Clinical feasibility of wireless handheld ultrasound in closed reduction of nasal bone fractures: a comparative study with high-end probes
Article information
Abstract
Background
Ultrasound-guided closed reduction allows for real-time visualization of fracture segments, overcoming the limitations of blind palpation. However, standard probes vary in resolution and adaptability. This study aimed to evaluate the clinical feasibility and efficiency of a wireless handheld ultrasound device (V-scan) by comparing it with high-end linear and hockey stick probes through a retrospective analysis.
Methods
This retrospective comparative study reviewed the medical records of 160 patients with nasal bone fractures treated between January 2024 and January 2026. Closed reductions were performed by four experienced plastic surgeons. Patients were categorized into three groups based on the ultrasound probe used: Group H (hockey stick, 8–18 MHz), Group L (linear, 3–12 MHz), and Group V (V-scan Air, 3–12 MHz). We compared radiologic reduction accuracy (residual depression and deviation), intraoperative image visibility, surgical convenience, and operative time.
Results
Baseline fracture characteristics were comparable among the groups, although age differed significantly (p= 0.036). Regarding radiologic outcomes, there were no significant differences in postoperative residual depression depth (p= 0.294) or deviation angle (p= 0.139) among the groups. Even in complex fractures, reduction accuracy was comparable (p= 0.198). Qualitatively, Group H achieved the highest image visibility score (4.79, p< 0.001). However, Group V demonstrated the highest surgical convenience (4.73) and shortest operative times (20.7 minutes) (p< 0.001).
Conclusion
The wireless handheld ultrasound device demonstrated clinical outcomes comparable to high-end probes. While the hockey stick probe offers superior image clarity, the V-scan provides adequate visualization with superior workflow efficiency, making it a viable tool for nasal fracture management.
INTRODUCTION
Nasal bone fractures are the most common type of craniofacial trauma [1]. High-resolution ultrasonography has proven to be a highly sensitive diagnostic tool, comparable to computed tomography (CT) [2]. The primary goal of treatment is to restore pre-injury appearance and function. Various surgical techniques exist for the treatment of nasal bone fractures, with closed reduction being commonly used, and postoperative management strategies continue to evolve [3]. Traditionally, closed reduction relied on digital palpation, but soft tissue edema often masks skeletal deformity, leading to residual deviations [4]. To address this, ultrasonography allows surgeons to visualize the fracture line and confirm reduction in real-time without radiation exposure [5-7]. Indeed, real-time surgical imaging and navigation technologies have significantly advanced in craniofacial surgery, improving the accuracy of procedures and minimizing complications [8].
Current standard practice utilizes high-end ultrasound systems with linear or hockey stick probes. The hockey stick probe is favored for its small footprint and high frequency. Recently, handheld point-of-care ultrasound devices, such as the V-scan, have gained popularity due to their portability and wireless design [9,10]. Despite their utility, concerns persist regarding their image quality compared to console systems [11].
We hypothesized that while high-end probes offer superior resolution, the handheld V-scan would provide adequate imaging for reduction owing to the superficial location and high echogenicity of the nasal bone. This retrospective study aimed to evaluate the clinical feasibility of handheld ultrasound by comparing it with high-end probes in terms of accuracy, visibility, and convenience.
METHODS
Study design and patient selection
This study was designed as a retrospective comparative analysis and was approved by the Institutional Review Board of Daejeon Eulji University Hospital. We performed a comprehensive review of medical records for 160 patients who underwent closed reduction for nasal bone fractures at our institution between January 2024 and January 2026. Patients with open fractures, a history of previous rhinoplasty, or those requiring combined septoplasty were excluded. The requirement for informed consent was waived by the Institutional Review Board due to the retrospective nature of the study.
Ultrasound equipment and group allocation
Patients were categorized into three groups based on the ultrasound probe utilized during the surgery. The selection of the probe was determined by device availability and the surgeon’s discretion at the time of the procedure (Fig. 1). Group H (hockey stick) utilized the L8-18i-D probe (8–18 MHz, 25 mm footprint; GE Healthcare) connected to the LOGIQ Fortis system (GE Healthcare), whereas Group L (linear) utilized the L3-12-D probe (3–12 MHz, 51 mm footprint; GE Healthcare) connected to the LOGIQ Fortis system. Group V (V-scan) utilized the Vscan Air SL (3–12 MHz, GE Healthcare), a wireless handheld device.
