DOI:10.2214/AJR.05.1067
AJR 2007; 188:W86-W92
© American Roentgen Ray Society
High-Resolution Sonography for Nasal Fracture in Children
Hyun Sook Hong1,
Jang Gyu Cha1,
Sang Hyun Paik1,
Seong Jin Park1,
Jai Soung Park1,
Dae Ho Kim1 and
Hae Kyung Lee1
1 All authors: Department of Radiology, Soonchunhyang University Hospital, 1174
Jung-Dong, Wonmi-Gu, Bucheon-Si, Gyeonggi-Do 420-021, South Korea.
Received June 21, 2005;
accepted after revision February 27, 2006.
Address correspondence to H. S. Hong.
WEB
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Abstract
OBJECTIVE. We describe the sonographic findings of nasal fracture in
children, and we evaluate the diagnostic value of sonography as compared with
conventional radiography and clinical findings to determine whether sonography
can be a primary technique for evaluating nasal fracture in children.
MATERIALS AND METHODS. Conventional radiographs and sonographic
scans were obtained in 26 consecutive children with nasal trauma who were seen
at our hospital from March 2003 to March 2005. There were five girls and 21
boys, and their ages ranged from 1 year 9 months to 15 years 11 months (mean
age, 9.9 years). The following sonographic scans (HDI-5000 unit with a
7-15-MHz linear array transducer) were used to evaluate the nasal bone at
different levels: a midline longitudinal image; axial scans of the nasal bones
at the upper, middle, and lower levels; images of the nasal septum; and
transverse and longitudinal scans of both lateral walls. Ten children also
underwent CT.
RESULTS. Conventional radiographs depicted 14 (54%) of 26 fractures.
Sonographic scans were able to show all the fracture lines. One case was
diagnosed as an old nasal fracture on the basis of a physical examination,
even though a visible fracture line was seen on sonography. The sonographic
findings of nasal fracture were disruption of the bone continuity with or
without separation of the fractured segment (7/26), displacement of the bone
segment as being depressed or overriding (20/26), associated septal deviation
(7/26), and separation of the pyriform aperture of the maxilla and nasal bone
(2/26). The associated findings were soft-tissue edema and hypoechoic hematoma
near the fracture lines in 25 cases. The fractures involved both sides of the
nasal bones in 11 of 26 cases, the midline part of the bones in six of 26
cases, and the unilateral paramedian or lateral part of the bones in 12 of 26
cases. Among the 10 CT scans, one CT scan did not depict the fracture, showing
only soft-tissue swelling, and one scan showed fractures of the orbital floor
and maxilla.
CONCLUSION. Sonography can be a primary diagnostic technique for
evaluating nasal fracture in children. It inflicts no radiation, provides
various imaging planes without positional change, and can be used to evaluate
the cartilaginous septum. Potential pitfalls are the nasofrontal suture, the
junction between the nasal bone and the pyriform aperture of the maxilla, the
vascular groove, and the presence of an old fracture. CT can be used in
addition to sonography in cases of suspected complex facial bone trauma.
Keywords: emergency radiology • facial fracture • injury • pediatric imaging • nose • sonography • trauma
Introduction
Nasal fracture is the most commonly seen facial fracture
[1,
2]. During the early years of
childhood, the nasal skeleton is proportionally more cartilage than bone, so
the diagnosis of nasal fracture is more difficult. The prompt identification
and management of nasal fractures and septal fractures are imperative to avoid
the potential complications of nasal obstruction and posttraumatic nasal and
septal deformity. Septal injury associated with nasal fracture is the main
cause of postoperative nasal deformity and obstruction
[3]. However, no imaging
techniques for the diagnosis of septal fractures in the case of simple nasal
fracture have yet been reported, to our knowledge.
Although a physical examination is regarded as the gold standard for the
diagnosis of nasal fracture, the surrounding hematoma and edema may be
considerable and can make the diagnosis of nasal fracture more difficult to
establish. Approximately 25% of the patients who are referred for evaluation
of nasal fracture are found not to have a new fracture
[2]. Adequate imaging of a
nasal fracture is often required because of the legal consequences that can
result from the injury's cause
[4]. Although a radiographic
examination remains the initial step for the radiologic assessment of nasal
injury, its sensitivity is not high and it is difficult to evaluate sidewall
injury on conventional radiographs
[2,
4-6].
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Fig. 1A —Examples of normal sonographic findings. Images illustrate
defined positions of head on longitudinal (A) and axial (B)
sonographic scans. Upper, middle, and lower levels of nasal bone are shown in
yellow, blue, and pink, respectively.
