Nasal fractureMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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418 items

☷ Legend

01Approach to the Critical Patient/attcp32

Immediate risks and red flags

›Stabilization priorities

›Airway compromise

›Massive facial swelling

›Expanding septal hematoma

›Hemorrhage

›Uncontrolled epistaxis

›Hypotension or syncope

›Associated high risk injury pattern

›Altered level of consciousness

›Cervical spine pain or neurologic deficit

›Vision change or diplopia

›Malocclusion or trismus

Immediate actions and escalation triggers

›Early escalation triggers

›If septal hematoma suspected, urgent drainage and ENT

›Cartilage necrosis risk

›Saddle nose deformity risk

›If clear unilateral rhinorrhea with concerning mechanism, CSF leak pathway and imaging

›Basilar skull fracture risk

›Meningitis risk

›If ocular symptoms, urgent ocular evaluation and CT facial bones

›Orbital fracture risk

›Retrobulbar hemorrhage risk

›If uncontrolled bleeding, resuscitation bay and hemostasis pathway

›Reversal considerations for anticoagulants

›Nasal packing complications risk

Key concepts

›Core management frame

›Clinical diagnosis is primary

›Imaging rarely changes isolated nasal fracture management

›Septal hematoma exclusion is time critical

›Timing dependent reduction

›Swelling can obscure deformity for several days

›Reduction window typically within 1 to 2 weeks for best results

02History/hx54

Mechanism and symptom pattern

›Injury context

›Time since injury

›Same day presentation

›Delayed presentation after swelling

›Mechanism

›Low energy direct blow

›High energy facial trauma

›Immediate deformity versus delayed swelling

›Audible crack sensation

›Immediate epistaxis

›Nasal symptoms

›Obstruction

›Unilateral

›Bilateral

›Pain and tenderness

›Progressive pain suggesting septal hematoma

›Disproportionate pain suggesting septal abscess

›Epistaxis severity

›Persistent bleeding

›Recurrent bleeding after initial control

Associated injury screen

›Head and neck symptoms

›Loss of consciousness

›Concussion symptoms

›Amnesia

›Neck pain

›Midline tenderness

›Paresthesias

›Eye and midface symptoms

›Vision change

›Blurred vision

›Diplopia

›Facial numbness

›Infraorbital numbness

›Dental numbness

›Jaw symptoms

›Malocclusion

›Trismus

Risk factors and modifiers

›Bleeding and infection modifiers

›Anticoagulants or antiplatelets

›Warfarin

›Direct oral anticoagulant

›Bleeding disorder history

›Hemophilia

›von Willebrand disease

›Immunocompromise

›Diabetes mellitus

›Systemic steroids

›Prior nasal anatomy

›Prior nasal fracture

›Baseline deformity

›Baseline obstruction

›Prior septoplasty or rhinoplasty

›Hardware or graft history

›Altered exam landmarks

03Physical Exam/exam47

Focused nasal and facial exam

›Nasal inspection and palpation

›External deformity

›Deviation

›Dorsal depression

›Point tenderness and crepitus

›Bony step off

›Mobility of nasal bones

›Skin and soft tissue injury

›Laceration suggesting open fracture

›Contamination

›Intranasal exam

›Septal hematoma exclusion

›Fluctuant septal swelling

›Bilateral boggy swelling

›Mucosal laceration

›Active bleeding point

›Exposed cartilage

›Septal deviation

›Acute deviation causing obstruction

›Turbinate contact

Associated exam domains

›Eye and orbit

›Visual acuity

›New deficit triggers urgent pathway

›Contact lens consideration

›Extraocular movements

›Diplopia

›Pain with gaze

›Periorbital exam

›Subconjunctival hemorrhage

›Proptosis

›Midface and jaw

›Maxillary stability

›Midface mobility

›Zygoma tenderness

›Occlusion

›Dental step

›New malocclusion

›Trismus

›Limited opening

›TMJ tenderness

PITFALLS

›Common misses

›Septal hematoma missed due to swelling or poor lighting

›Deformity can be absent early

›Obstruction can be the main clue

›Isolated nasal fracture assumed with occult orbital or maxillary fracture

›Diplopia and numbness are key clues

›Malocclusion indicates mandible or midface injury

04Differential Diagnosis/ddx32

Traumatic nasal and midface conditions

›Differential set

›Nasal bone fracture (ICD-10 S02.2)

›Displaced

›Nondisplaced

›Nasal septal fracture

›Obstruction predominant

›Deviation predominant

›Septal hematoma

›Fluctuant septal swelling

›Progressive obstruction

›Septal abscess

›Fever

›Worsening pain

›Nasal laceration with open fracture (ICD-10 S02.2 with open wound codes as applicable)

