Fracture Nasal Bone Closed Reduction

By

Dr. T. Balasubramanian M.S. D.L.O.

This patient had sustained Class I fracture of nasal bone.  These patients can be easily treated by closed reduction of the nasal bones.  If the nasal bones had become impacted then it will be necessary to disimpact the fragment before attempting repositioning.  This patient also had associated fracture of the nasal septal cartilage, hence it should also be reduced.  Reduction of fractured septal cartilage is very important because it is the septum that governs the ultimate shape of the nose.

Precautions:  All patients who sustain fracture of nasal bones will have varying degrees of nasal mucosal trauma leading on to epistaxis.  It must be controlled by nasal packing before a clear assessment of the patient's condition is possible.  These patients also have significant amount of soft tissue swelling over dorsum of the nose making clinical assessment difficult.  It is always better to defer definitive treatment till the oedema subsides, i.e. one week to 10 days.  Reassessment of the patient can be done once the oedema over the dorsum of the patient subsides.  Clear cut history must be elicited regarding any pre existing deviations of the nose.  If necessary study of old photographs must be resorted to before deciding on the amount of deformity and its management.  If the patient had a pre existing nasal deformity then simple reduction will not suffice, osteotomy will have to be resorted to for optimal correction.

Fracture of nasal bone is a clinically diagnosed condition.  Clinical pointers towards the diagnosis of fracture of nasal bone are:

1. Swelling over the nasal bone area
2. Tenderness over the nasal bone area
3. Oedema over the dorsum of the nose

Radiological investigation:

Xrays nasal bone will reveal fracture of nasal bone.  The nasal bone has two components,  a thick superior portion and a thinner inferior portion.  The junction between these two portions are indicated roughly by the intercanthal line.  Any fracture of nasal bone always occur below this line.

Xray paranasal sinuses water's view should be taken to rule out damage to the medial wall of the orbit and ethmoidal complex.

Closed reduction:

Is ideally performed under general anesthesia.  The nasal cavities are packed with ribbon gauze impregnated with 4% xylocaine mixed with 1 in 10,000 adrenaline.  Three packs are used to pack each nasal cavities.  One pack each is used to pack the middle and inferior meatus, and the last pack is slide under the frontonasal process to get into contact with the mucosa underlying the fractured nasal bone. 
     The patient is anesthetised and intubated, draped.  A Welsham forceps is used to disimpact the fractured fragment of the nasal bone.  The surgeon now moves to the head end of the patient.  Using index and thumb of both hands the surgeon kneeds the nasal bone fragments into position.  The septal cartilage is elevated using Ash's forceps.  The nasal cavities are packed with ointment impregnated gauze.  The reduced nasal bones are stablised using a POP cast.