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Closed reduction in nasal fractures: a step-by-step
description and brief literature review
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Reducción cerrada en fracturas nasales: descripción
paso a paso y breve revisión de la literatura
Ballesteros Ibañez, N. Macchiavello Macho, R. Hernández Flores, J.P. Gazitua Larraín, G.
a. DDS, Universidad de Los Andes, Santiago, Chile.
b. DDS, Universidad Diego Portales, Santiago, Chile.
c. MD, Plastic Surgery Residency, Universidad Finis Terrae, Santiago, Chile.
d. DDS, OMF, Instituto Traumatológico Dr. Teodoro Gebauer Weisser, Santiago, Chile.
Recibido 2024-10-23
Revisado 2024-03-05
Aceptado 2024-03-16
Escobar Riquelme, S.abc d d
Abstract
Introduction:
Nasal bone fractures represent one of the most prevalent facial injuries in adults, mainly attributable to the nose’s prominent
and exposed anatomical position.
These fractures constitute approximately 40% of all facial fractures and are frequently the result of high-impact events, such
as motor vehicle collisions, sports-related trauma, and interpersonal violence.
Given the nose’s integral role in facial aesthetics and respiratory function, managing nasal fractures is fundamental to ensure
optimal outcomes in cosmetic appearance and functional restoration.
Objective:
This paper aims to present a step-by-step guide for performing a closed nasal reduction, using the clinical case of a patient
with a nasal fracture as an example, along with a brief literature review on efficacy, aesthetic and functional considerations,
and appropriate timing for intervention.
Case presentation:
A 47-year-old male patient presented to the emergency department with a nasal bone fracture sustained during an assault.
Upon evaluation, the fracture was deemed suitable for management through closed reduction. A detailed step-by-step
description of the closed reduction technique for nasal fractures, performed on the patient as an example, is provided.
Post-procedure care included the use of internal and external splints, as well as a regimen of antibiotics and
anti-inflammatory medications.
Conclusion:
Closed nasal reduction remains a widely used and effective procedure in the treatment of nasal bone fractures, particularly
when performed early after injury.
The procedure is minimally invasive and can yield satisfactory aesthetic and functional outcomes. However, its success
depends on factors such as the timing of the intervention and the surgeon’s experience.
While closed reduction is effective for most simple fractures, more complex cases may require additional surgical interventions,
such as nasal osteotomy, particularly if bone fusion has already occurred. The management of nasal fractures is an
elementary skill that maxillofacial surgeons must have, given the prevalence of these injuries in emergency settings.
Escobar Riquelme, S., Ballesteros Ibañez, N., Macchiavello Macho, R., Hernández Flores, J.P., Gazitua Larraín, G. (2025) Closed reduction in nasal fractures: a step-by-step description and brief
literature review, Odontología Vital, 2(43) 68-78. https://doi.org/10.59334/ROV.v2i43.640
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Keywords:
Closed fracture reduction; Nasal bone; Nasal trauma; Bone fractures.
Resumen
Introducción:
las fracturas de los huesos nasales representan una de las lesiones faciales más prevalentes en adultos, atribuibles en gran
medida a la posición anatómica prominente y expuesta de la nariz.
Estas fracturas constituyen aproximadamente el 40 % de todas las fracturas faciales y son con frecuencia el resultado
de eventos de alto impacto, como accidentes automovilísticos, traumas que se relacionan con el deporte y violencia
interpersonal. Debido al papel integral de la nariz, tanto en la estética facial como en la función respiratoria, el manejo de
las fracturas nasales es fundamental para garantizar resultados óptimos en la apariencia cosmética y en la restauración
funcional.
Objetivo:
El objetivo de este artículo es presentar una guía paso a paso para la realización de una reducción nasal cerrada, utilizando
el caso clínico de un paciente con fractura nasal como ejemplo, junto con una breve revisión de la literatura sobre la
ecacia, las consideraciones estéticas y funcionales y el momento adecuado para la intervención.
Presentación del caso: un paciente masculino de 47 años se presentó al servicio de urgencias con una fractura del hueso
nasal sufrida durante una agresión.
