II. Prerequisites

  1. Requires experienced clinician

III. Indications: Emergency Department Closed Reduction

  1. Nasal obstruction from deviated Fracture fragments (e.g. whistling or noisy nasal breathing on inspiration or expiration)
  2. Significant Epistaxis
  3. Minimal swelling (typically <3-6 hours from Fracture)
  4. Simple Nasal Fracture (especially if unilateral)
  5. Soft tissue swelling not hindering reduction
    1. Swelling often increases after 3 hours
    2. Swelling makes reduction more difficult

IV. Contraindications: Emergency Department Closed Reduction

  1. Significant nasal swelling (typically>3-6 hours after Fracture)
  2. Orbital wall Fracture
  3. Ethmoid Fracture
  4. Open Fracture
  5. Nasal deviation more than half the nasal bridge width
  6. Significant Fracture dislocation of caudal septum

V. Preparation: Instruments

  1. Obtain standard instruments from OR - ENT set
  2. Forceps
    1. More prone to crush injury with higher risk of Septal Hematoma
    2. Types (either set of forceps may be used interchangeably)
      1. Asch forceps (designed for reduction of displaced septum)
      2. Walsham forceps (designed for reduction of impacted nasal bones)
    3. Substitutes if forceps not available
      1. Needle drivers (caution - risk of greater crush injury)
  3. Boies elevator
    1. Less likely to cause crush injury than forceps
    2. Hard flat substitutes if Boies Elevator not available
      1. Scalpel handle without blade
      2. Miller 1 Laryngoscope Blade

VI. Procedure

  1. Conscious Sedation and analgesia
    1. Example: Versed and Morphine IV
    2. Titrate to adequate effect
    3. Consider regional Nerve Block
      1. Inject lateral to the nasal bone with Lidocaine 1% 1-2 cc
  2. Preparation
    1. Optimal lighting
    2. Suction
    3. Boies elevator (or similar)
  3. Technique: Realigning nasal bones
    1. Insert Boies elevator (or other flat firm device) into nare
    2. Opposed against external thumb
    3. Nasal bone and cartilage manipulated, gently rocked back into place
  4. Technique: Reducing posteriorly displaced bones and cartilage
    1. Place Endotracheal Tube against the upper lip
    2. Use the ET Tube as a fulcrum to pry the bones anteriorly
  5. Technique: Septal Fracture (50% of cases) reduction
    1. Realign after reduction of Nasal Bone Fracture
  6. Careful re-exam after reduction
    1. Observe for nasal deformity externally
    2. Observe for Septal Hematoma internally
      1. May be a small, subtle purplish discoloration
      2. Incise and drain if present (critical)
  7. External splint to nasal dorsum post-reduction

VII. Complications

  1. Septal Hematoma
    1. May occur from either initial injury with Nasal Fracture or the subsequent closed reduction

VIII. Follow-up

  1. Refer for ENT or plastic surgery follow-up in 5-7 days
  2. Reduction best attempted within 5-10 days of injury
  3. Most patients should be offered consult for cosmesis

IX. References

  1. Wu in Majoewsky (2012) EM:Rap 12(11): 10
  2. Kucik (2004) Am Fam Physician 70(7):1315-20 [PubMed]

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