A Modified Approach to Closed Nasal Fracture Reduction Using Lateral Osteotomy

Displaced Nasal Fracture Treated with Closed Reduction and Lateral Osteotomy

Our patient contacted us after sustaining a blow to the nose while playing sports abroad, which resulted in significant nasal deformity and breathing difficulties. Nasal fractures are among the most common traumatic injuries to the facial region. Blows to the nose can occur as a result of sports injuries, falls, traffic accidents, physical trauma, or accidents in daily life. Depending on the direction and severity of the trauma, complications such as displacement of the nasal bones, curvature of the nasal bridge, deviation of the nasal axis, aesthetic irregularities, and—in some patients—difficulty breathing through the nose may develop. Treatment for a nasal fracture must be planned based on the fracture pattern, the degree of displacement of bone fragments, the time elapsed since the trauma, and the patient's existing aesthetic and functional complaints. Upon examination, we determined that our patient had a nasal fracture displaced to the right.

What Are the Appropriate Timeframes for Reduction After a Nasal Fracture?

The first few hours following the trauma: If the patient reaches a specialist immediately after the injury—before any edema or swelling develops—the fracture can often be successfully realigned within those initial hours. Sometimes, the procedure can even be performed in an office setting.

Children have a higher incidence of "greenstick" fractures, and their bones heal faster than those of adults. The period between 3 and 7 days post-trauma is crucial for children. Because bone healing and recovery occur much more rapidly in children, performing the reduction within the first 7 days is critical. In cases of simple depressed fractures, one might sometimes choose to wait without intervening, considering the possibility of a greenstick fracture; however, the patient must be examined by an ENT specialist to rule out potential complications such as septal hematoma.

Days 5–10 post-fracture (The "Golden Period" for adults): Intense post-traumatic edema can prevent the physician from accurately palpating the fracture lines or clearly visualizing the nasal shape. A waiting period of 3–5 days is usually observed to allow the swelling to subside. For adults, the window between days 5 and 10—when the bones have not yet fully set but the edema has decreased—is the ideal time for intervention.

Days 10–14 (Maximum Limit): After day 14, the nasal bones begin to knit (fixate) in the incorrect position. Beyond this timeframe, performing a closed reduction becomes extremely difficult or impossible.

In the case of the patient shown here, as more than 14 days had elapsed, the patient was informed about the challenges of the procedure and the potential need for an additional osteotomy.

In this case, a patient presented with a displaced nasal bone fracture following a blow to the nasal region sustained more than two weeks prior. The patient visited our clinic from abroad to correct the nasal deformity resulting from the trauma. Examination revealed trauma-induced displacement of the nasal bones and asymmetry in the nasal contour. The fact that the patient presented more than 14 days after the injury was particularly significant for treatment planning. Closed reduction performed in the early stages of a nasal fracture is easier to execute because the displaced bones have not yet fully united. However, once several weeks have elapsed since the trauma, healing and stabilization of the fracture segments may have already begun, making it more difficult to restore the bones to their original positions using only standard closed reduction.

Indications for Lateral Osteotomy During Closed Nasal Fracture Reduction

Conventional closed reduction techniques may sometimes prove insufficient during nasal fracture reduction, creating a need for lateral osteotomy—a method involving controlled bone incision.

The primary indications for lateral osteotomy during the management of acute nasal trauma or early-stage fractures are as follows:

Mobilization (Disimpaction) of Fixed and Impacted Fractures: If the nasal bone has become jammed or locked against the frontal process or maxilla due to the severity of the trauma, the routine use of elevators (such as Asch or Walsham forceps) may be inadequate to mobilize the bone. In such cases, a controlled lateral osteotomy is required to free the bone.

Delayed Presentation and Early Union: If more than 7–14 days have elapsed since the injury and the bone fragments have begun to unite in a malpositioned state, mobilizing the fracture via closed reduction becomes impossible. Lateral osteotomy is essential to remobilize the bony segments.

Inadequate or Unstable Reductions (Asymmetric Spring-Back): If, immediately after being repositioned, the fracture fragments revert to their original deviated position—often due to the "memory" of the cartilaginous/bony septum or tension from soft tissues (the "spring-back" phenomenon)—bilateral or unilateral lateral osteotomy is employed to fully release the bony wall and stabilize it at the midline. 

Anatomy of Complex and Displaced Fractures – Severe Lateral Displacement (Deviated Nose): In cases where the nasal pyramid as a whole has shifted significantly off the midline, correcting only the fractured side is insufficient; the contralateral bony wall—which remained stable but became angulated—must also be fractured via lateral osteotomy and repositioned medially (toward the midline).

Pre-existing Deformities Present at the Time of Trauma – Hump or Wide Nose: If the patient had a marked axial deviation, excessive width (wide nasal vault), or a large hump prior to the trauma, correcting only the fracture caused by the trauma would yield an asymmetrical and cosmetically unsatisfactory result. Since the patient is already undergoing intervention, a simultaneous lateral osteotomy can be performed to ensure structural stability and aesthetic harmony.

