A Single Center Review of Pediatric Nasal Bone Fractures – An Analysis of Concomitant Injuries, Management, and Outcomes

Pediatric facial fractures are rare, accounting for only 15% of all facial fractures due to pediatric facial bone elasticity, full facial fat pads, small face to head volume ratio, incomplete pneumatization of sinuses, and maxillary stabilization by unerupted dentition.¹ The thin, prominent nature of nasal bones, however, still leaves them vulnerable for injury, and pediatric nasal bone fractures often prove challenging for both the patient and the physician.¹ The most common causes of nasal bone fractures in the pediatric population are assault and motor vehicle collisions, often related to airbag deployment or lack of seat belt restraints leading to facial injury.^2-4 Typical management strategies of isolated nasal bone fractures in children consist of watchful waiting versus closed reduction.^5-7 For pediatric nasal bone injuries, literature is limited on suggested management protocols to limit long-term sequelae of functional and aesthetic deformity of unrepaired fractures. Analysis of trends and management patterns at an urban, level-one trauma center provides insight into more severe clinical presentations. A single institution, 14-year retrospective review was conducted comparing all pediatric patients who sustained isolated nasal bone fractures to those with nasal bone fractures and concomitant facial fractures, as well as the morbidity and mortality between groups and the reconstructive options utilized. 

All radiographically diagnosed pediatric nasal bone fractures at a level-one trauma center between January 2000 and December 2014 were retrospectively assessed. Data points were obtained regarding patient demographics, etiology of injury, concomitant facial fractures and other systemic injuries, management, morbidity, and mortality. A pediatric patient was defined as any patient younger than 18 years. Morbidity was evaluated based on the occurrence of traumatic brain injury, admission to the intensive care unit (ICU), surgical intervention required for facial injuries, severe hemorrhage, Glasgow Coma Scale (GCS) score, need for intubation, and intrathoracic injury, as well as intrapelvic injury or fractures of the cervical spine, long bones, or pelvis. Exclusion criteria included adult age and craniofacial injuries that did not involve the nasal bone. All computed tomography (CT) scan reports used were extracted from the official attending radiologist report read on the day of admission. The total cohort of pediatric nasal bone fracture patients were compiled and assessed using Statistical Product and Service Solutions (SPSS) version 23 (IBM). Demographic information including sex and age were compiled, and the extent of facial fractures was tabulated and assessed. Patients were divided into cohorts based on whether or not they had an isolated nasal bone fracture. Groups were compared using Chi-squared analysis, and a Bonferroni correction was utilized for a more conservative alpha (a = 0.004). An Institutional Review Board approval for this investigation was obtained.

Cohort Demographics and Injury Etiologies

A total of 122 pediatric patients with nasal bone fractures presented from 2000 to 2014. Average age of the patients was 14.0 years (± 3.2), and the majority (91) were male. The most common etiology of nasal bone fracture was assault in 46 of the 122 followed by motor vehicle accident in 27 (Figure 1). Other causations included pedestrian struck by motor vehicle (16 of 122), blunt trauma (10 of 122), fall (13 of 122), sports (8 of 122), and gunshot wound (2 of 122). Table 1 presents the overall etiologies and fracture extent.  Figure 2 compares the etiologies of injuries for patients with isolated nasal bone fractures versus nasal bone plus concomitant facial fractures.

Distribution of Fractures

Of the patients with nasal bone fractures, 62 presented with an isolated nasal bone fracture while 60 presented with concomitant facial fractures. In the multifracture group, there were 53 orbital fractures, 21 frontal sinus fractures, 15 zygoma fractures, 13 nasoorbitoethmoid (NOE) fractures, 10 LeFort fractures, 7 maxillary sinus fractures, 7 mandibular fractures, 6 zygomaticomaxillary (ZMC), and 5 palate fractures in addition to the nasal bone fracture (Figure 3).

Fracture Management

Five of the 62 patients from the isolated nasal fracture group were treated with operative repair, 2 with closed reduction, 1 with open reduction, 1 with a septoplasty, and 1 with rhinoplasty. The latter 3 patients received their surgeries at a point in time after their original nasal bone trauma to both relieve functional obstruction and for aesthetic purposes. This is in comparison to the 60 patients with nasal bone fractures that occurred with concomitant facial fractures, of whom only 3 received treatment for their nasal bone fractures (2 received closed reduction treatment and 1 received an open reduction). Nasal bone fractures were treated equally when presenting in isolation and with other facial fractures (Table 2).

Morbidity and Mortality 

Morbidity results outlined in Table 3 show that 16 of the 62 isolated nasal bone fracture patients experienced loss of consciousness resulting from their injuries compared to 31 of the multifracture patients (P = 0.008). Seven of the isolated nasal bone fracture patients sustained intracranial hemorrhage compared to 21 of the multifracture group (P = 0.002). The average lowest GCS score was 13.3. Nine of the 62 isolated nasal fracture cases sustained a traumatic brain injury, in comparison to 33 of multifracture cases (P < 0.05) and 3 patients who suffered isolated nasal fractures were admitted to the ICU in comparison to 31 in the multifracture group (P = .000002). In both groups, there were 2 patients who sustained severe hemorrhage (P = 1.00). Cervical spine fractures were sustained in 4 patients in the multifracture group, compared to no patients in the isolated nasal fracture group (P = 0.056). There was no significant difference in need for intubation or a surgical airway, long bone or pelvic fracture, and intrathoracic or intrapelvic injury between groups. The average length of stay for the isolated nasal fracture group was 11.03 hours (sd = 45.42), compared to 10.93 hours (sd = 18.72) in the multifracture group (P = .988). There was 1 fatality in the isolated nasal fracture group and 2 in the multifracture group (P < 0.613).

