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J Oral Maxillofac Surg69:2841-2847, 2011

A New Approach to the Treatment ofNasal Bone Fracture: Radiologic

Classification of Nasal Bone Fractures andIts Clinical Application

Daniel Seung Youl Han, MD, Yea Sik Han, MD, PhD, and

Jin Hyung Park, MD

Purpose: A radiologic examination is required in the treatment of nasal bone fracture to determine thefracture condition. Thus, there is an increasing need for radiologic classification of nasal bone fracturesthat can be applied to clinical practice.

Materials and Methods: Computed tomography was performed in 125 patients with nasal bonefractures to determine which axial view best showed the entire nasal view. The obtained axial view wasthen used as a reference for classification. The length from the top to the base of the nasal bone wasdivided into upper, middle, and lower levels, after which the fracture location was determined. If thefracture spanned the boundaries of these levels, it was classified as the total level. Subsequently, thefracture was subclassified based on the fracture direction and pattern and the concurrent fracture.

Results: Radiologic examination of patients with nasal bone fracture showed that nasal bone fracturewas frequently found at the total, middle, upper, and lower levels, in that order. Nasal bone fractures atthe upper level showed lower frequencies of complication and reoperation than the fractures at theother levels, whereas nasal bone fractures at the total level showed the highest frequencies of compli-cation and reoperation.

Conclusion: Radiologic classification can be useful for preoperative and postoperative evaluations ofnasal bone fractures and can be helpful in understanding such fractures because it can efficiently predictthe prognosis of a fracture.© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:2841-2847, 2011
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asal bone fractures account for the largest propor-ion of facial traumas. The number of cases of nasalone fracture has been increasing with the increase inhe number of injuries or car accidents.1 Nasal bone

fracture can lead to complications such as a severelydeformed nose and intranasal dysfunction unless it istreated. Furthermore, if it is not treated properly, themorbidity of complications will be higher than withother facial fractures.2

To properly treat nasal bone fracture, it is impor-tant to diagnose and evaluate it by a physical or

Received from the Department of Plastic and Reconstructive Sur-

gery, Kosin University Gaspel Hospital, Busan, Republic of Korea.

Address correspondence and reprint requests to Dr Y. S. Han:

Department of Plastic and Reconstructive Surgery, Kosin Univer-

sity, Gaspel Hospital, Amnam-dong, Seo-gu, Busan, 602-702, Repub-

lic of Korea; e-mail: [email protected]

© 2011 American Association of Oral and Maxillofacial Surgeons

278-2391/11/6911-0029$36.00/0

loi:10.1016/j.joms.2011.01.013

2841

radiologic examination. In general, nasal bone frac-ture can be diagnosed by identifying crepitus andtenderness in a physical examination. A radiologicexamination is commonly conducted to check thenasal bone, the fractured bone, and the nasal sep-tum. With the development of radiology and relatedtechnologies, most nasal bone fractures can be di-agnosed with radiographs and with computed to-mography (CT). Radiography is also required foraccurate treatment and postoperative evaluation, inaddition to the diagnosis of nasal bone fracture.3 Aadiologic classification of nasal bone fractures,hich plays a key role in the diagnosis and evalua-

ion of nasal bone fractures, has not been estab-ished, and its necessity has been increasing.

The present investigators classified nasal bone frac-ures based on radiography, which is commonly usedefore and after an operation, and further investigatedhe characteristics and prognoses of nasal bone frac-ures based on fracture location according to a radio-
ogic classification. Accordingly, this study reports the
mailto:[email protected]

2842 NEW APPROACH TO NASAL BONE FRACTURE

usefulness of a radiologic classification in understand-ing nasal bone fractures.

Materials and Methods

Radiographs and CT, which produce a nasal lateralview and a Water view, are commonly conducted todiagnose nasal bone fractures. In general, if abnormalfindings are seen on plain x-ray, CT is conducted.These 2 radiologies are also commonly conducted toidentify other facial fractures in patients with facialfractures. Therefore, if nasal bone fractures can beclassified based on the 2 radiologic examinations,then such examinations will be useful in clinicalpractice.

