close reduction nasal bone

asch forcep

walsham forcep

Technique
Nasal pyramid fractures should be reduced first, followed by nasal septum reduction.
Explain the risks, benefits, and alternatives to the patient. Obtain a signed informed consent, if possible.
Deliver appropriate anesthesia. For details, see Anesthesia.
To reduce nasal pyramids, measure the distance from the alar rim to the depressed fragment externally. Mark position with thumb. Reduce depressed side of nose first.
Insert Boies or Salinger elevator into the nose under the depressed fragment. Apply steady outward pressure on the posterior aspect of the nasal bone. Control outward pressure with counterpressure exteriorly with the other thumb. Fragments may need to be molded into the proper position.

Nasal bone reduction.
If unable to reduce with elevators, use Walsham forceps to directly grasp the nasal bone. Insert one blade beneath the bone as the other blade is opposed on the outer skin surface. Manipulate the bone into position.
Check for septal reduction. If not adequately reduced, use Asch forceps to elevate the nasal pyramid while applying direct pressure to the displaced portion of the septum until it is moved back into the proper position.

Septal reduction with forceps.
Check for septal hematoma (drain if present).
Stabilize reduction with internal packing (eg, Vaseline gauze or 8-cm Merocel) and an external splint (eg, Thermaplast, Aquaplast). These external splints require intense heat for activation and molding, so the nasal dorsal skin should be protected with Steri-Strip bandage application prior to placement of the splint.
Remove packing in 5 days and remove nasal splint in 7 days. While the nasal packing is in place, the patient should be on an oral antibiotic with adequate Staphylococcus aureus coverage (eg, cephalexin) in order to prevent sinusitis and toxic shock syndrome.

ANATOMIC CONSIDERATIONS IN NASAL BONE FRACTURE PART II: Blood supply

The rich blood supply to the nasal region predisposes individuals to epistaxis in nasal trauma. Epistaxis can be categorized as anterior or posterior, depending on the source of bleeding. The most common location is anterior epistaxis, originating from Kiesselbach’s plexus in the anteroinferior septum, which receives its blood supply from both internal and external carotid arteries. Posterior epistaxis typically arises from branches of both the sphenopalatine and anterior ethmoidal arteries. It is less common than anterior bleeding but a more frequent cause of severe hemorrhage. Nasal hemorrhage can usually be controlled by direct manual pressure in anterior bleeds. Hemorrhage from posterior sources usually resolves spontaneously, particularly if the patient’s blood pressure is controlled. However, in persistent cases, posterior packing or Foley balloon catheterization of the nasal passage may be necessary. In the most severe cases, usually secondary to maxillary arterial sources, interventional embolization may be required. Both the ophthalmic and maxillary divisions of the trigeminal nerve supply sensation to the nose. The infratrochlear nerve provides sensation to the skin of the upper nasal dorsum and sidewalls, and the anterior ethmoidal supplies the lower dorsum and tip.

ANATOMIC CONSIDERATIONS IN NASAL BONE FRACTURE PART I: Bony part

The skeletal component of the nose includes the frontal process of the maxilla, the nasal process of the frontal bone, the ethmoid, the vomer, and the nasal bones. Fractures of the nasal bones occur more commonly distally, where they are broader and thinner. Significant force is required to fracture the more proximal nasal bones, in which case injury extension into the frontal process of the maxilla and frontal bone may be present.
The cartilaginous structures include the two lower lateral cartilages, two upper lateral cartilages, and the central septal cartilage. Paired upper lateral cartilages have solid attachments to the caudal aspect of the nasal bones and help maintain the midline location of the quadrangular cartilage. The lower lateral cartilages provide little midline
structural support but are responsible for much of the aesthetics and contour of the nasal tip. The fact that cartilage surrounds the bony matrix both dorsally and laterally to provide a soft and malleable framework allows some dissipation of force without incurring a permanent deformity. In general, significant force is required for a cartilaginous
injury.