Tras evaluarlo, se consideró que la fractura era adecuada para manejarla mediante reducción cerrada. Se proporciona
una descripción detallada, paso a paso, de la técnica de reducción cerrada para fracturas nasales, que se realizó en el
paciente como ejemplo. Los cuidados posoperatorios incluyeron el uso de férulas internas y externas, así como un régimen
de antibióticos y medicamentos antiinamatorios.
Conclusión:
La reducción nasal cerrada es un procedimiento ampliamente utilizado y efectivo en el tratamiento de fracturas de huesos
nasales, en especial cuando se realiza poco después de la lesión.
El procedimiento es mínimamente invasivo y puede ofrecer resultados satisfactorios, tanto estéticos como funcionales.
Sin embargo, su éxito depende de factores como el momento de la intervención y la experiencia del cirujano. Aunque
la reducción cerrada es efectiva para la mayoría de las fracturas simples, los casos más complejos pueden requerir
intervenciones quirúrgicas adicionales, como la osteotomía nasal, en particular si ya ha ocurrido la fusión ósea.
El manejo de las fracturas nasales es una habilidad fundamental que deben poseer los cirujanos maxilofaciales, debido a la
prevalencia de estas lesiones en contextos de emergencia.
Palabras clave:
Reducción cerrada de fractura; hueso nasal; trauma nasal; fracturas óseas.
INTRODUCTION
Among the most frequent injuries to the facial
bones in adults are nasal bone fractures. Their
high incidence is due to the nose’s prominence,
making it susceptible to impact and fractures,
even with relatively low-energy blows (Jung et
al., 2022). The epidemiology of these fractures
varies depending on age, gender, and risk
activities, with an incidence of approximately
40% of facial fractures (Nagaratna et al.,
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2023; Trujillo & Lee, 2023). These fractures are
frequently caused by automobile accidents,
sports injuries, ghts, among others (Plath et al.,
2023).
Anatomy
The nose is a fundamental structure in the facial
skeleton, playing an important role in facial
aesthetics and respiratory physiology. From an
anatomical perspective, the external nose is
divided into three parts: the upper third consists
of a bony structure, while the lower two-thirds
comprise cartilage. The bony upper section,
known as the vault, includes paired nasal bones
that connect superiorly with the frontal bone at
the nasion. Inferiorly, these nasal bones join the
paired upper lateral cartilages at the rhinion.
This combination of nasal bones and upper
lateral cartilages shapes and supports the nasal
dorsum. In the lower portion, the paired lower
lateral (also called alar cartilages) shape the
nasal tip and provide structure to the external
nasal valve (Fig. 1) (Greenlund et al., 2023; Trujillo
& Lee, 2023).
Figure 1. Anatomical depiction of the osteocartilaginous
framework of the nose (Greenlund et al., 2023).
Fracture Classication
Currently, there is no universally standardized
classication system for nasal bone fractures.
Nonetheless, Hwang et al. have suggested
a system that divides these fractures into
three primary categories: Type I: Simple
without displacement; Type II: Simple with
displacement; Type IIA: Unilateral; Type IIAs:
Unilateral with septal fracture; Type IIB: Bilateral;
Type IIBs: Bilateral with septal fracture; Type III:
Comminuted (Fig. 2) (Hwang et al., 2006).
Figure 2. Classication of nasal fractures proposed by
Hwang et al. (Hwang et al., 2006).
Closed Nasal Reduction
When treating nasal fractures, functionality and
aesthetics are critical considerations. Closed
reduction is a minimally invasive procedure
designed to reposition the fractured bones,
enhancing the appearance and minimizing
septal deviation (Trujillo & Lee, 2023).
The main indications for closed reduction in a
nasal fracture are primarily aesthetic deformities
and changes in functionality. However, there are
also several limitations and contraindications
for this treatment, such as: excessive edema,
which can lead to inadequate reduction;
panfacial fractures, as the nasal fracture is often
the last to be treated; naso-orbito-ethmoidal
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fractures, as the nasal fracture is part of a more
complex injury requiring special considerations;
cerebrospinal uid leak, which requires
neurosurgical evaluation and management
(Kademani et al., 2017).
