the nasal skeleton are among the most common facial fractures, the literature on therapeutic results is sparse. (1-4) The standard procedure performed by most otorhinolaryngologists is reduction of the fracture with either local or general anesthesia. The choice of operative technique (i.e., closed vs open reduction) and the timing of fracture repair are still controversial (see DISCUSSION). (2,3,5-9)

Closed reduction of the nose is generally safe and easy to perform, and morbidity is minimal. In those patients who do not achieve satisfactory results, open reduction and traditional septorhinoplasty can be performed at a later date.

The goal of treatment is to restore the appearance and function of the nose to their pretrauma state. It is generally accepted that the final result of treatment cannot be properly evaluated until 1 or 2 years have passed since treatment. The reason is that both the trauma and the reduction might cause fibrosis that can lead to a secondary deformity of the nasal pyramid. (2)

In this article, we describe our retrospective clinical review of 187 patients with nasal trauma, 96 of whom underwent closed reduction for nasal fracture. The purpose of our study was to assess the necessity, technique, and timing of reduction in light of each patient's posttrauma clinical findings.

Patients and methods

We retrospectively reviewed the records of 187 patients--140 males and 47 females, aged 1 to 98 years (median: 22)--who had been evaluated for nasal bone trauma between Jan. 1, 1997, and Dec. 31, 1998.

All patients provided a detailed history, including information on the mode of their injury, any previous injury or previous nasal deformity, and the presence of posttrauma airway obstruction. All patients underwent a thorough nasal examination and radiographic evaluation with standard x-rays, including Waters' (occipitomental) and lateral views of the nasal bones and paranasal sinuses.

Results

The three most common causes of trauma were falls, fights, and sports activities (table 1). The most common primary findings on physical examination were swelling (figure 1) and deviation of the nasal dorsum (table 2). Thirteen of the 187 patients (7.0%) had a history of nasal injury, and all 13 had had various degrees of deformity prior to their new trauma.

Type of trauma. Of the 187 patients, 75 (40.1%) had a nondislocated fracture, 60 (32.1%) had a dislocated fracture, and 52(27.8%) had only a contusion (table 3). Among the 135 patients with either type of fracture, 34 (25.2%) had a severe bony or cartilaginous deviation as a result of an irregular-fragment fracture or pyramid dislocation. Eleven of these 34 patients also had an open fracture.

In addition to their nasal trauma, eight patients had related injuries, as well; two had a fracture of the maxillary sinus; one patient each had a fracture of the frontal sinus, ethmoid bone, floor of the orbita, and multiple walls of the orbita; one patient had a contusion of the eye; and one patient had a laceration of the lower eyelid. Computed tomography (CT) of the paranasal sinuses and the nose was obtained on six patients to investigate the possibility of a fracture in the middle face. Prior to treatment, six patients developed a septal hematoma and one developed an abscess of the nasal septum; all seven of these patients underwent incision, drainage, and treatment with oral antibiotics.

Management. Of the 187 patients, 96 (51.3%) were treated with one of three methods of closed reduction: under local anesthesia, under general anesthesia, or with septoplasty under general anesthesia. The remainder did not undergo reduction (table 4): Local anesthesia. Of the 187 patients, 68 (36.4%) underwent reduction under local anesthesia. Of these, 40 (58.8%) had a nondislocated fracture and 28 (41.2) had a dislocated fracture. Their mean age was 24 years. The local anesthesia was delivered through tampons of tetracaine and xylometazoline 0.1%. The tampons were usually placed beneath the nasal dorsum and at the posterior edge of the middle turbinate and left in place for 10 minutes. In some cases, the infratrochlear, infraorbital, and nasopalatine nerves were also blocked with a local anesthetic, such as lidocaine 1 to 2% with 1/100,000 epinephrine. Adjunctive intramuscular sedation and analgesia were not generally administered.

General anesthesia. A total of 21 patients (11.2%) underwent reduction under general anesthesia. Eleven (52.4%) had a nondislocated fracture and 10 (47.6%) had a dislocated fracture. Most of these patients were younger than 14 years of age (mean: 12).

Septoplasty under general anesthesia. Seven patients (3.7%), all males, underwent a septoplasty under general anesthesia in addition to a closed reduction. One (14.3%) had a nondislocated fracture and six (85.7%) had a dislocated fracture. Three of these patients had a fracture of the nasal septum and two had a septal hematoma.

No treatment. A total of 88 patients (47.1%) did not require nasal reduction. Of these, 22 (25.0%) had a nondislocated fracture, 15 (17.0%) had a radiologically dislocated fracture, and 51 (58.0%) had a plain contusion. The 37 patients who had either type of fracture did not require reduction because their noses were absolutely straight after their swelling had subsided and they did not experience any impairment of nasal airflow.