›Contamination

›Tetanus considerations

Mimics and associated injuries

›Mimic and associated injury set

›Orbital blowout fracture

›Diplopia

›Restricted gaze

›Zygomaticomaxillary complex fracture

›Infraorbital numbness

›Flattened malar eminence

›Le Fort fracture pattern

›Midface mobility

›Malocclusion

›Mandibular fracture

›Malocclusion

›Trismus

›Basilar skull fracture

›CSF rhinorrhea concern

›Battle sign or raccoon eyes

05Laboratory Tests/lt18

Routine labs and selective testing

›Testing strategy

›No routine labs for isolated uncomplicated injury

›Clinical diagnosis and outpatient follow up

›Avoid low value testing

›Targeted labs for complications or comorbidity

›Hemoglobin for significant bleeding concern

›Ongoing heavy epistaxis

›Symptomatic anemia concern

›Coagulation studies for anticoagulant use or bleeding disorder

›INR for warfarin

›aPTT when indicated

Infection and operative planning

›Infection and perioperative considerations

›White blood cell count for suspected abscess or systemic infection

›Fever

›Purulent drainage

›Type and screen for uncontrolled bleeding or operative expectation

›Large volume hemorrhage

›Anticipated operative intervention

06Diagnostic Tests/dt44

Scoring Systems

›Classification and decision supports

›Injury pattern classification for communication and planning

›Isolated nasal bone fracture

›External deformity predominant

›Airway obstruction predominant

›Nasoseptal complex injury

›Septal deviation with obstruction

›Septal hematoma or mucosal injury

›Practical decision anchors

›No deformity and no obstruction

›Conservative management pathway

›Delayed reassessment if swelling limits exam

›Deformity or obstruction

›ENT or facial plastics follow up for reduction planning

›Reduction timing within typical window

MRI

›Limited role

›Not first line imaging

›Bony injury evaluation better with CT

›Time and availability limitations

›Select indications

›Suspected soft tissue complication when CT nondiagnostic

›Septal abscess extension concern

›Complex soft tissue injury

›CT indications and performance

›CT face for suspected associated facial fractures

›Diplopia

›Infraorbital numbness

›Malocclusion

›CT head consideration based on head injury features

›Loss of consciousness

›Persistent vomiting

›Isolated nasal fracture without red flags

›CT usually not required

›Management rarely changes

Ultrasound

›Point of care and adjunct roles

›Limited bedside adjunct for nasal bone discontinuity

›Radiation free option

›Operator dependent

›Not a substitute for intranasal septal exam

›Septal hematoma remains clinical diagnosis

›Direct visualization required

›Epistaxis adjunct

›Assessment for hematoma formation

›Guidance for packing complications recognition

07Disposition/dispo20

Level of care and follow up timing

›Disposition pathways

›Discharge with follow up for uncomplicated injury

›No septal hematoma

›Bleeding controlled

›Urgent ENT or facial plastics referral

›Visible deformity

›Persistent obstruction

›Immediate ENT involvement

›Septal hematoma

›Suspected septal abscess

Admission and transfer triggers

›Higher level care criteria

›Uncontrolled epistaxis requiring packing with instability

›Hemodynamic compromise

›Ongoing transfusion need

›Complex facial fractures requiring operative management

›Orbital fracture with ocular findings

›Le Fort pattern suspicion

›CSF leak concern

›Clear unilateral rhinorrhea after significant trauma

›Basilar skull fracture concern

08Treatment/t65

Analgesia and initial supportive care

›Symptom control

›Pain management

›Paracetamol dosing per local protocol

›Avoid duplication with combination products

›Hepatic disease precautions

›Ibuprofen dosing per local protocol

›Avoid with significant bleeding risk

›Renal disease precautions

›Epistaxis control basics

›Direct pressure

›Continuous pressure duration guidance

›Avoid repeated short attempts

›Topical vasoconstrictor when appropriate

›Oxymetazoline intranasal dosing per local protocol

›Hypertension precautions

Septal hematoma and abscess management

›Septal hematoma pathway

›If septal hematoma present, urgent drainage

›ENT preferred when available

›Time critical to prevent cartilage necrosis

›Post drainage measures

›Nasal packing or splints per ENT

›Close follow up within 24 to 48 hours

›Antibiotics for hematoma or abscess pathway

›Coverage per local antibiogram

›Staphylococcus aureus consideration

Reduction and stabilization

›Closed reduction planning

›Reduction indications

›Cosmetic deformity bothersome to patient

›Nasal airway obstruction

›Timing considerations

›Reassessment after swelling improves

›Typical reassessment within several days

›Window before fracture sets

›Reduction commonly within 1 to 2 weeks

›Earlier if minimal edema

›Avoid late reduction without specialist plan

›Splinting and packing

›External splint post reduction per specialist

›Wear duration per local protocol

›Skin care under splint

›Internal packing when indicated

›Septal support

›Bleeding control

Antibiotics and tetanus