The nasal lateral view, Water view, and computedtomographic facial view were taken to analyze nasalbone fractures of 125 patients who visited the KosinUniversity Gaspel Hospital from January 2006 throughDecember 2008. Before the study, the researchersobtained informed consent from all patients and in-stitutional review board approval from the clinicaland educational institutions. Plain x-ray and CT wereconducted in all patients before an operation, fol-lowed by closed reduction to treat the nasal bonefracture. A nasal lateral view and a Water view weretaken 1 day after the operation. Plain x-ray was con-ducted 1 more time 1 week after the operation whilethe nasal pack was removed. CT was also conductedto evaluate concurrent fractures depending on itsnecessity, but it was not a routine study. Subse-quently, plain x-ray was conducted for 6 months at a2-month interval to observe complications and theneed for additional treatment such as corrective rhi-noplasty because of complications.

For radiologic classification of nasal bone fractures,the computed tomographic axial view that bestshowed the entire nasal bone was used as a referencefor classification.4 The length from the top to the baseof the nasal bone was divided into upper, middle, andlower levels, after which the fracture location wasdetermined. If the fracture spanned the boundaries ofthese levels, it was separately classified as the totallevel (Figs 1, 2). The fracture location was evaluatedhorizontally, after which the right side, left side, andright and left sides were denoted as R, L, and B,respectively. In addition, according to the pattern ofthe fracture, ie, depressed, elevated, cracked (green-stick), and comminuted, the fractured bone was de-noted as D, E, G, and C, respectively. In principle, if afracture was seen on the right and left sides, the rightside was described first. No concurrent fracture, nasalseptal fracture, another concurrent fracture, andnasal septum fracture and another concurrent frac-ture were denoted as N, S, O, and SO, respectively
(Table 1).
In the radiologic classification that was applied clin-ically, if the fractured nasal bone without a concur-rent fracture was depressed at the left side of theupper level, it was denoted as upper-level L-D-N; if thefractured nasal bone was accompanied by a maxillarysegmental fracture and the septal fracture was de-pressed to the right side of the middle level, it wasdenoted as middle-level R-D-SO. If the fractured nasalbone that was accompanied by a blowout fracturewas depressed to the right side of the lower level, itwas denoted as lower-level R-D-O; if the fracturednasal bone without another fracture was depressed tothe right side of the lower level and was elevated tothe left side of the middle level, it was denoted astotal-level B-DE-N (Fig 2). Based on these denotations,all nasal bone fractures were easily denoted to reviewthe information that should be reviewed before theoperation.

According to this radiologic classification, the dis-tribution of nasal bone fracture locations, complica-tions, and reoperation rate were investigated retro-spectively. In addition, the direction and form of thefractured bone based on fracture location and concur-rent fractures were identified, and the morbidity ofcomplications and reoperation rate based on eachcharacteristic were investigated. Complications suchas a fine imbalance of the nasal bone, a hump nose,and septal deviation in patients with nasal bone frac-ture were classified as deformities of the externalnose, whereas complications such as intranasal syn-echia and nasal obstruction caused by nasal septaldeviation were classified as intranasal dysfunctions.The percentages that were used in this study were

FIGURE 1. Based on a computed tomographic axial view, thelength from the top to the base of the nasal bone was divided intoupper, middle, and lower levels.

Han, Han, and Park. New Approach to Nasal Bone Fracture.J Oral Maxillofac Surg 2011.

rounded off and recorded to the nearest tenth.

HAN, HAN, AND PARK 2843

FIGURE 2. Radiographic classifications of the nasal bone. B, right and left; C, comminution; D, depression; E, elevation; G, greenstick; L,left; N, none; O, other combined; R, right; S, septum.
Han, Han, and Park. New Approach to Nasal Bone Fracture. J Oral Maxillofac Surg 2011.