Other. Two patients had a wound that required only cleaning and suturing, and one patient refused any kind of therapy.

Technique. Manipulation was performed by exerting external pressure and by using Boies' elevator, Walsham's forceps, and Asch's forceps when needed. After the procedure was completed, a plaster of Paris splint was applied and left in place for 7 days. During the subsequent week, the splint was worn only at night. In some cases of unstable fracture, nasal pats were inserted to add to the strength of the splint.

Timing. The earliest reductions were performed on the day of the trauma, and the latest was performed 12 days following the trauma (mean: 4 [+ or -] 2.7 days post-trauma). When edema of the nasal pyramid or surrounding tissues was present, reduction was postponed for 5 to 8 days to allow the swelling to subside. Once it did, we used photographs of the patient taken before the injury to compare the state of the nose pre- and post-trauma in order to decide whether reduction was necessary. In those cases when the swelling did not abate after 8 days (and thus the contour of the nose could not be assessed), reduction was ruled out and the patient instead underwent septoplasty or septorhinoplasty at a later date.

Outcomes. Patients' satisfaction with their procedure was assessed immediately after each procedure, 1 week later when the splint was removed, and at the final follow-up. The duration of follow-up ranged from 1 to 2 years.

There was no significant difference in the overall success rate between the local and general anesthesia groups. Of the 96 patients who underwent reduction, 91 (94.8%) expressed complete satisfaction with their clinical outcome. Of the five patients who were not satisfied, four had undergone reduction under local anesthesia and one under general anesthesia. Two of the five unsatisfied patients decided to undergo a second operation; one underwent septorhinoplasty 6 months following the initial trauma, and the other required septoplasty to correct a nasal obstruction.

Three patients required a second reduction. Two were carried out on the 9th day after the initial trauma and one was performed 11 days after.

Only three patients experienced complications after reduction. Two developed a septal hematoma and one an abscess of the nasal septum. All three underwent incision, drainage, and antibiotic therapy.

Discussion

Causes. Our findings with respect to the causes of nasal trauma coincide with those published by Dickson and Sharpe (4) and by Perkins et al, (10) who also found that falls, fights, and sports activities were among the three leading causes.

Management. The decision whether to perform reduction is guided primarily by the clinical findings, such as deviation, obstruction of airflow, and the appearance of the nose after swelling has subsided. Whenever possible, a pretrauma photograph of the patient should be examined for comparison purposes. In our study, reduction was not necessary for 22 patients who had a radiologically nondislocated fracture and 15 who had a radiologically dislocated fracture because their noses were absolutely straight and their nasal airflow was unimpeded.

Type of reduction. The decision as to which reduction technique to use when treatment is necessary has been the subject of controversy in the literature. (2-3,5-9) Simmen reported that the failure rate seen with closed reduction techniques is significant, and he advocated open methods in the belief that they produce better results. (3) In his study, 30 of 34 patients (88.2%) who underwent open reduction of a fracture of the nasal bone said they were satisfied with the results. (3) Renner maintained that although closed reduction provides satisfactory results in most cases of nasal fracture, open reduction is a more appropriate choice. (11) Mayell, (7) Harrison, (8) and Eichhorn et al (12) reported that only about one-third of their patients experienced satisfactory results with closed reduction.

Conversely, Illum, (2) Dickson and Sharpe, (4) Newton and White, (13) and Watson et al (14) reported that closed reduction yielded good results in 71 to 90% of their patients. We agree that closed reduction appears to be a reasonable choice for most acute nasal fractures. If it should prove to be inadequate, the surgeon can safely proceed to open reduction at a later date. In any event, the ideal option is the least invasive technique that provides the best long-term result.

Anesthesia. Another debated issue is whether closed reduction should be performed with local or general anesthesia. (15-17) Several authors have argued that general anesthesia is the better choice for nasal bone manipulation. (2-4) On the other hand, Newton and White studied 32 patients who underwent nasal manipulation under local anesthesia and found that 29 of them (90.6%) said the procedure was less painful than a dental filling; moreover, 31 of the 32 (96.9%) said they would undergo the same procedure again if necessary. (13) Similar findings were reported by Watson et al (14) in 29 patients and Houghton et al (18) in 33 patients. In our study, we were able to perform simple closed reduction with local anesthesia in 68 patients, whereas only 21 required general anesthesia. Those in the latter group were either young ([less than or equal to]14 yr) or their fracture was severely dislocated.