Ultrasound probes used for closed reduction of nasal bone fractures. (A) The hockey stick probe (L8-18i-D, 8–18 MHz) features a small 25-mm footprint, ideal for pediatric or small nasal bones. (B) The linear probe (L3-12-D, 3–12 MHz) has a standard 51-mm footprint. (C) The V-scan Air SL (3–12 MHz) is a wireless handheld device, offering portability without cable interference. (D) Side-by-side comparison of the three probes showing the relative differences in footprint width and thickness. Each probe is indicated by a colored arrow: the linear probe (blue arrow), the hockey stick probe (red arrow), and the V-scan Air SL (yellow arrow).
Surgical procedure and postoperative care
Closed reductions were performed by four experienced plastic surgeons following a standardized protocol. Under general anesthesia, the nasal cavity was packed with cottonoids soaked in 1:100,000 epinephrine mixed with 2% lidocaine for 10 minutes. Following this, the assigned ultrasound probe was covered with a sterile surgical drape, and sterile ultrasound gel was applied. The probe was placed on the nasal dorsum and sidewalls to identify the fracture line. Reduction was then performed using a Boies elevator. The endpoint of reduction was defined as the restoration of cortical continuity and symmetry confirmed on the ultrasound monitor.
After reduction, the nasal cavity was packed with expandable polyvinyl alcohol sponges (Merocel, Medtronic Xomed) to support the reduced bone and prevent septal hematoma. An external thermoplastic nasal splint was applied to protect the nasal framework. The Merocel packing was removed on postoperative day 5, and the external nasal splint was maintained for 3 weeks to ensure bony stability.
Outcome assessment
Radiologic accuracy was evaluated by comparing preoperative and immediate postoperative CT scans. Depression depth was measured on three-dimensional volume rendering technique images as the maximal vertical distance (mm) from the ideal imaginary nasal arch to the deepest point of the depressed fragment (Fig. 2A). Deviation angle was assessed on the axial view showing the maximal displacement. To establish the ideal reference, the longitudinal axis of the non-fractured contralateral nasal bone was mirrored across the facial midline. The deviation angle was defined as the angle formed between this mirrored reference line and the longitudinal axis of the deviated fracture fragment (Fig. 2B).
Radiologic measurement methods for nasal bone fractures. (A) Depression depth was measured on a three-dimensional volume rendering technique image. The depth (green line) is defined as the maximal distance from the virtual ideal dorsal contour to the deepest point of the depressed fragment. (B) Deviation angle was measured on the axial view showing the maximal displacement. The axis of the non-fractured side was mirrored across the midline to create an ideal reference line (yellow line). The angle (θ) was measured between this reference line and the axis of the fractured fragment (red line).
Qualitative outcomes, specifically image visibility and surgical convenience, were analyzed based on the operative records. In our routine clinical practice for ultrasound-guided procedures, the operating surgeon consistently evaluates and documents device performance immediately upon completion of the surgery. The image visibility (clarity of fracture line) and surgical convenience (ease of handling) are graded on a 5-point Likert scale (1=very poor, 5=excellent) and recorded in the operative notes. For this study, we retrospectively extracted these routinely recorded scores from the electronic medical records. Operative time was calculated from the anesthesia record, defined as the duration from the start of reduction to the completion of packing.
Statistical analysis
Data were analyzed using SPSS software version 25.0 (IBM Corp.). Continuous variables were expressed as mean±standard deviation. Comparisons among the three groups were performed using one-way analysis of variance followed by Tukey’s post hoc test. Additionally, an independent-samples t-test was performed to directly compare postoperative residual depression depth and deviation angle between Groups H and V. For subgroup analysis regarding fracture severity, patients were stratified into two categories: “Simple” (Stranc plane I) and “Complex” (Stranc plane II and comminuted). Categorical variables were analyzed using the chi-square test. A p-value <0.05 was considered statistically significant.
