Penetration of Energized Metal Fragments to Porcine Thoracic Tissues.

Energized fragments from explosive devices have been the most common mechanism of injury to both military personnel and civilians in recent conflicts and terrorist attacks. Fragments that penetrate into the thoracic cavity are strongly associated with death due to the inherent vulnerability of the underlying structures. The aim of this study was to investigate the impact of fragment-simulating projectiles (FSPs) to tissues of the thorax in order to identify the thresholds of impact velocity for perforation through these tissues and the resultant residual velocity of the FSPs. A gas-gun system was used to launch 0.78-g cylindrical and 1.13-g spherical FSPs at intact porcine thoracic tissues from different impact locations. The sternum and rib bones were the most resistant to perforation, followed by the scapula and intercostal muscle. For both FSPs, residual velocity following perforation was linearly proportional to impact velocity. These findings can be used in the development of numerical tools for predicting the medical outcome of explosive events, which in turn can inform the design of public infrastructure, of personal protection, and of medical emergency response.

Comparing the Management of Eye Injuries by Coalition Military Surgeons during the Iraq and Afghanistan Conflicts.

PURPOSE: To compare incidences, ocular injury types, and treatment performed on United States and United Kingdom military service members and host nation civilians within the Iraq and Afghanistan conflicts to inform future military surgical training requirements and military medical planning. The United States routinely deployed ophthalmologists, whereas the United Kingdom did not. DESIGN: Retrospective cohort study of the United States and United Kingdom military Joint Theatre Trauma Registries. PARTICIPANTS: All patients with eye injuries treated at a deployed Military Treatment Facility between March 2003 and October 2011. METHODS: An adjusted multiple logistic regression model was performed using enucleation or evisceration and primary open-globe repair as dependent variables and casualty nationality, location, and the presence of an ophthalmic surgeon as independent variables. MAIN OUTCOME MEASURES: Incidence of eye removal (enucleation or evisceration) or primary repair for open globe injury. RESULTS: Five thousand seven hundred nineteen of 67 586 (8%) survivors or those who died of wounds were recorded to have sustained eye injuries. The most common eye injuries were open-globe injury without intraocular foreign body (3201/5719 [56%]). Adnexal injuries (eyelid lacerations and damage to lacrimal apparatus) were recorded in 1265 of 5719 patients (22%). The odds of undergoing evisceration or enucleation for open-globe injury was highest in host nation civilians (odds ratio [OR], 9.23; P < 0.001), but there was no evidence of a difference between United States and United Kingdom military service member casualties (P = 0.38). The presence of an ophthalmic surgeon (OR, 16.3; P < 0.001) significantly affected the odds of eye removal. CONCLUSIONS: Eye injuries were more likely to have been treated definitively in United States Medical Treatment Facilities (MTFs), reflecting the absence of ophthalmologists in most deployed United Kingdom MTFs. The Iraq and Afghan conflicts were notable for coalition air dominance; the shape of future conflicts may mandate delays in evacuation, which may affect visual outcomes negatively, particularly if primary repair of patients with open-globe injuries is delayed. This study provides evidence to support the maintenance of specialist ophthalmic surgical competencies in deployed coalition MTFs for future conflicts.

Survival after traumatic brain injury improves with deployment of neurosurgeons: a comparison of US and UK military treatment facilities during the Iraq and Afghanistan conflicts.

INTRODUCTION: Traumatic brain injury (TBI) is the most common cause of death on the modern battlefield. In recent conflicts in Iraq and Afghanistan, the US typically deployed neurosurgeons to medical treatment facilities (MTFs), while the UK did not. Our aim was to compare the incidence, TBI and treatment in US and UK-led military MTF to ascertain if differences in deployed trauma systems affected outcomes. METHODS: The US and UK Combat Trauma Registries were scrutinised for patients with HI at deployed MTFs between March 2003 and October 2011. Registry datasets were adapted to stratify TBI using the Mayo Classification System for Traumatic Brain Injury Severity. An adjusted multiple logistic regression model was performed using fatality as the binomial dependent variable and treatment in a US-MTF or UK-MTF, surgical decompression, US military casualty and surgery performed by a neurosurgeon as independent variables. RESULTS: 15 031 patients arrived alive at military MTF after TBI. Presence of a neurosurgeon was associated with increased odds of survival in casualties with moderate or severe TBI (p<0.0001, OR 2.71, 95% CI 2.34 to 4.73). High injury severity (Injury Severity Scores 25-75) was significantly associated with a lower survival (OR 4×104, 95% CI 1.61×104 to 110.6×104, p<0.001); however, having a neurosurgeon present still remained significantly positively associated with survival (OR 3.25, 95% CI 2.71 to 3.91, p<0.001). CONCLUSIONS: Presence of neurosurgeons increased the likelihood of survival after TBI. We therefore recommend that the UK should deploy neurosurgeons to forward military MTF whenever possible in line with their US counterparts.

