Executive Editor: Edward Ellis III, Kazuo Shimozato General Editor: Daniel Buchbinder

Authors: Carl-Peter Cornelius, Nils Gellrich, Søren Hillerup, Kenji Kusumoto, Warren Schubert, Stefano Fusetti

Midface - Nasal bone - Closed reduction

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Glossary

1 General considerations top

General considerations enlarge

Bleeding

Most nasal fractures cause significant bleeding. Proper techniques for hemostasis should be applied prior to any diagnostic procedure and any definitive treatment of nasal fractures.

Click here for more details on hemostasis.


Choice of anesthesia

Local anesthesia
Closed reduction of nasal fractures can be performed under local anesthesia in the majority of patients.
The nasal cavity should be prepared with cotton pledgets moistened in a solution with topical anesthetic with vasoconstrictor. In addition, local anesthetic is injected to block the infraorbital nerve.

IV sedation can be added for the comfort of the patient.

General anesthesia
General anesthesia is an option according to the surgeon’s and/or patient’s preference.

2 Fracture reduction instruments top

Fracture reduction instruments enlarge

Instruments commonly used for closed treatment of nasal fractures are:

  • Asch septum-straightening forceps
  • Walsham septum-straightening forceps
  • Boies nasal fracture elevator
  • Mayo hemostat with rubber tubing
  • Killian nasal septum speculum

3 Reduction of nasal bones top

Reduction of nasal bones enlarge

In laterally displaced fractures

Commonly laterally displaced fractures on one side are medially depressed on the other side. We will describe their treatment together.

Place an instrument (eg, Boies elevator) in the depressed side along the lateral wall of the nose to a point below the nasal frontal angle.

Place a finger along the lateral side of the nose above the depressed area.


Reduction of nasal bones enlarge

Pearl: correct instrument placement
Prior to the endonasal placement of the elevator, it is placed against the outside of the nose to the level of the medial canthus. The index finger is then placed against the edge of the elevator and is used as a stop when the elevator is placed intranasally to ensure that it can not be advanced too far superiorly
.


Reduction of nasal bones enlarge

Carefully position the instrument under the depressed nasal bone.


Reduction of nasal bones enlarge

In centrally depressed fractures

Sometimes the frontal processes of the maxillae are displaced laterally with the nasal bones impacted inside them.


Reduction of nasal bones enlarge

Reduction requires elevation of the nasal bones anteriorly and repositioning of the frontal processes medially.

The elevator must not be inserted too far into the nasal cavity.

In this case the elevator is placed in the nose and lifts the nasal dorsal pyramid anteriorly, while simultaneously the thumb and index finger put medial pressure on the displaced frontal processes of the maxillae.

4 Closed reduction top

Closed reduction enlarge

Alternative technique
In some cases, Asch or Walsham forceps can be used to elevate the dorsum and disimpact the displaced septum.

5 Reduction of the nasal septum top

Reduction of the nasal septum enlarge

Reduction of the nasal septum

The Asch or Walsham septum-straightening forceps are used to straighten the nasal septum.

Grasp the nasal septum with the blades of the instrument and gently manipulate the septum into proper alignment.


Reduction of the nasal septum enlarge

Centrally depressed fractures require posterior to anterior elevation which can often be achieved by reducing the nasal septum.

6 Splinting top

Splinting enlarge

Nasal bones
After reduction, adhesive strips are placed over the skin of the nasal dorsum and the nasal bones are splinted using an external splint that conforms to the patients nose. If the nasal bones are comminuted or loose, they should be supported with an intranasal packing, which should be placed prior to placing the external splint.


Splinting enlarge

Nasal septum
The nasal septum can be stabilized with splints or packs.

Removal of packings and splints
Hemostatic packs are removed after 24 hours. Packs that are supporting the nasal bones are left in place as long as the external splint is in place. (Various surgeons leave these in place from anywhere between 5-10 days).
The patient should be prescribed antibiotic treatment for as long as the nasal packs are in place.

v1.0 2009-12-03