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Should nasal fractures be treated on the spot?
  1. Jane Dunbar
  1. Dunblane, Scotland

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    We all know the scenario at the side of the rugby pitch, as the team attendant or doctor yanks a nose straight before any pain is perceived by a front row “beauty” who then returns to play. But should nasal fractures be treated in this way, on the spot?

    Would sports medicine doctors let their own broken noses be treated on the spot?

    “Yes, I'd have it put back pitch side—once I've retaliated and before the pain starts.”

    “Depends who by.”

    “Yes I'd like it put back immediately . . .but I've had my nose put back on the field several times and then had to have a surgeon sort it all out later, but that's OK.” (Personal discussions at the BASM 1999 conference)

    What are the dangers of this procedure?

    If looks are spoilt, an athlete may be persuaded to sue who ever tampered with their nose and make the culprit pay for their private plastic surgery and loss of modelling career. Worse still would be the scenario of an underlying cribriform plate fracture (and possible other complications) being further disrupted by incompetent attempts at nasal fracture reduction or uncontrollable bleeding of the nose pitch side and miles from help.

    Some questions before letting the doc sort the nose

    Is the heat and pressure of the sports field the place to be deciding the severity of the fracture even if you are a doctor?

    How much ENT training has the average sports doctor had?

    Would an ENT surgeon reduce a fracture pitch side?

    Would an ENT surgeon be happy for doctors, physiotherapists, or first aiders to reduce a nasal fracture “on the spot”?

    ENT surgeons' opinions varied among those I contacted.

    “Allowing a GP colleague, if experienced, or ENT surgeon to put their nose back pitch side. But not a `bag man' pitch side or a casualty SHO (even after an x ray) to do the same procedure.”

    “Bleeding following repositioning is unpredictable and it should be done in a hospital environment by an ENT colleague.”

    “Yes I would let an ENT colleague, GP or first aid/bag man put my nose back pitch side as I don't think x rays are necessary for nasal fractures.” (Personal correspondence with ENT surgeons in Scotland)

    The Defence Unions referred to the Bolam Defence of “accepted practice” for a sports doctor. “If a member were to treat a displaced nasal fracture on the spot, and there was an unsatisfactory outcome, it may well be alleged that it was negligent to undertake such a procedure. In defending a member we would need to take into account the training and experience of the member and an independent expert opinion from a practitioner in the same speciality.” (Personal correspondence with The St Paul International Insurance Agency).

    “Advocates of an on the spot treatment of nasal fractures would have to show good supporting evidence that the outcome is at least as good, if not improved, by undertaking urgent reduction, rather than waiting for ENT specialist care a few days after the injury.” (Personal correspondence with the Medical Defence Union).

    My search for what is accepted practice for “on the spot” treatment of nasal fractures proved fruitless!

    In conclusion, I think that until “What is accepted practice for sports medicine doctors” is tested in a court of law, we are still left with no straight answer to the question. In simple terms, individual doctors must ask themselves whether they are competent to undertake the procedure.

    First aiders are covered by the Good Samaritan Act of 19831 to administer first aid according to the accepted practices and manuals of the voluntary first aid societies; this does not include reducing nasal fractures.

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