How are we currently training and maintaining clinical readiness of US and UK military surgeons responsible for managing head, face and neck wounds on deployment?

INTRODUCTION: The conflicts in Iraq and Afghanistan provided military surgeons from the USA and the UK with extensive experience into the management of injuries to the head, face and neck (HFN) from high energy bullets and explosive weaponry. The challenge is now to maintain the expertise in managing such injuries for future military deployments. METHODS: The manner in which each country approaches four parameters required for a surgeon to competently treat HFN wounds in deployed military environments was compared. These comprised initial surgical training (residency/registrar training), surgical fellowships, hospital type and appointment as an attending (USA) or consultant (UK) and predeployment training. RESULTS: Neither country has residents/registrars undertaking surgical training that is military specific. The Major Trauma and Reconstructive Fellowship based in Birmingham UK and the Craniomaxillofacial Trauma fellowship at Duke University USA provide additional training directly applicable to managing HFN trauma on deployment. Placement in level 1 trauma/major trauma centres is encouraged by both countries but is not mandatory. US surgeons attend one of three single-service predeployment courses, of which HFN skills are taught on both cadavers and in a 1-week clinical placement in a level 1 trauma centre. UK surgeons attend the Military Operational Surgical Training programme, a 1-week course that includes 1 day dedicated to teaching HFN injury management on cadavers. CONCLUSIONS: Multiple specialties of surgeon seen in the civilian environment are unlikely to be present, necessitating development of extended competencies. Military-tailored fellowships are capable of generating most of these skills early in a career. Regular training courses including simulation are required to maintain such skills and should not be given only immediately prior to deployment. Strong evidence exists that military consultants and attendings should only work at level 1/major trauma centres.

Skill sets required for the management of military head, face and neck trauma: a multidisciplinary consensus statement.

INTRODUCTION: The evolution of medical practice is resulting in increasing subspecialisation, with head, face and neck (HFN) trauma in a civilian environment usually managed by a combination of surgical specialties working as a team. However, the full combination of HFN specialties commonly available in the NHS may not be available in future UK military-led operations, necessitating the identification of a group of skill sets that could be delivered by one or more deployed surgeons. METHOD: A systematic review was undertaken to identify those surgical procedures performed to treat acute military head, face, neck and eye trauma. A multidisciplinary consensus group was convened following this with military HFN trauma expertise to define those procedures commonly required to conduct deployed, in-theatre HFN surgical combat trauma management. RESULTS: Head, face, neck and eye damage control surgical procedures were identified as comprising surgical cricothyroidotomy, cervico-facial haemorrhage control and decompression of orbital haemorrhage through lateral canthotomy. Acute in-theatre surgical skills required within 24 hours consist of wound debridement, surgical tracheostomy, decompressive craniectomy, intracranial pressure monitor placement, temporary facial fracture stabilisation for airway management or haemorrhage control and primary globe repair. Delayed in-theatre procedures required within 5 days prior to predicted evacuation encompass facial fracture fixation, delayed lateral canthotomy, evisceration, enucleation and eyelid repair. CONCLUSIONS: The identification of those skill sets required for deployment is in keeping with the General Medical Council's current drive towards credentialing consultants, by which a consultant surgeon's capabilities in particular practice areas would be defined. Limited opportunities currently exist for trainees and consultants to gain experience in the management of traumatic head, face, neck and eye injuries seen in a kinetic combat environment. Predeployment training requires that the surgical techniques described in this paper are covered and should form the curriculum of future military-specific surgical fellowships. Relevant continued professional development will be necessary to maintain required clinical competency.

Defining the essential anatomical coverage provided by military body armour against high energy projectiles.

