Courtesy of Godoy Medical Forensics
Nasal fractures are the most common facial fracture and the third most common fracture of any bone in the body. They most frequently occur as a result of assault or motor vehicle collisions. What we call our “nose” is made up of both bone and cartilage where the cartilage sits in front of the bone. The cartilage acts as a shock absorber when the nose is impacted.: An impact that comes from the front requires more force to fracture the bone than an impact that comes from the side.
Many nasal fractures result in obvious deformity and most result in nasal bleeding. Some patients may also have bruising to one or both of their eyes (black eyes). Acute complications include septal hematomas, which are a collection of blood in the nose and may lead to tissue death.
Long term complications include:
- Nasal obstruction;
- Frequent nose bleeds due to a deviated septum.
Does My Patient Have a Nasal Fracture?
According to Dr. Greg Gilbert, from Stanford University Medical Center, x-rays of the nose serve no purpose in diagnosing nasal fractures: “A nasal fracture is a clinical diagnosis and not one that should be made with radiographs. They have a high false positive rate and cannot be relied upon with any degree of certainty as whether a nasal fracture is present or not.”
What is a “clinical diagnosis”? It is the use of a physical exam and a health history to determine a diagnosis. In the case of nasal fractures, it involves assessing for deformity, bruising, swelling, and tenderness. Questions about the injury are asked:
- How did this happen?
- Where did the object impact and from what direction?
- Have you ever had a nasal fracture?
- Do you have any other conditions?
These signs and symptoms are then used to determine whether or not a nasal fracture is likely to exist. A referral may be made to a specialist, especially if surgery is possible.
Another item that may be useful in confirming a diagnosis is the recovery. Nasal fractures can take six to eight weeks to heal and one would expect tenderness for many days—possibly weeks—while this healing process occurs. If the tenderness is gone within a day or two, it is unlikely that a nasal fracture is present.
What Does the Literature Say?
“Legal Aspects in Nasal Fractures”, Rhinology, 1991
A criminal act is involved in a high percentage of cases of nasal fracture, and exact medical information describing the damages found is mandatory for the criminal court. It is necessary, that the medical information are obtained from the ENT-department, where the patient is treated, as the information obtained from the [emergency] department has a too low degree of truth in the establishment of the diagnosis. The statement should include information on the treatment given, as linear fractures in good position requiring no treatment may be classified legally as an offence against the person rather than as a bodily harm. X-ray examination of the nose in cases of nasal fracture gives a much too high number of false positive and false negative results to have any legal value, and, having no medical value as well, they should not be taken unless for scientific purposes.
“…old nasal fractures heal by ossification in only 50%, while the remainder heal with more or less fibrosis connecting the fragments thus being visible by X-ray examination for the rest of the life….”
“…a linear nasal fracture in good position is diagnosed and no treatment is indicated. The frequency of this findings is 30-59% [sic]…”
“Medico-Legal and Ethical Aspects of Nasal Fractures Secondary to Assault: Do We Owe a Duty of Care to Advise Patients to Have a Facial X-ray?,” The Journal of Medical Ethics, 2013
Guidelines advise that x-rays do not contribute to the clinical management of simple nasal fractures. However, in cases of simple nasal fracture secondary to assault, a facial x-ray may provide additional legal evidence should the victim wish to press charges, though there is no published guidance.
“…Bolam establishes the principle that if a responsible body of opinion exists that nasal fractures can be diagnosed and managed on clinical findings alone this should constitute valid evidence for the courts…It may be deemed unethical to expose a patient to radiation to prove a point for law (and possible litigation) where there is no medical benefit…”
Our medical expert recently got retained in a criminal case where the victim suffered an injury to her nose. She had a reported history of previous nasal trauma but was diagnosed with a nasal fracture by x-ray in the emergency department. Our expert testified that a diagnosis of nasal fracture made by x-ray has a high false positive rate and cited literature to support his opinion. He also testified that there was no evidence of deformity or bruising in the photos taken two days later and that the victim didn’t use the pain prescriptions that were given to her. His opinion was that, if a nasal fracture existed at all, it was not recent. The client was acquitted of all charges.
In a civil medical malpractice case, the mismanagement of a nasal fracture can lead to long-term cosmetic or physical health issues. Surgical intervention to reduce the fracture may be necessary but first it is important to rule out associated injuries and complications, such as orbital blowout fractures, septal hematomas, and duct injuries.
If a fracture is confirmed, the case development should then focus on the necessary treatment. Many, if not most, fractures require no treatment at all and generate no long-term effects or complications. If this is the case, does the fracture still constitute great bodily injury (GBI) or are the damages significant enough to warrant restitution? Expert testimony in this area may be beneficial as well.
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