Nasal bone fractures in the pediatric population commonly occurred with young males (91 out of 122), with the most common etiology being assault. After splitting the group into isolated nasal fracture and nasal fracture plus concomitant facial injury, assault still remained the most common etiology of injury, followed by motor vehicle accident for the multifracture group. By comparison, the most common etiology of pediatric craniofacial fractures nationally in the United States is motor vehicle collisions.⁹ A needs assessment of the local community conducted in 2000 by Elliot et al found that youth violence ranked among the highest noted neighborhood problems, surpassing poor housing and chronic health problems.¹⁰ The results are consistent with a high rate of pediatric craniofacial fractures caused by assault this community relative to the national average. 

The most common nasal bone fractures in the pediatric population were orbital, frontal sinus, and zygoma fractures. National trends suggest that the most common pediatric facial fractures are mandibular in origin.⁴ The data suggests that fractures found in association with nasal bone fractures are restricted to areas closer in proximity to the nasal bone. In this study, the most common concomitant extrafacial injury was traumatic brain injury, which occurred in 42 cases, followed by intracranial hemorrhage. Patients who sustained a nasal bone fracture often had limited trauma to the thorax, abdomen, and pelvis. Intracranial hemorrhage and traumatic injury occurred in all of the 3 fatalities, while additional injuries to the thorax, abdomen, and pelvis were also present. No significant difference in fatality was noted between the isolated nasal fracture group and the nasal plus concomitant fracture group. This suggests that the extent of facial injury was not a predictor of survival in the population. Regardless of the extent of cranial injury in the trauma setting, imaging to screen for intracranial hemorrhage is imperative given the findings.

In pediatric patients, the standard treatment for nasal bone fractures is closed reduction, a non-surgical treatment option.¹¹ However, results of this study indicated that most patients, with or without concomitant injuries, were monitored for complications without any intervention for their nasal bone fractures. Two patients received open reduction internal fixation surgery. One had a concomitant palate fracture and was brought to the operating room to also close deep facial lacerations and debride exposed bone and cartilage in the nose. The concomitant palate fracture was not treated surgically, and no plates or grafts were used. The second patient, with an isolated nasal bone fracture, returned after 2 months of initial presentation for an open reduction surgery and nasal endoscopic submucous resection of the inferior turbinate to fix a deviated septum and fractured nasal bones. Again, no plates or grafts were used. Two patients with isolated nasal bone fractures who did not receive surgery at the time of injury returned months later to correct aesthetic and functional issues from the nasal bone trauma through septoplasty and rhinoplasty. In summary, patients receiving surgical treatment for their nasal bone fractures suffered from injuries that required additional procedures in the operating room or suffered from injuries that severely obstructed the nasal valves. 

While surgical intervention may be useful in specific cases, Kang et al demonstrated that pediatric patients who opted for conservative treatment of their nasal bone fractures were met with improved bony contours through remodeling, without the need of surgery.¹¹ The data supports this conclusion by showing how frequently expectant management and closed reduction nonsurgical treatment options are used for nasal bone fractures, both with and without concomitant fractures. Additionally, treatment practices for patients with isolated nasal bone fractures and nasal bone fractures with concomitant facial fractures were not significantly different. In this study, surgeons treating both patient groups opted more frequently for expectant management rather than closed reduction or surgical intervention, and  also chose with equal frequency closed reductions, open reductions, septoplasties, and rhinoplasties between the 2 groups. Therefore, non-surgical treatment is preferred for both isolated and non-isolated pediatric nasal fractures.

Pediatric nasal bone fractures are rare and can present in 2 groups: isolated nasal bone fracture or with concomitant fractures. In this study, the extent of facial injuries was not predictive of survivability in cases of facial trauma involving the nasal bone, and both groups experienced similar fatality rates. Patients with multiple facial fractures were more likely to have traumatic brain injuries than those with isolated nasal bone fractures. Patients with multiple facial fractures were also more likely to be admitted to the ICU. The treatment of the nasal bone fracture itself, however, was not significantly different between patients with isolated nasal fractures versus those with concomitant facial fractures. The rates of expectant management, closed reduction, open reduction, septoplasty, and rhinoplasty were not significantly different between the 2 groups as well. Both were treated more often with expectant management, although 1.7% of those who initially did not undergo surgery returned later for surgical intervention for aesthetic and functional reasons. While patients with nasal bone fractures and concomitant fractures may encounter increased ICU admittances and traumatic brain injuries, the ultimate treatment for the nasal bone fracture did not differ in practice in this study, and  surgeons opted for expectant management of pediatric nasal bone fracture 92% to 95% of the time regardless of the presence or absence of concomitant facial fractures.