In our opinion, local anesthesia is appropriate or most adults and general anesthesia appears to be a better choice for younger patients. In addition to the severity of the injury and the patient's age, the choice of anesthesia also depends on the patient's degree of apprehension and tolerance for pain. In our study, we found no obvious differences in clinical outcomes between the two anesthesia groups, a finding that corresponds with those of other researchers. (15,19,20)

Imaging studies. The role of radiography in the management of nasal fracture is likewise controversial. (20) Although long practiced as a standard procedure in many emergency rooms and trauma centers, radiographic evaluation of routine nasal fractures is now considered to be unnecessary by many authors. (1,2,20-22) Illum argued that these x-rays have no real clinical value and, in his home country of Denmark, no medicolegal value, as well. (23) In a prospective study, Clayton and Lesser evaluate 54 patients clinically, radiologically, and under general anesthesia. (24) Their findings suggested that radiographs are not useful in the routine management of nasal fractures because of the large number of false-positive and false-negative images.

Even so, all patients in our study had a Waters' view and a lateral view x-ray taken of the nasal bone (figure 2). These x-rays are still recommended as part of the routine management of nasal fractures by the German Society for Oto-Rhino-Laryngology-Head and Neck Surgery. (25) More important, x-rays can be useful in detecting unsuspected fractures following clinical evaluation. Whereas the lateral view is specific for evaluating nasal trauma, the Waters' view has potential value for evaluating other maxillofacial injuries.

CT also has value in certain circumstances. In our study, we were suspicious of the clinical and radiologic findings in six patients because they had injuries other than a fractured nose. Therefore, we obtained CT imaging, which was able to verify the presence of various maxillofacial fractures (figure 3). This experience highlights the importance of taking into account facial fractures other than nasal fractures. The opinions of Illum et al, (1,2) Rubinstein and Strong, (20) Nigam et al, (21) and Logan et al (22) notwithstanding, our analysis suggests that x-rays are indeed valuable in the diagnosis of nasal fractures.

Timing. Most of our patients had a marked swelling of the soft tissues and a nasal deformity that could not be properly assessed during the first few days following their injury. Rubinstein and Strong pointed out that most patients should be re-evaluated after 3 or 4 days and, if swelling persists, in another 3 or 4 days. (20)

Closed reductions should generally be performed between 3 and 10 days following the trauma. In our study, most fractures were reduced between 3 and 7 days (mean: 4 [+ or -] 2.71). A few reductions were performed on the day of the trauma because the swelling was very mild or the patient had an open fracture or an additional facial fracture. One fracture was not treated until post-trauma day 12 because the patient had not registered in our department until then.

Martinez emphasized that special care must be taken to avoid an unnecessary delay in treatment, particularly in children. (26) He noted that children with fractures are especially vulnerable if they are treated after post-trauma day 7 because they heal more quickly than adults. We recommend that reductions be performed within 10 days post-trauma for adults and within 7 days for children.

Outcomes. In our estimation, the best way to ascertain the cosmetic success of nasal reduction is to elicit the patient's opinion. In our group, 94.8% of all patients who had undergone closed reduction were fully satisfied with the result. Of the 68 patients who received local anesthesia, 64 (94.1%) were completely satisfied, and only two of the unsatisfied patients asked for a second corrective treatment 6 months after their initial trauma.

Follow-up. It is critical that patients younger than 18 years of age return for periodic follow-up for at least 24 months following fracture repair. Because the nose is still growing at this stage of life, neglect could lead to a deformity many months after an initially successful reduction. If a deformity does occur in a patient younger than 18 years, the surgeon should perform septorhinoplasty, and the patient should then be followed up for 6 to 12 months to assure that adequate results are obtained. If a later deformity should occur, the patient should be treated with septorhinoplasty and soft-tissue techniques.

From the Department of Otorhinolaryngology-Head and Neck Surgery, University of Freiburg, Germany (Dr. Ridder, Dr. Boedeker, and Dr. Schipper), and the Department of Otolaryngology-Head and Neck Surgery, B'nai Zion Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Isracl Institute of Technology, Haifa, Israel (Dr. Fradis).

References

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(2.) Illum P. Long-term results after treatment of nasal fractures. J Laryngol Otol 1986;100:273-7.

(3.) Simmen D. [Nasal fractures: Indications for open reposition]. Laryngorhinootologie 1998;77:388-93.

(4.) Dickson MG, Sharpe DT. A prospective study of nasal fractures. J Laryngol Otol 1986;100:543-51.

(5.) Smith D, Mathog RH. Diagnosis and management of acute nasal fracture. In: Mathog RH, Arden RL, Marks SC, eds. Trauma of the Nose and Paranasal Sinuses. New York: Thieme Medical Publishers, 1995:21-38.

(6.) Clark WD, Stiernberg CM. Early aggressive treatment of nasal fractures. Ear Nose Throat J 1986;65:481-3.

(7.) Mayell MF. Nasal fractures. Their occurrence, management and some late results. J R Coll Surg Edinb 1973;18:31-6.

