What pre‑operative work‑up should be requested for a patient undergoing closed reduction of the nasal bone?

Pre-operative Work-up for Closed Reduction of Nasal Bone

For a patient undergoing closed reduction of nasal bone fracture, request: complete blood count (CBC), coagulation studies (PT/PTT), ECG if indicated by age/comorbidities, and ensure maxillofacial CT scan is available for surgical planning.

Essential Pre-operative Testing

Laboratory Studies

• CBC - Standard pre-operative assessment for any surgical procedure
• Coagulation studies (PT/PTT) - Critical to assess bleeding risk, especially given the vascular nature of nasal structures
• Blood typing and screening - Generally not required for this low-invasiveness procedure unless significant comorbidities exist

Cardiac Evaluation

The ASA guidelines 1 specify that ECG is NOT routinely required for low surgical invasiveness procedures in patients with low severity of disease. Closed reduction of nasal bone is classified as a low-to-medium invasiveness procedure. However, obtain ECG if:

• Patient has cardiovascular disease
• Patient age >50 years with risk factors
• Significant comorbidities present

Imaging Requirements

CT maxillofacial is the gold standard for pre-operative planning 2. The ACR Appropriateness Criteria 2 clearly establish that:

• MDCT provides superb delineation of osseous and soft-tissue structures with high resolution
• 3-D reformations are critical for surgical planning 2
• CT is more sensitive than plain radiographs (53-82% accuracy for radiographs vs near 100% for CT) 2
• Plain radiographs have limited diagnostic value and do not considerably alter management 2

The CT should already be available from initial trauma evaluation. If not present, obtain it before surgery as it:

• Characterizes extent of septal deviation (important prognostic factor) 3
• Identifies combined septal fractures (higher risk of post-operative synechiae) 3
• Assists with precise reduction planning 4

Airway Assessment

Per ASA guidelines 1, focused physical examination must include airway assessment with documentation of vital signs. This is mandatory regardless of surgical invasiveness level.

Timing Considerations

All pre-operative assessments should be completed prior to day of surgery 1, given that:

• This involves general anesthesia or deep sedation 5
• Patient has scheduled procedure requiring anesthesia clearance
• Adequate time needed for optimization of any identified issues

Common Pitfalls to Avoid

1. Do not rely on plain radiographs alone - They miss 18-47% of fractures and provide inadequate surgical planning information 2

2. Do not skip coagulation studies - Nasal structures are highly vascular; unrecognized coagulopathy can cause significant complications

3. Assess for septal deviation on CT - Higher septal deviation angles correlate with increased post-operative synechiae risk (SS = 0.216×SDA - 0.322) 3. Patients with combined septal fractures have significantly higher complication rates 6

4. Check for missing teeth on imaging - If tooth absent, chest radiograph warranted to exclude aspiration 2

Additional Considerations

• Glucose control if diabetic (standard pre-operative optimization)
• Anemia correction if present (improves healing outcomes)
• Medication review - particularly anticoagulants/antiplatelets requiring temporary discontinuation

The evidence strongly supports that closed reduction can be performed safely with appropriate pre-operative assessment 7, 5, with success rates >94% when proper patient selection and timing occur 7. However, 11.3% may require revision rhinoplasty 6, with subjective airway obstruction at cast removal being a key predictor of need for secondary surgery 6.