›Antibiotic strategy

›Closed uncomplicated fracture after closed reduction

›Routine prophylaxis generally not beneficial

›Shared decision making for special risk contexts

›Antibiotics when higher infection risk

›Grossly contaminated open wound

›Skin laceration communicating with fracture

›Soil contamination

›Septal hematoma or abscess management

›Post drainage coverage

›Systemic infection features

›Tetanus prophylaxis

›Status review for any open wound

›Booster timing per local guidelines

›Immune globulin when indicated

Complication management

›Persistent obstruction or deformity

›Delayed septorhinoplasty discussion

›Typically delayed until healing complete

›Functional and cosmetic goals

›Persistent septal deviation

›Septoplasty consideration per specialist

›Mucosal injury considerations

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Imaging prioritization

›Clinical diagnosis favored when safe

›CT only when associated injury suspected and benefits outweigh risks

›Medication safety

›Paracetamol preferred for analgesia

›NSAID use considerations by trimester and local guidance

›Epistaxis physiology

›Increased mucosal vascularity

›Lower threshold for recurrent bleeding counseling

Geriatric

›Geriatric considerations

›Higher risk coagulopathy

›Anticoagulant prevalence

›Low threshold for targeted labs

›Frailty and fall mechanism

›Broader injury screening

›Head injury coexistence risk

›Reduction goals

›Airway and function emphasis

›Comorbidity informed anesthesia planning

Pediatrics

›Pediatric considerations

›Septal hematoma vigilance

›Mandatory exclusion on day of presentation

›Urgent management to prevent deformity

›Timing of specialist review

›Early follow up after swelling reduction

›Growth plate and cartilage injury consideration

›Imaging minimization

›Avoid routine nasal bone radiographs

›CT reserved for suspected associated facial fracture

10Background/b30

Epidemiology

›Frequency and patterns

›Common facial fracture

›Often managed without imaging

›High prevalence in assault and sports

›Pediatric patterns

›More cartilage injury relative to bone

›Deformity can be subtle early

›Practice recommendations against routine X ray

›Low diagnostic accuracy of plain films

›Low impact on management decisions

Pathophysiology

›Injury mechanics

›Nasal bone displacement

›Lateral impact causing deviation

›Frontal impact causing depression

›Septal injury

›Cartilage fracture or dislocation

›Subperichondrial bleeding forming septal hematoma

›Complication cascade

›Hematoma leading to cartilage ischemia

›Necrosis leading to saddle nose deformity

Therapeutic Considerations

›Treatment logic

›Clinical exam driven decisions

›Deformity and obstruction guide need for reduction

›Septal hematoma exclusion prevents major morbidity

›Reduction timing physiology

›Edema obscures anatomy early

›Callus formation reduces success later

›Antibiotic stewardship

›Low infection rates in closed reduction

›Prophylaxis not routinely helpful in uncomplicated cases

11Patient Discharge Instructions/pdi27

copy discharge instructions

›Discharge instructions

›Ice packs for swelling

›10 to 15 minutes at a time

›Skin protection barrier

›Head elevation during rest

›Reduce swelling

›Reduce bleeding risk

›Avoid nose blowing

›Prevent bleeding restart

›Reduce swelling and pain

›Avoid contact sports and re injury risk

›Activity restriction duration per clinician plan

›Protective gear discussion

›Pain control plan

›Paracetamol as directed

›NSAID only if approved given bleeding risk

›Return to emergency care now for red flags

›Worsening nasal blockage on one or both sides

›New or increasing deformity after swelling improves

›Persistent bleeding despite pressure

›Fever or worsening pain

›Clear watery fluid from one nostril after injury

›Vision change or double vision

›Severe headache or repeated vomiting

›Follow up plan

›Recheck once swelling decreases

›ENT or facial plastics appointment if deformity or obstruction

12References/r19

Guidelines and evidence sources

›Evidence base

›Choosing Wisely Canada recommendation against routine nasal bone X rays for nasal fractures

›Low sensitivity and specificity for plain films

›Low impact on management

›CMAJ clinical update on nasal fractures

›Septal hematoma exclusion is essential

›Reduction timing within typical window

›StatPearls nasal septal fracture review

›Closed reduction timing commonly within 2 weeks

›Edema delay of several days can improve precision

›ENT UK nasal trauma guideline

›Assessment timing and reduction timing guidance

›Complications including septal hematoma

›Royal Children’s Hospital clinical guideline on nasal fracture

›Septal hematoma must be excluded on presentation

›Pediatric follow up after swelling reduction

›Evidence on antibiotics after closed nasal reduction

›Studies showing no significant benefit of routine prophylaxis in uncomplicated closed reduction

›Stewardship rationale for selective use

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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