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Fig. 1B —Examples of normal sonographic findings. Images illustrate
defined positions of head on longitudinal (A) and axial (B)
sonographic scans. Upper, middle, and lower levels of nasal bone are shown in
yellow, blue, and pink, respectively.
|
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For trauma patients, CT can depict the position and orientation of the
displaced fracture. An alternative to radiography is sonography.
High-resolution sonography that can provide detailed information about the
more superficial regions has been developed; however, reports about
sonographic evaluations of nasal fracture are limited
[7-11].
We describe the sonographic findings of nasal fracture in children, and we
evaluate the diagnostic value of sonography as compared with clinical findings
and conventional radiographs.
Materials and Methods
Conventional radiographic and sonographic examinations were performed on 26
consecutive children with nasal trauma who were seen at our hospital from
March 2003 to March 2005. There were five girls and 21 boys, and their ages
ranged from 1 year 9 months to 15 years 11 months (mean age, 9.9 years). The
radiographic examinations were both the lateral view of the nose and the
Waters view. The following sonographic images (HDI-5000 with a 7-15-MHz linear
array transducer and a 3.5 x 1.2 cm hockey-stick probe, Advanced
Technology Laboratories) were used to evaluate the nasal bone at different
levels (Figs. 1A and
1B): a midline longitudinal
image (Fig. 2A); the axial
scans of the nasal bone at the upper (Fig.
2C), middle, and lower levels; images of the nasal septum
(Fig. 2D); and transverse and
longitudinal scans of both lateral walls
(Fig. 2B). The transducer was
applied directly to the skin without a standoff pad.
Ten of the children also underwent CT. Follow-up sonographic examinations
after reduction were performed for 11 of the 26 patients. The interval between
the injury and sonography was within 4 days and averaged 1.2 days. The
interval between conventional radiography and sonography was also within 4
days and averaged 1.4 days.
We evaluated the disruption of bone continuity, displacement of fracture
segments, and status of the septal cartilage. The patients' data are
summarized in Table 1. Two
conventional radiographs and the sonographic images of each patient were
analyzed by two radiologists at different times, and they then evaluated the
correlation of both examinations by working in consensus.
Results
The conventional radiographs depicted 14 (54%) of 26 fractures. Sonography
showed all of the fracture lines. One case was diagnosed as an old nasal
fracture on the basis of physical examination, although a fracture line was
visible on the sonographic examination. The sonographic findings of the nasal
bone fractures were disruption of bone continuity with or without separation
of the fractured segment (7/26) (Figs.
3A and
3B), displacement of the bone
segment as being depressed or overriding (19/26) (Figs.
4A and
5B), associated septal
deviation (7/26) (Fig. 4B and
5A), and separation of the
pyriform aperture of the maxilla and the nasal bone (2/26)
(Fig. 6A).
The associated findings were soft-tissue edema and hypoechoic hematoma
(Fig. 6B) near the fracture
lines in all patients except the patient with an old fracture
(Fig. 7B). The fractures
involved both nasal bones in 11 of 26 cases, midline fracture in four of 26
cases, and unilateral paramedian or lateral fracture in 11 of 26 cases.
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Fig. 7B —5-year-old boy with blunt nasal trauma. On axial sonogram of
upper nasal bone, focal bone disruption (arrow) is seen, but there is
no soft-tissue edema or hypoechoic hematoma near bone gap. On physical
examination, there is bump on nasal dorsum, but neither crepitation nor pain,
so plastic surgeon regarded bump as old fracture.
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Among the CT scans that were obtained in 10 patients, one CT scan did not
reveal the fracture, showing only soft-tissue swelling, and one scan showed
fractures of the orbital floor and maxilla. The causes of nasal fracture were
falling in 12 cases, direct trauma in seven cases, and sports injury in seven
cases. Eighteen (69%) of 26 patients underwent closed reduction under general
anesthesia. Clinical observation and conservative treatment were chosen for
the cases of fracture without bone displacement, nasal deformity, or
complaints about the nasal shape.
Sonography depicted all the fracture lines, so it was used as the gold
standard in this study. In one patient, we detected bone disruption on
sonography; however, because there was no associated hematoma, pain, or
crepitation on physical examination, the plastic surgeon regarded it as an old
fracture (Figs. 7A and
7B). Postreduction sonography
was used for the objective assessment of the reduction and of the
cartilaginous septum.