The high prevalence of nasal fractures justies
the need for their management to also be the
responsibility of the maxillofacial surgeon, an
integral emergency team member responsible
for the care of facial fractures.
To structure the research question guiding
this work, the PICO model was used: (P) Adult
patients with nasal bone fractures; (I) Closed
reduction of the nasal fracture; (C) Other
management options such as open reduction
or conservative treatment; (O) Satisfactory
aesthetic and functional results.
The research question was: “In adult patients
with nasal bone fractures, is closed reduction
effective in achieving satisfactory aesthetic
and functional results, compared with other
treatment options, such as open reduction or
conservative treatment?” This paper aims to
provide maxillofacial surgeons a comprehensive
step-by-step guide to perform a closed nasal
reduction by presenting a clinical case of a
patient with a nasal fracture, accompanied by a
brief literature review.
CASE REPORT
A 47-year-old male patient with no signicant
medical history presents to the emergency
department following facial trauma due to
an assault. Upon examination, the patient is
conscious, lucid, and oriented to time and place.
The evaluation reveals a nasal deformity with a
right lateral deviation, left nasal compression,
partial collapse of the left nostril, and reduced
airow through this side (Fig. 3).
Additionally, the patient reports difculty
breathing. Nasal speculum examination shows
erythematous nasal mucosa, a nasal septum
deviated to the right, and no septal hematoma.
Waters’ view radiograph (Fig. 4) and nasal bone
radiographs (Fig. 5) are requested to conrm the
nasal fracture.
Since the evaluation of the patient was made
early, and the fracture involved just the nasal
bones and not the septum, a closed reduction in
an outpatient setting with local anesthesia was
planned. Treatment was deferred for 7 days.
Figure 3. Preoperative appearance: (A) bottom view, (B)
top view. A right deviation and a left nasal depression
stand out.
Figure 4 (A). Waters’ radiograph shows the left HPN’s
collapse.
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Figure 5 (A). Left HPN radiograph; (B) Right HPN
radiograph.
Surgical Technique for Closed Nasal Reduction
Required Instruments
• Walsham Forceps
• Nasal Speculum
• Boies Elevator
• Asch Forceps
• Tweezer
These are shown in order, from left to right, in
Figure 6.
Figure 6: Instruments for the closed nasal reduction
technique.
1. Local Anesthesia:
The procedure should be carried out using
local anesthesia. Initially, inltrative anesthesia
is administered to the infraorbital and
infratrochlear nerves using 2% Lidocaine
combined with 1:100,000 Epinephrine (Fig.
7). Then, bilateral nasal packing with gauze
soaked in 2% Lidocaine + 1:100,000 Epinephrine
is performed, and 10 minutes are allowed to
elapse, providing adequate mucosal anesthesia
and vasoconstriction for the procedure (Fig. 8)
(López-Cedrún, 2019).
Figure 7. Inltrative anesthesia of the infraorbital and
infratrochlear nerves.
Figure 8. Bilateral nasal packing with gauze soaked in 2%
lidocaine and vasoconstrictor to enhance anesthesia at
the surgical site.
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2. Straightening of the Nasal Pyramid
The deviated nasal pyramid is manually
straightened by pressing the thumb on the
deviated side, applying counterpressure on the
contralateral hemiface to stabilize the head
(López-Cedrún, 2019).
Measuring the instruments before insertion into
the nasal cavities is essential, as the cribriform
plate of the ethmoid bone, which connects
the nasal cavity to the anterior cranial fossa, is
situated in the upper region of the nasal cavity.
The measurement is taken from the base of the
nose to the tip, subtracting 1 cm to obtain a safe
measurement for instrument insertion, thereby
reducing the risk of complications.
3. Reduction of Nasal Bone Depression:
Lateral Rectication with Boies Elevator:
The Boies elevator or a similar blunt-edged
instrument of comparable size is inserted
into the nasal cavity, positioned against the
inner surface of the depressed nasal bone,
and outward pressure is applied until lateral
realignment is accomplished (Fig. 9) (López-
Cedrún, 2019).
Figure 9 (A). Boies’ elevator measurement from the tip
of the nose to the root of the nose. (B) Application of
force laterally using the Boies elevator.