INTRODUCTION: Body armour is a type of equipment worn by military personnel that aims to prevent or reduce the damage caused by ballistic projectiles to structures within the thorax and abdomen. Such injuries remain the leading cause of potentially survivable deaths on the modern battlefield. Recent developments in computer modelling in conjunction with a programme to procure the next generation of UK military body armour has provided the impetus to re-evaluate the optimal anatomical coverage provided by military body armour against high energy projectiles. METHODS: A systematic review of the literature was undertaken to identify those anatomical structures within the thorax and abdomen that if damaged were highly likely to result in death or significant long-term morbidity. These structures were superimposed upon two designs of ceramic plate used within representative body armour systems using a computerised representation of human anatomy. RESULTS AND CONCLUSIONS: Those structures requiring essential medical coverage by a plate were demonstrated to be the heart, great vessels, liver and spleen. For the 50th centile male anthropometric model used in this study, the front and rear plates from the Enhanced Combat Body Armour system only provide limited coverage, but do fulfil their original requirement. The plates from the current Mark 4a OSPREY system cover all of the structures identified in this study as requiring coverage except for the abdominal sections of the aorta and inferior vena cava. Further work on sizing of plates is recommended due to its potential to optimise essential medical coverage.

Defining combat helmet coverage for protection against explosively propelled fragments.

INTRODUCTION: Prevention against head wounds from explosively propelled fragments is currently the Mark 7 general service combat helmet, although only limited evidence exists to define the coverage required for the helmet to adequately protect against such a threat. The Royal Centre for Defence Medicine was tasked by Defence Equipment and Support to provide a framework for determining the optimum coverage of future combat helmets in order to inform the VIRTUS procurement programme. METHOD: A systematic review of the literature was undertaken to identify potential solutions to three components felt necessary to define the ideal helmet coverage required for protection against explosively propelled fragments. RESULTS: The brain and brainstem were identified as the structures requiring coverage by a helmet. No papers were identified that directly defined the margins of these structures to anatomical landmarks, nor how these could be related to helmet coverage. CONCLUSIONS: We recommend relating the margins of the brain to three identifiable anatomical landmarks (nasion, external auditory meatus and superior nuchal line), which can in turn be related to the coverage provided by the helmet. Early assessments using an anatomical mannequin indicate that the current helmet covers the majority of the brain and brainstem from projectiles with a horizontal trajectory but not from ones that originate from the ground. Protection from projectiles with ground-originating trajectories is reduced by helmets with increased stand-off from the skin. Future helmet coverage assessments should use a finite element numerical modelling approach with representative material properties assigned to intracranial anatomical structures to enable differences in projectile trajectory and helmet coverage to be objectively compared.

Using computerised surface wound mapping to compare the potential medical effectiveness of Enhanced Protection Under Body Armour Combat Shirt collar designs.

INTRODUCTION: Protecting the neck from explosively propelled fragments has traditionally been achieved through a collar attached to the ballistic vest. An Enhanced Protection Under Body Armour Combat Shirt (EP-UBACS) collar has been identified as an additional method of providing neck protection but limited evidence as to its potential medical effectiveness exists to justify its procurement. METHOD: Entry wound locations and resultant medical outcomes were determined using Abbreviated Injury Scale (AIS) for all fragmentation neck wounds sustained by UK soldiers between 01 January 2010 and 31 December 2011. Data were prospectively entered into a novel computerised tool base and comparisons made between three EP-UBACS neck collar designs in terms of predicted reduction in AIS scores. RESULTS: All collars reduced AIS scores, with the greatest reduction provided by designs incorporating increased standoff from the neck and an additional semi-circle of ballistic material underneath the collar at the front and back. DISCUSSION: This technique confirms that reinforcing the neck collar of an EP-UBACS would be expected to reduce injury severity from neck wounds. However, without knowledge of entry wound locations for injuries to other body areas as well as the use of AIS scores without clinical or pathological verification its further use in the future may be limited. The ability to overlay any armour design onto a standardised human was potentially the most useful part of this tool and we would recommend developing this technique using underlying anatomical structures and not just the skin surface.

Ergonomic assessment of enhanced protection under body armour combat shirt neck collars.

