TREATING A BROKEN NOSE

See also Section 61.4.

CONTROLLING BLEEDING If this is severe, pack the patient’s nose with ribbon gauze soaked in saline. Treat him as soon as possible without waiting for the swelling to go down.

EQUIPMENT If possible, use Walsham’s forceps to reduce his nasal bones, and Ash’s forceps to straighten his nasal septum. If you don’t have them, you can use any stout clamp, but don’t close it tight. Walsham’s forceps don’t quite meet, and therefore don’t crush tissue.

Figure 62.9: ELEVATING A FRACTURE OF THE NOSE. A, inflitrating the site of the fracture. B, raising the depressed bones with curved artery forceps. Always suspect a fracture after any blow on the nose. Swelling of the soft tissues can easily hide it. Kindly contributed by Peter Bewes.

ANAESTHESIA (1) Pterygopalatine block (A 6.4). (2) Give the patient a general anaesthetic, and pass a tracheal tube (A 13.2). (3) Use local infiltration anaesthesia.

PROTECT THE PATIENT’S EYES Put squares of vaseline gauze over both his eyes to prevent plaster getting into them.

REDUCTION Clean the patient’s face with cetrimide to remove grease. Examine his nose carefully with your fingers.

Cover one blade of Walsham’s forceps, or some other suitable instrument, with rubber tube. Pass it into his nose and lever the fragments of his bridge into place. Then do the same on the other side.

If necessary, mould his comminuted lachrymal bones, and the medial walls of his orbits, so as to reconstitute the bridge of his nose.

CAUTION! (1) Don’t forget to protect his eyes. (2) Try hard to restore the full height of the bridge of his nose.

When you have done this, pass one blade of Asch’s septal forceps, or any other suitable instrument, down each side of the patient’s septum and straighten it, so that it lies in the midline. If necessary, grasp his septal cartilage, bring it forward, and replace it in its groove in his vomer.

Pass an instrument down each side of the nose to make sure he has a clear nasal airway. Pack both his nostril’s with 1 cm selvedgeless gauze soaked in liquid paraffin.

SPLINTING If the fracture is mild, no splint is needed. If the fracture is severe, splint it, either with a plaster cast, or with lead splints.

Figure 62.10: A PLASTER NASAL SPLINT. A, reducing the fracture with Walsham’s forceps. B, the splint in place. C, dry plaster bandage ready for preparing the splint. Kindly contributed by Peter Bewes.

A plaster cast

Make eight thicknesses of plaster bandage into a T–shape. Wet this and put it on the patient’s nose and forehead. If any plaster overlaps the lower end of his nose, turn it up like a brim. As it sets, mould it to his forehead and the sides of his nose. Strengthen the plaster over the bridge of his nose with two more layers of plaster bandage.

Remove the vaseline gauze squares from his eyes, and then wrap a crepe bandage round his head to hold the cast. Or, hold it in place with adhesive strapping. It will hold his nose in place by suction.

CAUTION! Don’t fix the splint to a plaster headcap, because if this displaces, it will displace his broken nose.

When oedema has subsided in a few days, fit a fresh cast. Leave this for 2 weeks.

A lead splint

If the fracture is too severely comminuted to be held in a plaster splint, hold it with two lead plates, one on each side of the patient’s nose. You can use two or three layers of the lead backing from some infra–oral X–ray films. Pass a mattress suture of 0.35 mm soft stainless steel wire through his nose with a straight needle.