RESULTS
Demographics and baseline characteristics
The study population consisted of 160 patients (Group H: n=53, Group L: n=54, Group V: n=53), ranging from pediatric to elderly patients. Age differed significantly among the groups (p=0.036), whereas sex distribution did not differ significantly (p=0.337). There were no significant differences in the distribution of Stranc classification (p=0.920), preoperative depression depth (p=0.197), or deviation angle (p=0.912), indicating that the baseline injury severity was comparable among the groups (Table 1).
Patient demographics and injury characteristics
Radiologic reduction accuracy
Regarding surgical outcomes, there were no significant differences in the postoperative residual depression depth (p=0.294) or residual deviation angle (p=0.139) among the three groups. Furthermore, a direct comparison between Group H and Group V using an independent t-test revealed no significant difference in postoperative residual depression (p=0.149). However, Group H demonstrated a statistically significant superiority in correcting the deviation angle compared to Group V (0.34°±0.48° vs. 0.75°±0.97°; p=0.006).
We further performed a subgroup analysis on complex fractures (Stranc plane II and comminuted). Although Group H showed a numerically lower mean residual depression (0.21 mm) compared to Group L (0.38 mm) and Group V (0.35 mm), this difference did not reach statistical significance (p=0.198). This finding suggests that all three probes, including the handheld V-scan, facilitated effective reduction even in complex cases.
Qualitative outcomes and efficiency
In terms of image visibility, Group H achieved the highest score (4.79±0.42), which was significantly superior to Group V (4.27± 0.59; p<0.001). Group L scored 4.61. Although Group V had the lowest visibility score, it remained above 4.0 (“Good”), indicating sufficient clarity for clinical use. Conversely, regarding surgical convenience, Group V achieved the highest score (4.73±0.45), significantly outperforming Group L (3.65) and Group H (3.39) (p<0.001). Furthermore, the mean operative time was significantly shorter in Group V (20.7±3.7 minutes) compared to Group L (31.3 minutes) and Group H (31.8 minutes) (p<0.001), highlighting the efficiency of the wireless workflow (Table 2).
Comparison of surgical outcomes and qualitative assessments
Complications
Complications occurred in 10 patients (6.3%), including two cases of over-correction, five cases of under-correction, and three cases of epistaxis. There was no statistically significant difference in the complication rate among the groups (p=0.660). The intraclass correlation coefficient for subjective scores was 0.86, indicating excellent agreement among the four surgeons.
DISCUSSION
This study demonstrates that the wireless handheld ultrasound device (V-scan) serves as a feasible and efficient alternative to high-end console systems for the closed reduction of nasal bone fractures. Our results highlight a strategic balance between image resolution and workflow efficiency, while maintaining comparable surgical accuracy.
A key finding of this study is the comparable efficacy of the Vscan in terms of reduction accuracy. In the overall three-group analysis, there were no significant differences in postoperative residual depression depth (p=0.294) or deviation angle (p=0.139). Even in the complex fracture subgroup, the V-scan performed comparably to the hockey stick and linear probes (p=0.198). Although a direct t-test analysis revealed that the high-resolution hockey stick probe provided statistically superior alignment in terms of deviation angle compared to the Vscan (p=0.006), the absolute mean difference between the two groups was merely 0.41°. Since previous studies have established that the visual perceptive threshold for nasal deviation is approximately 3° [12], a minimal deviation of 0.41° is clinically imperceptible and does not result in any cosmetic or functional deficits. Therefore, we determine that this statistical difference does not significantly impact the final clinical outcome. Ultimately, the V-scan provides adequate visualization to achieve successful real-world clinical outcomes that are comparable to those of high-end console systems.
This can be attributed to the high echogenicity of the nasal bone [13,14]. Since the cortical bone provides strong acoustic contrast against the surrounding soft tissue, the fracture line remains clearly visible even at the V-scan’s lower frequency range (3–12 MHz) (Figs. 3, 4). Postoperative CT outcomes confirmed excellent symmetric restoration in both adult and pediatric cases treated with the handheld device (Fig. 5).
Intraoperative ultrasound findings in control groups. (A, B) A case treated with the hockey stick probe. (A) Pre-reduction ultrasound image showing a distinct fracture line with cortical disruption (yellow arrow). (B) Post-reduction image confirming the restoration of cortical continuity and alignment. (C, D) A case treated with the linear probe. (C) Pre-reduction image showing the depressed nasal bone fragment (blue arrow). (D) Post-reduction image demonstrating successful realignment of the bony contour.