INTRODUCTION: Combat neck injury due to explosively propelled fragments is a significant cause of mortality and long-term morbidity in UK soldiers deployed on current operations. Reinforcing the collar of the existing under body armour combat shirt (UBACS) has been suggested as a potential method for reducing the incidence of combat neck injury. METHOD: 20 soldiers serving in Afghanistan objectively compared three designs of enhanced protection UBACS (EP-UBACS) using 10 representative military tasks against a baseline of a standard UBACS. Each EP-UBACS design was trialled using three constituent materials: two layers of para-aramid felt, one layer of ultra high molecule weight polyethylene (UHMWPE) felt or two layers of a silk fabric. Subjective assessment of these nine configurations in terms of comfort, heat dissipation and overall acceptability were compared with the standard UBACS using a χ² test. RESULTS: All military tasks could be performed with all nine configurations of EP-UBACS. Although silk was the most comfortable material, it was not functionally practical in any of the three designs. Crossover collars incorporating UHMWPE or para-aramid were the only two of the nine configurations to demonstrate similar user acceptability to a standard UBACS. CONCLUSIONS: The EP-UBACS has the potential to provide neck protection without reducing performance incorporating materials analogous to either of the felts assessed in this study. The collar should provide stand-off from the skin to improve heat dissipation and comfort, which can be maximised by changing the current UBACS collar shape to one that crosses over at the front. Should a zip be desired, it should be moved to one side of the midline to reduce rubbing on the chin and be covered with ballistic protective material. Additional semi-circles of silk beneath the collar at the front and back would improve protection without affecting comfort.

Determining the wounding effects of ballistic projectiles to inform future injury models: a systematic review.

INTRODUCTION: Penetrating wounds from explosively propelled fragments and bullets are the most common causes of combat injury experienced by UK service personnel on current operations. There is a requirement for injury models capable of simulating such a threat in order to optimise body armour design. METHOD: A systematic review of the open literature was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Original papers describing the injurious effects of projectiles on skin, bone, muscle, large vessels and nerves were identified. RESULTS: Projectiles injure these tissues by producing a permanent wound tract (PWT), comprised of a central permanent wound cavity, in conjunction with a zone of irreversible macroscopic tissue damage laterally. The primary mechanism of injury was the crushing and cutting effect of the presented surface of the projectile, with an additional smaller component due to macroscopic damage produced by the radial tissue displacement from the temporary tissue cavity (TTC). No conclusive evidence could be found for permanent pathological effects produced by the pressure wave or that any microscopic tissue changes due to the TTC (in the absence of visible macroscopic damage) led to permanent injury. DISCUSSION: Injury models should use the PWT to delineate the area of damage to tissues from penetrating ballistic projectiles. The PWT, or its individual components, will require quantification in terms of the amount of damage produced by different projectiles penetrating these tissues. There is a lack of information qualifying the injurious effect of the temporary cavity, particularly in relation to that caused by explosive fragments, and future models should introduce modularity to potentially enable incorporation of these mechanisms at a later date were they found to be significant.

Determining the velocity required for skin perforation by fragment simulating projectiles: a systematic review.

INTRODUCTION: Explosively propelled fragments are the most common cause of injury to soldiers on current operations. Researchers desire models to predict their injurious effects so as to refine methods of potential protection. Well validated physical and numerical models based on the penetration of standardised fragment simulating projectiles (FSPs) through muscle exist but not for skin, thereby reducing the utility of such models. METHOD: A systematic review of the literature was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology to identify all open source information quantifying the effects of postmortem human subject (PMHS) and animal skin on the retardation of metallic projectiles. Projectile sectional density (mass over presented cross-sectional area) was compared with the velocity required for skin perforation or penetration, with regard to skin origin (animal vs PMHS), projectile shape (sphere vs cylinder) and skin backing (isolated skin vs that backed by muscle). RESULTS: 17 original experimental studies were identified, predominantly using skin from the thigh. No statistical difference in the velocity required for skin perforation with regard to skin origin or projectile shape was found. A greater velocity was required to perforate intact skin on a whole limb than isolated skin alone (p<0.05). An empirical relationship describing the velocity required to perforate skin by metallic FSPs of a range of sectional densities was generated. DISCUSSION: Skin has a significant effect on the retardation of FSPs, necessitating its incorporation in future injury models. Perforation algorithms based on animal and PMHS skin can be used interchangeably as well as spheres and cylinders of matching sectional density. Future numerical simulations for skin perforation must match the velocity for penetration and also require experimental determination of mechanical skin properties, such as tensile strength, strain and elasticity at high strain rates.

Concussion in facial trauma patients: a retrospective analysis of 100 patients from a UK major trauma centre.