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Results

Radiologic examination of patients with nasalbone fracture showed that the fracture was fre-quently found at the total, middle, upper, and lowerlevels, in that order. Because a fracture at the lowerlevel, which is the thickest portion of the nasalbone, occurs from a strong impact, it was com-monly classified under the total level because itoccurs in the middle and upper levels and is notrestricted to the lower level. Of 125 patients, 18.4%complained of external nose deformity and 15.2%complained of intranasal dysfunction. The reopera-tion rate was 5.6%.

Nasal bone fractures at the upper level showedlower frequencies of complications and reopera-tions than fractures at the other levels. In particu-lar, the frequency of complications related to intra-nasal dysfunction was significantly lower. Incontrast, nasal bone fractures at the total levelshowed the highest frequencies of complicationsand reoperations (Table 2). For the direction ofnasal bone fractures, fractures at the right and leftsides accounted for 36.8%, which was the highestfrequency, and fractures at the left side and at theright side accounted for 33.6% and 29.6%, respec-tively. For fractures at the middle level, the fre-quency of fractures at the left side was higher. Thefrequency of fractures at the right and left sides wassignificantly lower at the lower level and signifi-cantly higher at the total level (Table 3). For thepattern of nasal bone fractures, fractures at the

Table 1. DETAILED CLASSIFICATION AND DISPLAYPATTERNS OF THE NASAL BONE

DetailedClassification Display Pattern

Fracture site B, left and right; L, left; R, rightFracture pattern C, comminution; D, depression;

E, elevation; G, greenstickCombined fracture N, none; O, other combined; S,

septum


Table 2. DISTRIBUTION AND POSTOPERATIVE PROGNO

No. ofPatients

NasaDeformi

pper level 28 4 (14iddle level 35 7 (20

ower level 25 3 (15otal level 37 9 (24otal 125 23 (18

Han, Han, and Park. New Approach to Nasal Bone Fracture. J Oral Ma

right and left sides were classified individually. De-pression accounted for 45%, which was the highestfrequency. For patterns of nasal bone fracturesbased on location, greenstick accounted for 39.4%,which was the highest frequency at the upper level,whereas comminution accounted for 6.1%, whichwas lower at the upper level. Comminution ac-counted for 35.4%, which was the highest fre-quency at the total level (Table 4). Nasal bonefractures alone accounted for 52%, concurrent na-sal septal fractures accounted for 30.4%, and otherconcurrent facial fractures such as at the orbitalwall or maxilla accounted for 24%. For fracturesrestricted to the upper level, because these couldoccur from a weak impact, nasal bone fracturesalone accounted for the largest proportion. In con-trast, nasal bone fractures were relatively less fre-quently accompanied by nasal septal or other facialfractures. Nasal septal fractures or other facial frac-tures more frequently accompanied the nasal bonefractures at the total level (Table 5). For a prognosisbased on characteristics of nasal bone fracture,morbidity from complications was higher in casesof nasal bone fracture at the right and left sides.Morbidity from complications was lower for green-stick fractures, but frequencies of complicationsand reoperations were higher for comminuted frac-tures. In addition, frequency of complications washigher in cases with concurrent nasal septal frac-tures. In particular, frequency of complications re-lated to intranasal dysfunctions because of nasal

F NASAL BONE FRACTURE BASED ON ITS LOCATION

Dysfunction ofNasal Cavity (%)

Reoperation(%)

2 (7.1) 1 (3.6)6 (17.1) 2 (5.7)4 (16.0) 1 (4.0)7 (18.9) 3 (8.1)

19 (15.2) 7 (5.6)

Table 3. FRACTURE DIRECTION BASED ON NASALBONE FRACTURE LOCATION

Right (%) Left (%)Right andLeft (%)

pper level 12 (42.9) 11 (39.3) 5 (17.9)iddle level 9 (25.7) 16 (45.7) 10 (28.6)

ower level 12 (48.0) 10 (40.0) 3 (12.0)otal level 4 (10.8) 5 (13.5) 28 (75.7)otal 37 (29.6) 42 (33.6) 46 (36.8)


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septal deviation was higher and led to an increasedreoperation rate (Table 6).

