Lesson 8:-
The nose is the most common facial bone to be fractured. The injury involves the nasal septum. This structure is composed of the vomer, the nasal bone and the cartilaginous quadrangular cartilage. A blow to the inferior nose is more likely to injure the cartilagenous septum. A lateral blow is more likely to injure the nasal bones (superior 1/3 of the nose).
Nose bleeding (or epistaxis) is a relatively common occurrence (and may be due to many different causes). The source of bleeding is rarely visible. This can be difficult to manage on the field of play. Direct compression, the application of Vaseline or packing the nose can all be good strategies. Topical decongestants (like Otrivine) can also be used to help reduce bleeding. Off-the-pitch cautery, using a silver nitrate stick, might be needed.
Examination: Ask the player and their friends whether they feel that their physical appearance has changed. Inspect the external nose and internal structure using a nasal speculum. Careful palpation of the bony structures about the face, an assessment of facial sensation and checking visual fields and eye movements are all important. Always remember to assess for associated injuries.
When inspecting the nose, it is especially important to look for a septal haematoma. Failure to identify these can lead to long-term deformity and morbidity. Haematomas can be confused with the inferior turbinate, especially when they are bilateral. When probed, a haematoma is soft as compared with the firm texture of the neighbouring nasal septum. Haematomas need drainage and packing by an ENT surgeon.
Investigations: In cases where a “simple” nasal fracture is suspected, no imaging is needed. Facial X-rays are generally not helpful as they have poor sensitivity and specificity and are frequently confusing. Facial CT is much more reliable when a more significant bony injury (i.e. a facial fracture) is suspected.
Treatment: It is almost always acceptable to treat the player with regular decongestants and review in two days. In the acute setting, where significant deformity exists, consider closed manipulation using a gloved hand. There is, however, no good evidence favouring early reduction of simple nasal fractures.
In most situations, it is usually preferable to allow several days for any swelling to improve. Reduction should be done within 5-10 days. This can be done by both open and closed methods.
Return to play following nasal fracture: Best practice in this area is somewhat debatable. In most cases, fracture healing occurs within three weeks. Ideally, the player should avoid contact during this time. Some athletes will, however, decide to accept the deformity and continue playing. Thermoplastic facemasks can be used to help protect the injury.
Any septal deviation can be treated as a delayed procedure. This may be required for cosmetic and functional reasons.
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Jatin Tyagi 