Lateral Rectication with Asch Forceps:
The Asch forceps are introduced into the nostril
on the affected side and closed, generating
pressure on both the internal and external
surfaces to rectify the lateral wall (Fig. 10).
Figure 10: Asch forceps in operation on the left nostril to
reduce the left nasal bone.
4. Evaluation and Treatment of the Nasal
Septum:
The Walsham forceps are introduced, with each
active part in each nostril, and closed to apply
pressure on both internal walls of each nostril to
rectify the septum’s shape (Fig. 11).
After performing reduction maneuvers, it
is essential to verify both nostrils’ correct
patency and rule out the presence of a septal
hematoma.
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Figure 11. Walsham forceps in operation for nasal
septum rectication.
5. Nasal Packing and External Splint:
Internal and external splinting is performed
after completing the procedure and achieving
fracture reduction (Fig. 12). Anterior packing
with gauze is left in place to generate outward
forces, maintaining the position of the cartilage
and bones as an internal splint. Additionally, an
external rigid splint, made of plaster bandage, is
applied (Fig. 13), maintaining the reduction of the
fragments and controlling the edema.
Figure 12. Post-reduction situation, highlighting the
rectication of the nasal dorsum, from the nasion to
the tip of the nose. The image is immediately post-
reduction, so it is possible to see the inammation and
edema produced by the procedure.
Figure 13. Fixation of internal and external splints using
medical tape.
6. Post-operative Care
• Relative rest.
• Antibiotic therapy for 7 days.
• NSAIDs for 3 days.
• Maintain internal and external splints for 7
days.
• Sneeze with the mouth open.
• Avoid nose blowing.
DISCUSSION
This case highlights the importance of early
evaluation in the management of nasal
fractures, as it enabled the timely planning
of a closed reduction, achieving satisfactory
functional and aesthetic outcomes. Furthermore,
this therapeutic approach contributed to
reducing the associated costs for the patient
and prevented the need for more invasive
surgical intervention. These ndings align with
the evidence reported in recent studies, which
support the effectiveness of closed reduction as
a reliable therapeutic option for treating nasal
fractures.
For instance, Raq et al. conducted a study
comparing the aesthetic outcomes after surgery
under local versus general anesthesia following
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closed reduction of nasal bone fractures,
emphasizing the common use of closed
reduction for simple nasal fractures (Raq et
al., 2023). According to a systematic review
by James et al., the success rate of closed
reduction of nasal fractures was 70% to 95%
when performed early (James et al., 2020).
A study by Choi et al. showed that closed
reduction in patients with nasal fractures can
signicantly minimize post-operative septal
deviation in certain fracture types (Choi et al.,
2022).
Conversely, Plath et al. found that individuals
with nasal bone fractures generally experience
more aesthetic improvements than functional
benets following closed reduction (Plath et
al., 2023). These studies underscore closed
reduction’s ongoing relevance and effectiveness
in managing nasal bone fractures.
Functional and Aesthetic Considerations
Complications arising from the closed reduction
of a nasal fracture can be categorized into
functional issues and deformities. Functionally,
nasal fractures may result in septal deviation,
impacting respiratory function even if the
septum itself is not fractured. Choi et al. studied
the impact of closed reduction in various nasal
fracture patterns (without septal fractures)
and its implications for septal deviation, nding
that closed reduction signicantly reduced
septal deviation in all fracture types studied
(unilateral, bilateral, and comminuted). However,
comminuted fractures may result in persistent
septal deviation despite the intervention (Choi
et al., 2022). The aesthetic outcome depends on
the level of deformity caused by the fracture,
and evaluating it is always a challenge. Closed
nasal reduction is the ideal treatment for cases
with minor deformities or when aesthetics are
not a priority for the patient; otherwise, the ideal
treatment is rhinoseptoplasty. Besmens et al.
reported that the incidence of nasal deformities
following reduction, which require rhinoplasty
or rhinoseptoplasty, falls between 14% and 15%
(Besmens et al., 2023).
Regarding patient perception, Park et al.
examined patients’ quality of life post-closed
reduction for nasal bone fractures, shedding
light on the overall satisfaction and outcomes
following the procedure (Park et al., 2023).