Concussion is a common and potentially debilitating condition. Research has shown that one-third of patients admitted with facial trauma have concurrent concussion. This study aimed to investigate the burden and management of concussion in patients presenting with acute facial trauma, and to identify potential risk factors within this population. A retrospective observational study was conducted at a UK major trauma centre between 1 January 2019 and 1 February2020. One hundred randomly selected patients who attended the acute clinic responsible for managing facial trauma were identified. No parametric data were included. The Mann-Whitney test was used to detect differences for continuous data, the X2 test for categorical data. Clinical significance was defined as p < 0.05. Forty of 100 patients (40%) had evidence of concussion, of which only 4/40 (10%) had evidence that head injury advice had been given. There was no statistically significant difference between the non-concussed and concussed groups for age (p = 0.145), gender (p = 0.921), mechanism of injury (p = 0.158), or location of facial injury (p = 0.451). Clinical features of concussion were found in 40% of patients suffering from facial injury. Despite this, we found that head injury advice was rarely given. In addition, we identified no risk factors for concussion within this population, highlighting the need to screen all patients who present with facial injury. To improve the identification and management of concussion in these patients, future work should focus on the development of simple screening tools for use in clinic, and the signposting of patients to existing written and online concussion resources.

The risk of fragment penetrating injury to the heart.

Injury due to the penetration of fragments into parts of the body has been the major cause of morbidity and mortality after an explosion. Penetrating injuries into the heart present very high mortality, yet the risk associated with such injuries has not been quantified. Quantifying this risk is key in the design of personal protection and the design of infrastructure. This study is the first quantitative assessment of cardiac penetrating injuries from energised fragments. Typical fragments (5-mm sphere, 0.78-g right-circular cylinder and 1.1-g chisel-nosed cylinder) were accelerated to a range of target striking velocities using a bespoke gas-gun system and impacted ventricular and atrial walls of lamb hearts. The severity of injury was shown to not depend on location (ventricular or atrial wall). The striking velocity with 50% probability of critical injury (Abbreviated Injury Scale (AIS) 5 score) ranged between 31 and 36 m/s across all 3 fragments used. These findings can help directly in reducing morbidity and mortality from explosive events as they can be implemented readily into models that aim to predict casualties in an explosive event, inform protocols for first responders, and improve design of infrastructure and personal protective equipment.

Impact of patient-related factors on complications when treating mandibular fractures by load-sharing and load-bearing osteosynthesis.

The decision about the choice of load-sharing (LS) or load-bearing (LB) osteosynthesis is determined by an interplay of fracture-related and patient-related factors. In some situations a similar fracture in two different patients may be treated successfully by either of these methods. Our aim was to identify preoperative patient-related factors that may assist in deciding which form of osteosynthesis is employed. All adult patients who underwent open reduction and internal fixation of mandibular fractures (excluding condyle) between 1 October 2018 and 1 June 2021 were retrospectively identified. The odds of developing postoperative complications and requiring a return to theatre (RTT) were calculated for each method of fixation together with the following patient factors: smoking, excess alcohol, substance misuse, and severe mental health issues. Of 337 fractures treated using LS principles, 27 (8%) developed complications, of which 20 (6%) required a RTT for repeat osteosynthesis. Of 74 fractures treated using LB principles, seven (10%) developed complications and two (3%) required a RTT for repeat osteosynthesis. The only patient factor that had statistically significant increased odds of a complication requiring RTT was LS osteosynthesis in patients who admitted drinking excess alcohol (OR = 7.83, p = 0.00, 95% CI = 3.13 to 19.60). Complications when treating mandibular fractures are rarely reported in the literature, and lack standardisation in their clinical significance. Figures generally represent overall numbers of patients, whereas the number of individual fractures treated is more accurate. In our study complications occurred in 8% of treated fractures and 10% of patients. The RTT rate was 7% of patients, which compares favourably with a recently stated standard of 10% of patients, as suggested by the Getting it Right First Time (GIRFT) report.

Using CT scans to determine the optimal sizes of hard armour plates to protect the torso for UK female Armed Forces personnel.

