Hematoma block versus sedation for the reduction of distal radius fractures in children

Ultrasound-Guided Hematoma Block for Distal Forearm Fracture Reduction in Adolescent With History of Difficult Airway: A Case Report

ABSTRACT

Distal forearm fractures are frequently encountered in the pediatric emergency department and often require reduction. Procedural sedation is commonly used to facilitate reduction of these injuries, although it can be associated with potentially severe complications, particularly in patients with cardiorespiratory comorbidities. The ultrasound-guided hematoma block has been gaining popularity as an analgesic alternative in adult patients, but literature supporting its use in pediatric patients is limited. We describe a point-of-care ultrasound-guided hematoma block used to facilitate successful reduction of a distal radius fracture in an adolescent patient with a history of a difficult airway for whom procedural sedation would have posed considerable risk.

Pediatric and Adolescent Distal Radius Fractures: Current Concepts and Treatment Recommendations

Distal radius fractures are the most common skeletal injuries requiring intervention in children. These injuries are classified by fracture pattern, location, displacement, and angulation. While each unique fracture pattern warrants slightly modified treatment plans and follow-up, the goals of treatment remain constant. Successful outcomes depend on restoration of motion and function, and attaining acceptable sagittal and coronal alignment is a necessary first step. For displaced fractures, closed reduction is often necessary to restore alignment; well-molded cast application is important to maintain fracture alignment. Fractures with bayonet apposition, if well aligned, may not need formal reduction in some patients. Special attention should be paid to the physis-not only for physeal-involving fractures but also for all distal radius fractures-given that the proximity to the physis and amount of remaining skeletal growth help guide treatment decisions. Casting technique is essential in optimizing the best chance in maintaining fracture reduction. Surgical intervention may be indicated for a subset of fractures when acceptable alignment is not achieved or is lost at subsequent follow-up. Even among experts in the field, there is little consensus as to the optimal treatment of displaced metaphyseal fractures, illustrating the need for prospective, randomized studies to establish best practices.

Haematoma block is the most efficient technique for closed forearm fracture reduction: a retrospective cohort study

BACKGROUND

Forearm fractures are a common ED presentation. This study aimed to compare the resource utilisation of three anaesthetic techniques used for closed forearm fracture reduction in the ED: haematoma block (HB), Bier's block (BB) and procedural sedation (PS).

METHODS

A retrospective multicentre cohort study was conducted of adult patients presenting to either Port Macquarie Base Hospital ED or Kempsey District Hospital ED in New South Wales, Australia, from January 2018 to June 2021. Patients requiring a closed reduction in the ED were included. ED length of stay (LOS) was compared using a likelihood ratio test. Successful reduction on the first attempt and the number of ED specialists present for each method were both modelled with a linear regression. Staff utilisation by the level of training, cost of consumables and complications for each group were presented as descriptive statistics.

RESULTS

A total of 226 forearm fractures were included. 84 used HB, 35 BB and 107 PS. The mean ED LOS was lowest for HB (187.7 min) compared with BB (227.2 min) and PS (239.3 min) (p=0.023). The number of ED specialists required for PS was higher when compared with HB and BB (p=0.001). The cost of consumables and a total number of staff were considerably lower for HB compared with PS and BB methods. PS had the highest proportion of successful reductions on the first attempt (94.4%) compared with BB (88.6%) and HB (76.2%) (p=0.006). More patients experienced complications from PS (17.8%) compared with BB (14.3%) and HB (13.1%).

CONCLUSIONS

In this study, the HB method was the most efficient as it was associated with a shorter ED LOS, lower cost and staff resource utilisation. Although PS had a significantly greater proportion of successful reductions on the first attempt, HB had fewer complications than BB and PS. EDs with limited resources should consider using HB or BB as the initial technique for fracture reduction with PS used for failed HB or when regional blocks are contraindicated.

No-anesthesia for Colles fracture

BACKGROUND

This study aims to measure the perceived pain during the reduction of Colles fracture without anesthesia in both children and adults. It describes the process and reveals duration for reduction, total hospital stays and compares them with the same procedure under hematoma block.

METHODS

We employed the Wong-Baker FACES pain scale to assess pain reduction in 135 adults and 98 pediatric patients undergoing Colles fracture reduction with or without hematoma block. We also measured the time required for the reduction and the overall process.

