Diagnosing isolated nasal fractures in the emergency department: are they missed or overdiagnosed? Ten years experience of 535 forensic cases

Abstract

Aim: Nasal bone is the most common broken bone of the face. Incorrect assessments of nasal trauma are frequently encountered in forensic evaluations. Here, we aimed to determine the reasons and frequency of erroneous assessments of nasal trauma in emergency department (ED).

Methods: This is a cross-sectional multicentric study analyzing the Forensic Medical Department archive retrospectively. Epidemiologic features, type of fracture (depressed or non-depressed), and specialty of the doctor examining the cases in ED were studied. Forensic evaluation was reported by analyzing all radiologic examinations (CT and X-ray), medical records, and after repeated physical examination of nasal trauma by the forensic council, consisting of a forensic expert, a radiologist and an otolaryngologist. Nasal fracture was diagnosed when at least two of three physicians agreed.

Results: A total of 535 cases (mean age 31.7 ± 14.4, 87.1 % males) were analyzed. The most common causes of injuries were assault (81.8 %), followed by traffic accident (15.3 %) and falls from a height (2.1 %). There were misdiagnoses in ten patients (1.9 %) and overdiagnosis in 135 (24.5 %). The possibility of fracture overdiagnosis was 13.5 times higher than missing it. General practitioners and emergency physicians have 19.7 times (95 % CI 5.5-22. 3) and 3.4 times (95 % CI 1.5-7.8) the tendency to report soft tissue nasal injuries as non-depressed fractures, respectively.

Conclusion: We found that nasal fractures are rarely missed while the overdiagnosis was very common. Examination of patients by a general practitioner or an emergency physician without consultation with a specialist and using only plain radiographs were found to be independent parameters affecting overdiagnosis.

Keywords: Face; Forensic; Fracture; Legal; Nasal injury.