(8.) Harrison DH. Nasal injuries: Their pathogenesis and treatment. Br J Plast Surg 1979;32:57-64.

(9.) Rohrich RJ, Adams WP, Jr. Nasal fracture management: Minimizing secondary nasal deformities. Plast Reconstr Surg 2000; 106:266-73.

(10.) Perkins SW, Dayan SH, Sklarew EC, et al. The incidence of sports-related facial trauma in children, Ear Nose Throat J 2000;79:632-4, 636, 638.

(11.) Renner GJ. Management of nasal fractures. Otolaryngol Clin North Am 1991;24:195-213.

(12.) Eichhorn T, Schroeder HG, Kleinsasser O. [Follow-up examinations of patients with isolated fractures of the bony nasal pyramid]. Laryngol Rhinol Otol (Stuttg) 1983;62:112-5.

(13.) Newton CR, White PS. Nasal manipulation with intravenous sedation. Is it an acceptable and effective treatment? Rhinology 1998;36:114-6.

(14.) Watson DJ, Parker AJ, Slack RW, Griffiths MV. Local versus general anaesthetic in the management of the fractured nose. Clin Otolaryngol 1988;13:491-4.

(15.) Waldron J, Mitchell DB, Ford G. Reduction of fractured nasal bones: Local versus general anaesthesia. Clin Otolaryngol 1989; 14:357-9

(16.) Owen GO, Parker AJ, Watson DJ. Fractured-nose reduction under local anaesthesia. Is it acceptable to the patient? Rhinology 1992;30:89-96.

(17.) Jones TM, Nandapalan V. Manipulation of the fracture nose: A comparison of local infiltration anaesthesia and topical local anaesthesia. Clin Otolaryngol 1999;24:443-6.

(18.) Houghton DJ, Hanafi Z, Papakostas K, et al. Efficacy of external fixation following nasal manipulation under local anaesthesia. Clin Otolaryngol 1998;23:169-71.

(19.) Cook JA, McRae RD, Irving RM, Dowie LN. A randomized comparison of manipulation of the fractured nose under local and general anaesthesia. Clin Otolaryngol 1990;15:343-6.

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(22.) Logan M, O'Driscoll K, Masterson J. The utility of nasal bone radiographs in nasal trauma. Clin Radiol 1994;49:192-4.

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Table 1

Causes of nasal trauma (N = 187)

Cause                           n(%)

Falls                         79 (42.2)
Fights                        43 (23.0)
Sports activities             35 (18.7)
Accidents at home             16 (8.6)
Accidents in a motor vehicle  10 (5.3)
Accidents at work              4 (2.1)
Table 2

Clinical findings on physical examination (N = 187)

Finding                       n(%)

Swelling                    79 (42.2)
Deviation of nasal dorsum   46 (24.6)
Impression of nasal dorsum  20 (10.7)
Open fracture               11 (5.9)
Laceration                  10 (5.3)
Plain wound                  8 (4.3)
Hump                         4 (2.1)
Deviation and laceration     2 (1.1)
Impression and laceration    1 (0.5)
Hump and impression          1 (0.5)
No pathologic finding        5 (2.7)
Table 3

Specific trauma and the type of management (N = 187)

Type of trauma                       n (%)

Nondislocated fracture             75 (40.1)
 Closed reduction w/local          40 (53.3)
  anesthesia
 Closed reduction w/general        11 (14.7)
  anesthesia
 Closed reduction and septoplasty   1 (1.3)
 Cleaning and suturing only         1 (1.3)
 No treatment necessary            22 (29.3)

Dislocated fracture                60 (32.1)
 Closed reduction w/local          28 (46.7)
  anesthesia
 Closed reduction w/general        10 (16.7)
  anesthesia
 Closed reduction and septoplasty   6 (10.0)
 Refused treatment                  1 (1.7)
 No treatment necessary            15 (25.0)

Contusion                          52 (27.8)
 No treatment necessary            51 (98.1)
 Cleaning and suturing only         1 (1.9)
Table 4

Specific management for each type of trauma (N = 187)

Management                             n (%)

Closed reduction w/local anesthesia  68 (36.4)
 Nondislocated fracture              40 (58.8)
 Dislocated fracture                 28 (41.2)

Closed reduction w/general           21 (11.2)
 anesthesia
 Nondislocated fracture              11 (52.4)
 Dislocated fracture                 10 (47.6)

Closed reduction and septaplasty      7 (3.7)
 Nondislocated fracture               1 (14.3)
 Dislocated fracture                  6 (85.7)

No treatment necessary               88 (47.1)
 Nondislocated fracture              22 (25.0)
 Dislocated fracture                 15 (17.0)
 Contusion                           51 (58.0)

Cleaning and suturing only            2 (1.1)

Refused treatment                     1 (0.5)