Following the patient's assessment, the plan was to correct the trauma-induced deformity using the most limited surgical intervention possible, rather than performing a comprehensive rhinoplasty. To this end, a closed nasal fracture reduction combined with a unilateral external lateral osteotomy was performed. The primary objective of this approach was to achieve controlled mobilization of the displaced nasal bone and reposition it into a more appropriate anatomical alignment.

Lateral osteotomy is a key technique used—particularly in rhinoplasty—to achieve controlled mobilization of the nasal bones; however, it is also applicable in select cases of traumatic nasal bone fractures. It offers the surgeon a means of controlled correction, especially in situations where some time has elapsed since the trauma, the bone segment has begun to stabilize in a displaced position, and achieving adequate mobilization through manual manipulation alone is difficult.

In this patient, a unilateral lateral osteotomy was chosen because the fracture and deformity were more pronounced on one side. Bilateral osteotomy is not required for every nasal bone fracture. Performing the osteotomy only on the side necessary to correct the deformity—based on the fracture's anatomical characteristics—can facilitate adequate mobilization while minimizing unnecessary trauma to the bone. The fundamental goal of surgical planning is to restore the anatomical alignment of the nasal bones with the most limited intervention possible.

Following the external lateral osteotomy, the displaced nasal bone was mobilized in a controlled manner, and the closed reduction procedure was carried out. During the reduction, the position of the nasal bones, the contour of the nasal dorsum, and the alignment of the nasal axis were assessed. The aim was not merely to close the fracture line but also to restore the nasal framework—disrupted by the trauma—to the most symmetrical and properly aligned position possible. The timing of surgery is a crucial factor in nasal fracture reduction. Edema occurring immediately after trauma can hinder the assessment of the true extent of the nasal deformity. Once the edema subsides, the deformity becomes more apparent, allowing for a more accurate treatment plan. However, a significant delay following the injury—during which the bones may begin to heal in a displaced position—can limit the success of simple closed reduction. Therefore, the timing of presentation after trauma, the type of fracture, and the characteristics of the deformity must be evaluated collectively.

In this case, it was determined that standard closed reduction might not provide sufficient mobilization, given that more than two weeks had elapsed since the trauma. Controlled mobilization of the nasal bone via unilateral external lateral osteotomy, followed by closed reduction, facilitated the correction of the deformity. Thus, a targeted surgical treatment for the specific fracture was achieved without the need for more extensive open rhinoplasty or osteoplastic procedures.

Appropriate external support and bandaging were applied postoperatively to maintain the nasal bones in their new position. While awaiting stabilization of the nasal bones and the resolution of soft-tissue edema during the postoperative period, the patient was provided with necessary guidance regarding trauma avoidance and postoperative care. Preventing further impact to the nose, particularly during the initial weeks, is essential to avoid redisplacement of the bones.

Photographs taken at various stages of this patient's treatment process assist in evaluating the outcomes of the surgical approach employed. The article begins by presenting preoperative photographs, which reveal the trauma-induced nasal deformity, displacement of the nasal bones, and asymmetry in the nasal contour. Subsequently, photographs taken immediately after the procedure are presented to demonstrate the changes in the nasal framework and external appearance following reduction. Finally, photographs taken 12 days post-surgery, following the removal of bandages, are shared; images from this stage are crucial for assessing the nasal axis and contour during the early postoperative period.

It is not possible to apply the same treatment method to every patient with nasal fractures. While closed reduction alone may suffice for simple, minimally displaced fractures, a combination of surgical techniques may be required for patients presenting with significant displacement or delayed presentation. Lateral osteotomy is one such technique that can facilitate the controlled mobilization of nasal bones and the correction of deformity in suitable patients.

In our patient—who presented to our clinic more than two weeks after the trauma with a displaced nasal bone fracture—the aim was to correct the trauma-induced deformity by combining unilateral external lateral osteotomy with closed nasal fracture reduction. This approach allowed for the repositioning of the nasal bones through a more limited surgical intervention, tailored to the specific characteristics of the fracture line and deformity. Achieving controlled mobilization via lateral osteotomy can be a viable treatment option, particularly in selected cases where several weeks have elapsed since the trauma and the fractured segments have begun to stabilize in a displaced position. This case also demonstrates that treatment following nasal trauma should be planned by evaluating not only the presence of a fracture but also the fracture type, the degree of displacement, the time elapsed since the trauma, and the resulting aesthetic and functional deformities. Through appropriate patient selection and accurate surgical planning, the goal is to achieve a result that is satisfactory from both functional and aesthetic perspectives while preserving the anatomical integrity of the nasal skeleton as much as possible.

You can read articles related to "nasal fracture" prepared by Dr. Murat Enöz and published on this website via this search result link (you can see the articles by clicking on "more posts" at the end of the page) >> https://www.ent-istanbul.com/search?q=nasal+fracture

Source links >> Application of Lateral Osteotomy in Nasal Bone Fracture / Nasal Fracture Reduction - StatPearls - NCBI Bookshelf / Application of Lateral Osteotomy in Nasal Bone Fracture / Delayed Reduction of Nasal Bone Fractures / Understanding Nasal Bone Fractures and Its Effects on Management: A Prospective Study

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

Private Office:

Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
Appointment Phone: +90 212 561 00 52

E-Mail: muratenoz@gmail.com 
Mobile phone: +90 533 6550199

Fax: +90 212 542 74 47