Informed Consent For Closed Reduction of Nasal Fracture

Informed Consent for Closed Reduction of Nasal Fracture
Introduction
This information is given to you so that you can make an informed decision about
having closed reduction of nasal fracture. Take as much time as you wish to read this
information and ask questions of your doctor or the assistants. You have the right to ask
questions about and understand the surgery as well as you can before deciding to have the
surgery. After learning of your condition and your options for treatment, you and your
doctor are the ones who decide together if and when you should have this operation based
on your needs and medical condition. This surgery is not an emergency. You may
decide not to have this operation at all.
Nature of the Condition and Treatment
Except in unusual circumstances, closed reduction of nasal fracture is appropriate when

you have nasal deformity after nasal fracture. If you choose to have closed reduction of
nasal fracture, it is important to understand that the nose will be straightened by gently
forcing the broken bones back into place.
1. Complications of Surgery in General: As with all types of surgery, the

possibility of other complications exists due to anesthesia, drug reactions or
other factors which may involve other parts of my body, including a
possibility of brain damage or even death. The likelihood of these
complications is very low. The benefits of a straightened nose from
successful surgery are significantly greater than the possibility of a
complication noted below.
2. Specific Complications of Closed Reduction of Nasal Fracture: Risks of
closed reduction of nasal fracture include incomplete correction of nasal
deformity, asymmetry, nasal irregularity, palpable and/or visible bony,
cartilage, or skin deformity, dissatisfaction of patient, bleeding (possibly
severe), infection, septal perforation (hole in septum), infection in cartilage
leading to collapse of external nose (saddle nose), continued septal deviation,
continued nasal congestion, nasal valve collapse, loss or decrease of sense of
smell, scarring and adhesions (scar from septal to lateral nasal wall), and need
for further procedures. No closed reduction of nasal fracture is perfect, and
there will be minor flaws. The goal is an overall improvement in the
appearance and function of the nose. There is a 50 % chance that the
correction will be incomplete and you may ultimately need a rhinoplasty.
Alternative Methods of Treatment for Nasal Fracture

Alternative treatment for nasal fracture is doing nothing, or waiting 6-9 months
and doing a rhinoplasty at that time.
Patient Statement and Consent for Operation
I hereby authorize ___________________________, and any associates or

assistants of his choice to perform upon me closed reduction of nasal fracture.
I recognize that during the course of the procedure, unforeseen conditions may
necessitate additional or different procedures than those explained. I, therefore, further
authorize and request my doctor and any associates or assistants of his choice perform
such as are, in their professional judgment, necessary or appropriate for such procedures.
I understand that the proposed care may involve risks and possibilities of
complications, and that certain complications have been known to follow the procedure
to which I am consenting even when the utmost care, judgment and skill are used. I
acknowledge that no guarantees have been made to me as to the results of the procedure,
nor are there any guarantees against unfavorable results.
I accept the risks of substantial and serious harm, if any, in hopes of obtaining
desired beneficial results of such care and acknowledge that the physicians involved have
explained my condition, the proposed health care, and alternative forms of treatment in a
satisfactory manner.
The basic procedures of the proposed surgery, the advantages, disadvantages,

risks, possible complications, and alternative treatments have been explained and
discussed with me by my doctor. Although it is impossible for the doctor to inform me of
every possible complication that may occur, the doctor has answered all my questions to
my satisfaction. In signing this consent form, I am stating I have read this form (or it has
been read to me), and I fully understand it and the possible risks, complications and
benefits that can result from the surgery. I also acknowledge that the doctor has
addressed all of my concerns regarding this surgery.
Patient’s Name: Age
Patient’s Signature:
Date: Time: Place:
Witness’ Signature:
Doctor’s Signature:
As parent, guardian, caretaker, next of kin or other legal representative responsible for the
patient whose name appears above on the appropriate patient signature line, I have read
this document and, to the limit of the patient’s understanding, I have discussed this
informed consent and its terms with the patient. Due to the patient’s inability to sign this
informed consent, I agree, on behalf of the patient, to sign for the patient and bind
him/her to the terms of this informed consent.
Name: (printed)
Signature:
City: State: Zip:
Relationship to Patient:
Date: Time: Place:
I have received a copy of this informed consent for my own records. I have had the
opportunity to read this informed consent and my questions regarding the
surgery, alternatives, risks, and expected outcomes have been answered.
Signature:_______________________________________________________________
Name: (printed)___________________________________________________________

Informed Consent For Closed Reduction of Nasal Fracture

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Informed Consent for Closed Reduction of Nasal Fracture

Nature of the Condition and Treatment

Except in unusual circumstances, closed reduction of nasal fracture is appropriate when

1. Complications of Surgery in General: As with all types of surgery, the

Alternative Methods of Treatment for Nasal Fracture

Patient Statement and Consent for Operation

I hereby authorize ___________________________, and any associates or

The basic procedures of the proposed surgery, the advantages, disadvantages,

Patient’s Name: Age

Date: Time: Place:

City: State: Zip:

Date: Time: Place:

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