Welcome back to Mangled Mondays, where every Monday we talk about another facet of maiming, mangling, mauling, and mistreating your main characters — and all of their friends.
Today we’ll be talking about Broken Noses. For the rest of the Mangled Mondays series, [click here].
1 – Nonlethal
What Is It?
At first glance, a broken nose is a simple issue. A character absorbs a blow to the face, the bone or cartilage in the nose fractures, it’s set right away by an experienced mentor, and the character moves on with their life. Easy, right?
And indeed, some nasal fractures are exactly this simple. But others are more complicated. What determines the level of complication is the amount of damage to the bone structure in addition to damage to the cartilage, and whether any other structures, such as the zygoma (cheekbone), are involved.
When the latter happens, swelling will occur under both eyes, which may turn to bruising and give the appearance of two black eyes.
Another thing to know about a broken nose is that sometimes the injury may come with minimal bleeding, but sometimes the epistaxis (nosebleed) can be significant. This dramatic flowing of blood down the face and clothing can be useful for storytellers as a textural element.
- Epistaxis (nosebleed). This may be severe; if the bleeding isn’t stopped and the nose is blocked by packing with gauze, tissue, or a tampon, the blood may run down the back of the throat and cause gagging, vomiting, or choking.
- Swelling of the nose.
- Mucus drainage from the nose.
- Bruising around the nose, eyes, or both.
- Crooked or misshapen nose.
- Pain may be significant or minimal.
- Difficulty breathing through the nose.
- Muffled-sounding speech due to nasal inflammation.
How Does It Happen?
A broken nose is a result of…
…direct blunt injury to the nose. It is a common side-effect of contact sports such as boxing, kickboxing, football, basketball, etc. Head-butting or a fall may also produce this injury.
Broken noses that involve other facial fractures typically involve force coming from one side as opposed to head-on, or an impact on one side of the nose.
Field care of the broken nose is mostly limited to managing the associated bleeding. Characters should be instructed to keep their head tilted forward (not backward) to reduce the risk of choking on their blood. The nose may be stuffed with gauze or a tampon to help stop bleeding.
Ice packs will help the character’s pain and reduce inflammation and swelling of the nose.
If there’s bleeding from the skin on the bridge of the nose, it can be managed with gauze and pressure (which, given the underlying fracture, will be painful.)
There are two definitive treatments of the broken nose: setting the nose (if the break makes it sit crooked), and allowing it time to heal. Pain can be managed with over-the-counter pain medications such as ibuprofen or acetaminophen.
Manual realignment of the nose is a fairly straightforward procedure. Like much of orthopedics, the solution to the problem is the careful application of force. Bones will be pushed back into place with the thumbs, which are applied to the sides of the nasal bones and pushed in the direction the nose should go.
Bones must be set within 14 days to avoid requiring surgery, and the sooner they’re set, the better.
If the skin at the bridge of the nose is lacerated, sutures may be used to hold the skin together.
Surgery / Hospitalization
A broken nose, by itself, is not a sufficient reason for a character to be admitted to a hospital. If the injury is less than six hours old, the nose will be set in the emergency department and the character sent home.
If the injury is more than 6 hours old, or the character’s face is too swollen to adequately set the bone, they will be referred to an outpatient otolaryngology clinic to have it set by a specialist.
(Otolaryngologists are ear-nose-throat doctors, or ENTs, pronounced “Ee-enn-tees” rather than like a Lord of the Rings tree shepherd.)
Surgery to set a broken nose isn’t typical, but severe fractures may require surgery to set properly. This is particularly true if the break results in a deviated septum. Otolaryngologists prefer to wait at least a week to allow the swelling to go down before doing rhinoplasty (surgerical repair.)
In the Austere Environment
Fortunately, broken noses do as well in the austere environment as they do in high-level medical centers, provided (a) they are set quickly and (b) the associated damage to the skin is cleaned and cared for appropriately.
The Rocky Road to Recovery
Unless other injuries occur, characters should have all capabilities they had before, with the minor exceptions below.
Characters may lose the ability to breathe through the nose while the nose is fractured, while packing is in place, and until the swelling goes down a bit.
If the zygomatic bone, the prominence that creates the high cheekbones of stereotypically attractive characters, is involved, characters won’t be permitted to chew for 7–14 days after the injury and must take all sustenance by straw. This is to prevent worsening or dislocation of the bones.
Features of Recovery: Hospital Stay
Characters will not be admitted to the hospital for nasal fractures alone.
Features of Recovery: PT/OT
The New Normal
Nasal fractures that are unset or poorly set may cause the character’s nose to be permanently crooked.
Characters whose nasal fractures cause the septum to become deviated will have problems with nasal mucus and breathing through the affected nostril, until they receive surgery to correct the septal deviation.
Characters will be at elevated risk of nasal refracture for the first 4 months after the fracture.
Total Recovery Time (Typical)
Swelling reduction and preliminary healing: 14 days
Permanent setting of the bone: 4 months
Nosebleeds may be dramatic, especially if the character exhales sharply through their nose.
If the skin is broken, there may be external bleeding as well.
The character will smell blood; for bystanders, none.
Nasal bones and cartilage will crunch, both when they are broken and when they are set.
If a character’s nasal tampon is inserted by a medical professional, they may refer to it by the popular brand name “Rhino Rocket.”
It is anatomically impossible to kill someone by breaking the nose and driving the bone end up into the brain. This is admittedly not slang, but it’s important to know.
- Broken noses are common occurrences and typically uncomplicated.
- Characters may need surgery later to reset the bones or correct septal deviation.
- Characters whose injuries include the cheekbone may be restricted to liquids for 7–14 days. These injuries typically involve a lot of swelling under both eyes.
- Characters who receive no treatment will live with a crooked nose until the nose is rebroken and reset.
xoxo, Aunt Scripty
This post is an excerpt from Blood on the Page Volume One: A Writer’s Compendium of Injuries. The book details thirty-one injuries with which to maim, mangle, and maul your characters, as well as nine indispensable articles of Wound Wisdom covering everything from burn stages to suture selection.