Discussion

In 1978, Stranc and Robertson5 classified detailedracture patterns based on the direction of the impactnd its concurrent damage. According to the impactirection, impacts were classified as frontal impactsnd lateral impacts. According to the degree of dam-ge to the nasal bone and nasal septum, the impactas further classified into types 1, 2, and 3. This

lassification system is most commonly used for nasalone fractures, but it has some limitations in its ap-lication to clinical practice. Most nasal bone frac-ures are evaluated not by gross examination but byadiologic examination, and various classifications ofmpact direction and degree of damage cannot satisfyiverse treatments in clinical practice. That is, exceptor type 3 frontal impact and type 3 lateral impact,here is no difference in treatment methods for di-erse fracture types. Therefore, this classification sys-em is not clinically useful for the treatment of nasalone fractures.Murray et al6 examined nasal bone fractures in 50

orpses and classified these fractures as types 1 to 7.he classification criteria, however, were based on

he nasal septum, and the classification was con-ucted in corpses with a mean age of 71.6 years.ecause nasal septal fracture frequently occurs from

Table 4. FRACTURE PATTERN BASED ON NASAL BONE

Depression (%) Elevation (%)

pper level 12 (36.7) 6 (18.2)iddle level 28 (62.2) 7 (15.6)

ower level 20 (71.4) 3 (10.7)otal level 17 (26.2) 19 (29.2)otal 77 (45.0) 35 (20.5)

Han, Han, and Park. New Approach to Nasal Bone Fracture. J O

Table 5. CONCURRENT FRACTURE BASED ONNASAL BONE FRACTURE LOCATION

None(%)

Septum(%)*

Other Combined(%)*

pper level 21 (75.0) 4 (14.3) 3 (10.7)iddle level 17 (48.6) 14 (40.0) 7 (20.0)

ower level 12 (48.0) 8 (32.0) 7 (28.0)otal level 15 (40.5) 12 (32.4) 13 (35.1)otal 65 (52.0) 38 (30.4) 30 (24.0)

Nasal septal fracture and other facial fractures were seen inpatients.

Han, Han, and Park. New Approach to Nasal Bone Fracture.
wJ Oral Maxillofac Surg 2011.
he teenage years through the 30s (especially in the0s), the strength of the bone and cartilage of theorpses was likely to have differed from that of com-on nasal septal fractures. In addition, because the

one and cartilage could have been deformed byhemicals used in the corpses, it is difficult to con-ider this classification as a general classification ofasal bone fractures.Manson et al7 used CT to classify facial fractures into

ow-energy, middle-energy, and high-energy fracturesased on the degree of exodeviation and posterior de-iation of the nasal bone fracture and bilateral nasalone fracture. The direction of the external impact thataused the nasal bone fracture was classified as antero-osterior and lateral directions. Fracture patterns dif-

ered, however, because more impact can be exertediagonally to the bone; in addition, prediction of theracture pattern based on impact direction is only esti-ation. It is difficult to fully identify other concurrent

ractures using this classification.Before radiologic classification of nasal bone frac-

ures, the present investigators summarized the iden-ification of the criteria for nasal bone fracture andvaluation conducted by clinicians.

1. Determine the location of the nasal bone frac-ture—the side wall, the dorsum of the nasalbone, or the entire nasal bone.

2. Determine if the fracture is located at the right,the left, or bilaterally.

3. Determine if the fractured bone has been medi-ally displaced or laterally displaced and identifywhether the fracture is a slight crack or severecomminution.

4. Determine if there are other concurrent fractures,including nasal septal fracture. Open reduction orclosed reduction can be chosen because of theidentification. In general, if severe nasal septal frac-ture or another facial fracture accompanies thenasal bone fracture, open reduction is commonlyconducted, whereas closed reduction is con-ducted for mild nasal septal fracture.

When a new classification of nasal bone fractures

URE LOCATION

Greenstick (%) Comminution (%) Total

13 (39.4) 2 (6.1) 333 (6.7) 7 (15.6) 452 (7.1) 3 (10.7) 286 (9.2) 23 (35.4) 65

24 (14.0) 35 (20.5) 171

xillofac Surg 2011.