Furthermore, a more recent study conducted
by Sánchez-Álvarez et al. evaluated aesthetic
satisfaction using a subjective scale, and the
median total score increased from 32 to 72
points after closed reduction. Items related to
size, shape, and overall aesthetic appearance
received the highest scores (Sánchez-Álvarez et
al., 2023). These studies provide updated insights
into the functional and aesthetic outcomes of
closed reduction in nasal fractures, highlighting
the importance of patient satisfaction and long-
term results.
Time of intervention
Opinions vary regarding the appropriate timing
for intervention in isolated nasal bone fractures
and their impact on outcomes. Many experts
recommend early reduction for pediatric
patients, typically within 7 days due to their faster
healing rates, and within 10 days post-injury for
adults (Wang et al., 2019).
Trujillo et al. suggest an immediate closed
reduction is feasible if the patient receives care
within 3 to 6 hours of the injury, before signicant
swelling occurs. Beyond this period, it is generally
advisable to postpone the procedure until the
swelling subsides, which may take up to 14 days
in adults.
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However, authors like Yoon and Han have
reported successful outcomes even when
treatment was administered up to 41 days after
the injury (Yoon & Han, 2016).
Additionally, Koca et al. advised waiting 3–5 days
for the swelling to subside following the initial
diagnosis of a nasal fracture before deciding on
the most suitable treatment approach, providing
a window for evaluation and planning in the
early phase of the injury (Firat Koca et al., 2022).
Many experts recommend early reduction for
pediatric patients, typically within 7 days due
to their faster healing rates, and within 10 days
post-injury for adults (Wang et al., 2019). Trujillo
et al. suggest an immediate closed reduction is
feasible if the patient receives care within 3 to
6 hours of the injury, before signicant swelling
occurs.
Beyond this period, it is generally advisable
to postpone the procedure until the swelling
subsides, which may take up to 14 days in adults.
However, authors like Yoon and Han have
reported successful outcomes even when
treatment was administered up to 41 days after
the injury (Yoon & Han, 2016).
This approach underscores the importance of
monitoring the patient’s condition and edema
resolution before proceeding with intervention to
ensure optimal outcomes.
Kang et al. emphasized the signicance of early
intervention for pediatric nasal fractures, noting
that children’s faster bone healing process
necessitates an earlier reduction compared
to adults to ensure optimal surgical outcomes
(Kang et al., 2021).
In conclusion, when swelling is signicant
enough to hinder the intraoperative assessment
of the underlying nasal bones, it is permissible to
postpone closed nasal reduction for 7 to 10 days,
or potentially longer, to allow the skin swelling
to subside, with the preference being that this
occurs prior to bony fusion.
Should bony fusion have already taken place,
closed nasal reduction may necessitate a
concurrent nasal osteotomy to reposition the
displaced bone segment (Wang et al., 2019).
CONCLUSION
Closed nasal reduction in nasal fractures that
meet the aforementioned criteria can be safely
performed in the acute setting by Maxillofacial
surgeons, as it helps minimize secondary
rhinoseptoplasty, saving patients time and
money with acceptable long-term results.
However, it is not always indicated that if bone
fusion has already occurred, closed nasal
reduction may also require concurrent nasal
osteotomy to mobilize the displaced bone
segment, highlighting the importance of properly
referring such cases to otolaryngology.
Finally, as one of the most prevalent fractures
seen in emergency settings, its diagnosis
and management should be known to all
Maxillofacial surgeons.
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AUTHOR CONTRIBUTION:
The authors have contributed to the conception,
planning, execution and approval of the nal
version of this article.
Conict of interest:
The authors declare that they have no conicts
of interest.
Funding:
Conceptualización y diseño: SE, JH
Revisión de literatura: SE, NI, RM
Metodología y validación: SE, JH
Análisis formal: SE, NI
Investigación y recopilación de datos: SE, NI, RM
Recursos: GG, RM, SE
Análisis e interpretación de datos: SE, NI
Redacción-preparación borrador original: SE, NI
Redacción-revisión y edición: SE, NI, RM, JH, GG
Supervisión: JH, GG
Administración de proyecto: SE, JH, GG
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