Nasal bones are the most commonly fractured bones in the face. Fortunately most of the fractures are mild in nature and do not need any repair. If the fracture leads to change in the shape of the nose, it can be repaired.
At the time of initial injury there can be swelling of the nose and a subtle deviation of the nose might be missed. After the first few days as the swelling subsides a deviation of the nose can become noticeable. The nasal bones heal very fast. Usually in 10 to 14 days the nasal bones can heal enough that you cannot move them by force.
This has implications towards the timing of the repair. At the time of nasal injury x-rays of the nasal bones can be obtained but are not necessary. They usually help in legal issues related to assaults or injuries and might be necessary for insurance approval in certain cases. From a pure medical perspective, x-rays will not determine the nature of the treatment you receive.
There are two things that need to be addressed immediately after a nasal injury.
First is the ability to breathe through the nose. If the person cannot breathe at all through the nose immediately after nasal trauma, this could indicate collection of blood in the nasal septum (septal hematoma) which can block the nose. It needs to be surgically drained or will lead to an abscess and possible complete loss of nasal septum. That in turn can cause severe deformity of the nose such as ‘Saddle Nose’.
The other issue to determine is if the nose has become crooked compared to what it looked before the injury.
Closed Reduction of Nasal Fracture: This involves putting the patient to sleep and then moving the bones back towards the center using digital pressure with fingers and thumb. It can be facilitated with certain instruments that can act as levers to push the bones towards the center.
This approach can only be used in the first 10 to 14 days after a nasal fracture. After that time period the bones could be healed and you cannot manually move them back in place.
Open Reduction of Nasal Fracture: In this approach the nasal bones are re-fractured using chisels called osteotomes and a hammer. This approach is used in healed nasal fractures after the first two weeks of injury.
I use both approaches. My biggest concern is to differentiate between existing nasal deviation and a new deformity. At times a patient might have a slight deviation of the nose to begin with and was never aware of it. If that is not determined before surgery then the bones might not move back to place without breaking them again. In essence, I always plan to use open technique if the closed technique does not fix the problem.
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