Intraoperative ultrasound findings using the handheld V-scan device. (A, B) Representative images of an adult patient. (A) Pre-reduction image showing a displaced fracture segment. Although the resolution is lower than high-end probes, the fracture line is clearly visible. (B) Post-reduction image confirming adequate reduction. (C, D) Representative images of a pediatric patient. (C) Another case showing a depressed fracture. (D) Post-reduction image showing the restored nasal arch. Yellow arrows indicate the fracture site before reduction and the corresponding cortical contour after reduction.
Preoperative and postoperative computed tomography (CT) outcomes of patients treated with the V-scan. (A, B) Representative images of an adult patient. (A) Preoperative three-dimensional (3D) CT showing a depressed fracture of the right nasal bone with deviation to the left. (B) Postoperative 3D CT demonstrating symmetric restoration of the nasal dorsum. (C, D) Representative images of a pediatric patient. (C) Preoperative CT of a pediatric patient presenting with bilateral depression of the nasal bones. (D) Postoperative CT showing successful realignment.
However, the hockey stick probe (Group H) demonstrated superior image resolution (p<0.001). Its high frequency (up to 18 MHz) and small footprint allow for precise adaptation to the concave nasal sidewall, minimizing artifacts. This feature was particularly advantageous in our pediatric patients, whose nasal bones are smaller and more fragile, requiring the higher resolution and smaller footprint that the hockey stick probe provides for precise visualization.
The most distinct advantages of the V-scan (Group V) lie in its workflow efficiency and cost-effectiveness. The wireless design eliminates cable interference in the sterile field and significantly simplifies the setup process. In our study, this streamlined workflow translated into a clinically significant reduction in operative time, saving approximately 10 minutes per case compared to wired probes (p<0.001). Additionally, the device provides up to 50 minutes of continuous active scanning time on a full charge, which is more than sufficient to safely cover short procedures like nasal fracture reductions without any need for intraoperative recharging. Furthermore, the handheld device is substantially more affordable than high-end console systems, with lower acquisition and maintenance costs. This combination of efficiency and affordability makes it a financially viable option for resource-limited settings or smaller clinics, allowing for the widespread adoption of ultrasound-guided reduction without the burden of expensive infrastructure.
This study has limitations. First, it was a single-center study. Second, due to the retrospective nature of the study, strict randomization was not performed. Although age differed significantly among the groups, baseline fracture severity measures were comparable (Table 1); nevertheless, residual selection bias cannot be excluded. Third, the zero-inflation logic used for recording isolated deformities may have lowered the mean preoperative values, although this reflects real-world clinical presentations where multi-planar deformities are not always present.
The handheld V-scan device demonstrated comparable clinical accuracy to high-end linear and hockey stick probes in the closed reduction of nasal bone fractures, even in complex cases. While the hockey stick probe offers superior image clarity, the V-scan provides sufficient visualization combined with superior surgical convenience and time efficiency. These findings support the widespread adoption of handheld ultrasound as a valuable intraoperative adjunct for the closed reduction of nasal bone fractures.
Notes
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Funding
None.
Ethical approval
The study was approved by the Institutional Review Board of Daejeon Eulji University Hospital (File No. 2026-02-005). Written informed consent was waived by the Institutional Review Board because of the retrospective nature of the study.
Patient consent
Written informed consent for the use and publication of the images was obtained from the adult patient and the legal guardian of the pediatric patient.
Author contributions
Conceptualization: Sung Gyun Jung. Data curation: Ji Min Kim. Formal analysis: Ji Min Kim. Methodology: Chang Hoon Jeong. Project administration: Sung Gyun Jung. Visualization: Ji Min Kim. Writing–original draft: Ji Min Kim. Writing–review & editing: Sung Gyun Jung, Young Joong Hwang, Chang Hoon Jeong. Investigation: Ji Min Kim, Young Joong Hwang, Chang Hoon Jeong. Supervision: Sung Gyun Jung. All authors read and approved the final manuscript.