Discussion
Nasal fracture is usually diagnosed by performing a physical examination
and taking a good history and by assessing radiologic findings. A physical
examination is important because of the low sensitivity of radiography
[1,
2,
4,
6,
12]. Soft-tissue edema can
mask a mild to moderate nasal fracture and may hinder the physician if
performing an immediate closed reduction, so the patient must be reassessed
3-4 days after the injury [6].
The sensitivity of the Waters view and the sensitivity for detecting fracture
of the nasal bones on both the radiograph lateral views is reported to be
53-63% [13,
14]. The false-positive
findings are reported to be the midline nasal suture, the nasomaxillary
suture, and developmental defects or thinning of the nasal wall; and the
false-negative findings are the short radiolucent lines reaching the anterior
aspect of the nasal bone [1,
4].
CT scans give exquisite anatomic detail and contrast resolution, are not
operator-dependent, and give a global view of both the soft-tissue and the
osseous structures. Clinicians frequently find it easier to understand a CT
scan than a sonographic image
[5]. However, the CT findings
alone are not always adequate. A fracture line can be missed on a CT scan
because of partial volume effect, and a slightly depressed nasal fracture is
more easily diagnosed on a lateral view than on a CT scan.
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Fig. 4C —15-year-old boy with painful swelling of nose after blunt
trauma. CT scan obtained at same level as A and B shows anterior
portion of cartilaginous septum is deviated to left. However, associated
soft-tissue swelling and hypoechoic fluid are more clearly seen on
sonography.
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The sonographic findings of facial bone injuries have been reported. Danter
et al. [7] studied nasal
fractures using a 20-MHz transducer
[7]. Friedrich et al.
[8] reported the most important
deficiency of sonography in the diagnosis of midfacial fractures is the
difficulty in detecting nondislocated fractures. Hirai et al.
[9] were able to identify even
a 0.1-mm-wide bone disruption using sonography. Thiede et al.
[11] reported that the
assessment of the nasal dorsum on sonography was of comparable or higher value
than the radiographic examination. In contrast, assessment of the lateral
nasal wall was significantly better when based on a sonographic examination
than on a Waters view. This can be an advantage, especially in cases with
potential legal consequences, in which good documentation of the fracture is
important.
We used a 7-15-MHz transducer with a 3.5 x 1.2 cm probe, and this
equipment showed fracture lines, displaced bone fragments, the anterior
segment of septal cartilage, associated soft-tissue swelling, and hypoechoic
hematoma. In the one case of an old nasal fracture that was found at clinical
examination, we could detect bone disruption on the sonographic scan and on
the lateral nasal view. Old nasal fractures heal by ossification in only 50%
of cases, whereas the remaining heal more or less by fibrosis connecting the
fragments and thus the old fractures are visible on conventional radiography
for the rest of the patient's life.
Many patients suffering with nasal trauma from an assault are persons who
are regularly involved in fighting; the combination of a new blow on the nose
that leads to a contusion and an old fracture that healed with fibrosis is not
a rare finding. In these cases, a false-positive radiographic examination is
the consequence of the patient's history
[2]. A complete assessment of
the nasal septum is of paramount importance for determining the esthetic and
functional outcome of a nasal fracture
[6]. Septal injuries are really
the more important ones to diagnose, and these may be hard to detect
clinically in children without using sedation for the examination.
Most simple nasal fractures are managed by closed reduction only in the
absence of a complete evaluation of the septal fracture. Consequently, a
fractured septum unfavorably affects the alignment of the nasal bone during
the healing process [6,
15]. Fracture and dislocation
of the septal cartilage are frequent injuries accompanying fractures of the
nasal bones, and they are an important cause of secondary deformity and nasal
obstruction [15]. Septal
fracture usually goes unrecognized and untreated at the time of injury.
Although CT can be used to diagnose a fracture of the bone septum, it is
difficult to diagnose a fracture of the cartilaginous septum. We were able to
detect deformity of the anterior septal cartilage on sonographic images, and
these findings correlated well with the physical findings that were obtained
while the patient was under anesthesia for closed reduction.
Sonography provides a rapid topographic evaluation, often with good detail,
of the anatomic structures of the face. The major contribution of sonography
is as a screening tool for nasal fracture and as a diagnostic tool for
evaluation of the cartilaginous septum. It can provide an objective assessment
of the correction and the nasal appearance after reduction.
In conclusion, if sonography is performed as the first imaging examination
in cases of suspected nasal fracture, conventional radiography for
visualization of the fracture lines can be avoided. CT can be used in addition
to sonography in cases of suspected complex facial bone trauma.
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Abstract
Introduction