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that the new classification should be clinically usefulfor the evaluation and treatment of nasal bone frac-tures. Therefore, it was believed that a classificationsystem that could provide useful information for thetreatment of nasal bone fractures was more valuablethan a classification system that could identify alltypes of nasal bone fracture. In reality, to diagnoseand treat patients with nasal bone fracture in clinicalpractice, accurate identification of fracture location,direction and pattern of the fractured bone, and con-current fractures are more important than determina-tion of the degree of damage based on impact direc-tion or the power to increase a patient’s satisfactionand decrease complications. Based on this principle, anew classification was made using radiologic exami-nation, which is commonly conducted before andafter an operation, to evaluate the nasal bone. Further-more, criteria for the denotation and classificationincluded factors that are simple and can easily explainnasal bone fracture characteristics that should be con-sidered in clinical practice. In addition, the classifica-tion criteria were not determined for informationthat is seldom useful for the treatment of nasal bonefracture.

As mentioned in the Results, nasal bone fracturewas frequently found at the total, middle, upper, andlower levels, in that order. This result cannot fullyexplain, however, the frequency of nasal bone frac-tures based on their location. This is because thisstudy was conducted in patients with nasal bonefracture who visited the investigators’ hospital as ur-gent inpatients or outpatients because of trauma. Thatis, patients who were not aware that they had nasalbone fracture, such as greenstick at the upper level,even if they had nasal bone fracture, or patients whodid not wish to be treated even if they were aware

Table 6. DISTRIBUTION AND POSTOPERATIVE PROGNOFRACTURE

No. ofPatients (%) De

racture siteRight 37 (29.6)Left 42 (33.4)Right and left 46 (36.8) 1

racture patternDepression 77 (45.0)Elevation 35 (20.5)Greenstick 24 (14.0)Comminution 35 (20.5) 1

ombined fractureNone 65 (52.0)Septum 38 (30.4) 1Other combined 30 (24.0)

Han, Han, and Park. New Approach to Nasal Bone Fracture. J O

that they had nasal bone fracture were not included as

study subjects. This shortcoming is likely to be negli-gible because the investigators’ classification of nasalbone fractures focused more on providing informa-tion for the effective treatment of patients with nasalbone fracture than on the classification of fractures.

After the evaluation of the postoperative conditionof patients with nasal bone fracture according to thepresent radiologic classification of nasal bone frac-tures, the following results were obtained. Fracturesat the upper level of the nasal bone that were re-stricted to the nasal bone’s dorsum commonly oc-curred alone rather than being accompanied by otherfractures because of the weak impact that causedthem. Particularly, because nasal septal fracture israrely accompanied by other fractures, it producesfew complications such as intranasal dysfunction. Incontrast, fractures at the middle level, which is theweakest area of the nasal bone, had the highest fre-quency of occurrence and occurred more frequentlyat the left side of the nasal bone because the impactthat caused the fracture was frequently from the rightpunch of attackers. In addition, because a nasal septalfracture is commonly accompanied by another frac-ture, it is important to prevent related complications.Fractures at the lower level of the nasal bone hadmore depression patterns than other fractures. Theserarely occurred at the right and left sides and werecommonly accompanied by other facial fractures.Fractures at the total level of the nasal bone coveredlarge areas because of strong impact. Thus, thesecommonly occurred at the right and left sides ratherthan unilaterally. Because such fractures show a highfrequency of comminution and concurrent nasal sep-tal or other facial fractures, these also produce a highfrequency of complications or reoperation. Based onthese findings, results of an evaluation and prognosis

ASED ON CHARACTERISTICS OF NASAL BONE

l(%)

Dysfunction ofNasal Cavity (%)

Reoperation(%)

8) 2 (5.4) 1 (2.7)9) 3 (7.1) 1 (2.4)4) 14 (30.4) 5 (10.9)

) 3 (3.9) 2 (2.6)) 1 (2.9) 1 (2.9)) 1 (4.2) 0 (0.0)9) 14 (40.0) 4 (11.4)

) 3 (4.6) 1 (1.5)9) 14 (36.8) 4 (10.5)0) 2 (6.7) 2 (6.7)

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5 (6.53 (8.60 (0.05 (42.