INTRODUCTION: Hard armour plates provide coverage to essential anatomical structures in the torso that, if injured, would likely be responsible for death before damage control surgery can be undertaken. Existing front and rear OSPREY plates in conjunction with Mark 2 plates used at the sides in current UK Armed Forces personal armour systems are provided in a single size, used by both female and male users. METHODS: CT scans of 45 female UK military personnel were analysed. Distances between anatomical structures representing threshold (absolute minimum) and objective (the maximum level of coverage beyond which there is limited further benefit) coverage of the torso were determined and compared with OSPREY and Mark 2 plate dimensions. Sample characteristics were compared with the 2006/2007 UK Armed Forces Anthropometric Survey. RESULTS: No statistical difference was found between sample means for stature (p=0.131) and mass (p=0.853) from those of the anthropometric survey in this sample. The height of both the front OSPREY plates exceeded the threshold coverage (suprasternal notch to lower border of the 10th rib) for all women studied. The height of the Mark 2 plate exceeds the objective coverage from the side for all women studied. CONCLUSIONS: Based on a plate height providing threshold coverage of all women up to the 50th percentile, the height of the front and rear OSPREY plates could be reduced by 36mm and 31mm respectively. Based on a presumption that a side plate should cover up to the 95th percentile, the Mark 2 plate achieves the objective height and width for the female population studied. Strong evidence was found to support the UK Ministry of Defence requirement for procurement of new front and rear plates of multiple heights for both female and male users.

Management and outcomes of military penetrating neck injuries: An eleven-year retrospective case note review.

INTRODUCTION: Penetrating Neck Injuries (PNIs) affected 3.2% of trauma patients attending US and UK deployed medical treatment facilities (MTFs) during the Iraq and Afghanistan conflicts. Injured military personnel requiring aeromedical evacuation for such injuries were managed at the Royal Centre for Defence Medicine (RCDM), Birmingham, UK. The aim of this paper was to review the management of PNI in both deployed MTFs and when evacuated back to the UK. PATIENTS AND METHODS: A retrospective case note review was performed of all military patients who sustained PNI whilst on deployment overseas, and who were subsequently evacuated to RCDM between March 2003 and December 2014. RESULTS: Forty casualties who sustained PNI were identified, of which 28/40 (70%) sustained injury from explosive fragmentation, and 11/40 (28%) from gunshot wounds. Hard signs of PNI were present in 3/40 (7.5%) patients, soft signs in 14/40 (35%), no signs in 12/40 (30%), and unknown signs in 11/40 (28%) patients. Computed tomography angiography (CTA) was used in 39/40 (98%) patients, and was effective at ruling out significant injury, with 100% (29/29) of casualties with a negative CTA not developing vascular or aerodigestive injury. There were 9/29 (31%) patients who had surgical neck exploration despite both a negative CTA and absence of hard signs of PNI. There were 12/40 (30%) patients who required operative intervention at RCDM. CONCLUSION: UK military surgeons in Role 3 MTFs had a low threshold for surgical exploration, even in the absence of CT findings or hard signs. This was likely due to the high-energy mechanisms responsible for military PNI, in addition to the limited availability of equipment and clinical expertise in visualising the larynx.

Closed reduction of nasoseptal fractures: key concepts for predictable results.

Nasal complex injuries are the most common facial fracture encountered in the trauma population. Multiple surgical techniques for treatment of these fractures have been described with varying results. The goal of this study was to review the efficacy of closed reduction of nasal and septal fractures using a technique based upon several key concepts. We reviewed the records of patients who had undergone isolated nasal and/or septal fractures with closed reduction at our institution between January 2013 and November 2021. Inclusion criteria consisted of preoperative CT imaging, surgical treatment within fourteen days of initial injury, and follow up of at least one year. All patients were treated under general or deep sedation. The same surgical technique was applied with closed reduction of the septum and nasal bones with internal and external postoperative splints. Of the 232 records initially reviewed, 103 met inclusion criteria. Four patients had undergone revision septorhinoplasty (3.9%). Mean (range) follow up was 2.7 (1-8.2) years. Three patients had undergone revision nasal repair due to persistent airflow obstruction with complete resolution of symptoms after revision. The other patient received multiple revisions at another institution as a result of their dissatisfaction with cosmesis without improvement. Closed reduction of nasal and septal fractures can be a highly successful procedure and yield predictable results, limiting the need for post-traumatic open septorhinoplastic surgery. Five critical concepts of nasal fracture repair can help surgeons achieve predictable functional and cosmetic results: selection, timing, anaesthesia, reduction, and support.