Nasal bone fractures are the most common facial fracture, and they are especially common among adolescents and young adults who play competitive sports. The nasal bones are paired bones that form the upper third of the nose, attaching to both the forehead and the cheekbones.
The nasal bones give structure to the upper third of the nose; the lower two-thirds is made of cartilage. When the nasal bones fracture, the septal cartilage often fractures as well.
Evaluation
The first step in evaluating a possible nasal fracture is to make sure there is no evidence of brain or spine injury. If there is any concern for these, a comprehensive evaluation at a trauma center is recommended. The next step is to look for other facial fractures, such as orbital or mandible fractures; these are sometimes obvious and other times more subtle. The symmetry and shape of the nose and the septum are then assessed, and a collection of blood within the septum (a septal hematoma) must be ruled out. Rarely, cerebrospinal fluid can leak from the brain into the nose; persistent salty drainage should be investigated further.
Dr. Namin has a low threshold for obtaining a CT scan of the face after facial trauma. Plain X-rays provide little information and are not helpful in guiding treatment, whereas a CT scan shows the entire facial skeleton in great detail, allowing injuries, and the angulation and severity of nasal fractures, to be detected accurately. This helps determine whether a closed nasal reduction or a septorhinoplasty would best address the deformity.
Treatment Options
Observation (do nothing). In many situations, the best option during the acute phase is to do nothing. The improvement that can be achieved in minimally displaced fractures is small, and the potential benefit is usually not worth the risk.
Closed nasal reduction. Closed nasal reduction is a good option in some cases. Dr. Namin uses a metal instrument to manually move the bones back into position. It is an imprecise operation (the bones cannot be placed exactly where desired, and they cannot be fixed in place), but in cases of severe nasal deviation after a fracture, it can produce significant improvement. Patients are often happy with the result, which comes close to their pre-injury appearance.
Acute septorhinoplasty. As the pages above describe, preparing for a septorhinoplasty involves substantial planning and evaluation, as well as a degree of psychological readiness. After a nasal fracture, a patient is often still processing the trauma and not mentally prepared for a major surgery with lifelong cosmetic implications. For this reason, Dr. Namin typically avoids performing septorhinoplasty in the acute setting. In young patients playing competitive sports, he strongly recommends waiting until their competitive career is complete; after rhinoplasty, the nose is more susceptible to significant injury if it sustains blunt trauma in a contact sport. The patients most likely to undergo acute septorhinoplasty are middle-aged to older patients who sustain a severe nasal bone and septal fracture after a motor-vehicle collision or a fall. Nasal bones can be reduced, but cartilage cannot be “reduced” the way bone can; after a severe septal fracture, the cartilage typically needs to be rebuilt with rib grafting.
Delayed septorhinoplasty. Delayed septorhinoplasty is an excellent approach. Dr. Namin will often recommend observation or closed nasal reduction during the acute period, and then, at least three months after the injury, if breathing problems or cosmetic concerns persist, a delayed septorhinoplasty can be considered.
Returning to Contact Sports After a Nasal Fracture
Healing varies from person to person. By 4-6 weeks, the bones have regained most of their strength, and for most sports, such as soccer or basketball, there is minimal added risk in returning at that point. By 3 months, the bones are typically fully healed, though they will always be slightly weaker than before; this is why boxers and MMA athletes are usually advised to wait this long to minimize the risk of re-fracture.
A protective face mask can help shield the face and allow an earlier return to sport, but a custom-made mask is important. Generic, over-the-counter masks do not fit the face properly, and their benefit is likely minimal.
It is important to remember that all contact sports carry an inherent degree of risk. Even in healthy individuals, participation involves the possibility of facial fractures and other musculoskeletal injuries. So while the timeframes above are offered as general guidance, there is always some risk in returning to play, and much of it ultimately comes down to personal risk management.