6 (9.41 (28.6 (20.

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tion of the nasal bone fracture according to the frac-ture’s radiologic classification. In addition, mattersthat require attention can be reviewed during prepa-rations for the operation.

When nasal bone fracture is analyzed with radio-logic examination, there is a difference in the infor-mation that can be obtained from the nasal lateralview and the Water view, depending on the fracturelocation. That is, on plain x-ray, for a dorsum fracture,which is at the upper level, the fracture pattern canbe observed well in the nasal lateral view and rarelyobserved in the Water view (Fig 2). Conversely, for asidewall fracture, which is at the middle level andlower level, the fracture pattern can be observed wellin the Water view and rarely observed in the nasallateral view (Fig 2). The cost of treatment can likelybe decreased because the necessary radiologic exam-ination can be conducted before and after the opera-tion based on the aforementioned findings.

For a fracture that is at the boundary between thedorsum and the sidewall of the nasal bone at themiddle level, the fracture pattern can be clearly seenin the computed tomographic axial view, whereas itmight not be observed at all in the nasal lateral orWater view. Therefore, evaluation of nasal bone frac-ture with only a radiologic examination may causeerrors that would result in an inaccurate diagnosis.Therefore, in addition to a radiologic examination, aphysical examination should be conducted for thediagnosis and evaluation of nasal bone fracture.

The most important goal of treatment of patientswith nasal bone fracture is to return the patient’scondition to his/her condition before the injury.8 Tochieve this goal, it is important to conduct a radio-ogic examination from which the location of theasal bone fracture can be clearly determined be-ause an accurate evaluation of the nasal bone frac-ure should be conducted before the operation. In
ddition, results of the postoperative evaluation
hould be compared with results of the preoperativeadiologic examination. Therefore, it is likely thatadiologic classification of nasal bone fractures haslinical usefulness.According to the radiologic classification of nasal

one fractures, clinical information such as locationf the nasal bone fracture, fracture pattern, and con-urrent fractures can be easily analyzed. Furthermore,he characteristics and prognosis of nasal bone frac-ures based on fracture location can be predicted byhe radiologic classification. In addition, because nasalone fractures can be summarized with a simple de-otation according to this classification system, theppropriate operation method can be determined,nd matters that require attention during the opera-ion can be reviewed. Therefore, if the present radio-ogic classification of nasal bone fractures is applied inlinical practice, it will be useful in decreasing com-lications because important factors of the treatmentf nasal bone fracture can be identified.

References1. Atighechi S, Karimi G: Serial nasal bone reduction: A new ap-

proach to the management of nasal bone fracture. J CraniofacSurg 20:49, 2009

2. Schultz RC: One thousand consecutive cases of major facialinjury. Review Surg 27:394, 1970

3. Yabe T, Ozawa T, Sakamoto M, et al: Pre- and postoperativex-ray and computed tomography evaluation in acute nasal frac-ture. Ann Plast Surg 53:547, 2004

4. Finkle DR, Ringler SL, Luttenton CR, et al: Comparison of thediagnostic methods used in maxillofacial trauma. Plast ReconstrSurg 75:32, 1985

5. Stranc MF, Robertson GA: A classification of injuries of the nasalskeleton. Ann Plast Surg 2:468, 1979

6. Murray JA, Maran AG, Busuttil A, et al: A pathological classifica-tion of nasal fractures. Injury 17:338, 1986

7. Manson PN, Markowitz B, Mirvis S, et al: Toward CT-based facialfracture treatment. Plast Reconstr Surg 85:202, 1990

8. Hung T, Chang W, Vlantis AC, et al: Patient satisfaction afterclosed reduction of nasal fractures. Arch Facial Plast Surg 9:40,
2007

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