RESULTS

For fracture reduction without anesthesia, Wong-Baker FACES scores were 9.2 for children and 8.7 for adults. With hematoma block, scores dropped to 7.5 for children and 5.2 for adults with only a 10 min addition to the hospital stay. Pain scores among pediatric patients exhibited moderate to strong negative correlations with age. The reduction maneuver itself took an average of 5 s.

CONCLUSIONS

The reduction of a Colles fracture is nearly instantaneous, making the reduction without anesthesia tolerable. Pediatric patients don't benefit from hematoma block as much as adult counterparts. It significantly reduced pain scores by 1.7 points in children and 3.5 points in adults.

LEVEL OF EVIDENCE

Level I, Randomized Controlled Trial.

Comparison between the Effect of Lidocaine or Ropivacaine Hematoma Block and of Different Timings of Administration on Post-Operative Pain in Dogs Undergoing Osteosynthesis of Long-Bone Fractures

OBJECTIVE

We aimed to compare the efficacy of intra-operative lidocaine hematoma block (HB) to ropivacaine HB and to compare the efficacy of different timings of ropivacaine HB in controlling post-operative pain in dogs undergoing the osteosynthesis of long-bone fractures.

STUDY DESIGN

We conducted a randomized, blinded, prospective clinical study.

ANIMALS

Forty-eight dogs with long-bone fractures were included and were randomly allocated to four groups: lidocaine (L), ropivacaine (Rmid), ropivacaine pre- (Rpre) and ropivacaine post- (Rpost) groups.

METHODS

The dogs in group L (n = 14) and in group Rmid (n = 11) received a lidocaine or ropivacaine HB, respectively, after fracture reduction and before osteosynthesis material placement. Rpre dogs (n = 11) received ropivacaine HB before fracture reduction, and Rpost dogs (n = 12) received ropivacaine HB after osteosynthesis material placement. Eight post-operative pain assessments were performed using the University of Melbourne Pain Scale (UMPS) and an algometer. Rescue analgesia was administered based on UMPS scoring. For data analysis, the Shapiro-Wilk test of normality, chi-square, Student t test and Split Plot analysis were used. The level of significance was set at α = 0.05.

RESULTS

Rescue analgesia was administered to one dog in group L, one in group Rmid and one in group Rpost, with no significant differences detected. Compared to group Rmid, group L dogs exhibited significantly higher mean mechanical pain thresholds (p = 0.049) and lower mean UMPS scores (p = 0.001). Group Rpost dogs had statistically significantly higher mean pain thresholds compared to group Rmid (p = 0.009).

CLINICAL IMPLICATIONS

When performed after fracture reduction and before osteosynthesis material placement, lidocaine HB seems to be more effective than ropivacaine HB in controlling post-operative pain in dogs undergoing osteosynthesis of long-bone fractures. The administration of ropivacaine HB after osteosynthesis material placement seems to be more effective than administration after fracture reduction and before osteosynthesis material placement or administration before fracture reduction in controlling post-operative pain in dogs undergoing osteosynthesis of long-bone fractures.

Efficacy of Hematoma Block After Intramedullary Rod Fixation of Femoral Shaft Fractures: A Prospective, Double-Blinded, Randomized Controlled Trial

OBJECTIVES

To evaluate the efficacy of an intraoperative, postfixation fracture hematoma block on postoperative pain control and opioid consumption in patients with acute femoral shaft fractures.

DESIGN

Prospective, double-blinded, randomized controlled trial.

SETTING

Academic Level I Trauma Center.

PATIENTS/PARTICIPANTS

Eighty-two consecutive patients with isolated femoral shaft fractures (OTA/AO 32) underwent intramedullary rod fixation.

INTERVENTION

Patients were randomized to receive an intraoperative, postfixation fracture hematoma injection containing 20 mL of normal saline or 0.5% ropivacaine in addition to a standardized multimodal pain regimen that included opioids.

MAIN OUTCOME MEASUREMENTS

Visual analog scale (VAS) pain scores and opioid consumption.

RESULTS

The treatment group demonstrated significantly lower VAS pain scores than the control group in the first 24-hour postoperative period (5.0 vs. 6.7, P = 0.004), 0-8 hours (5.4 vs. 7.0, P = 0.013), 8-16 hours (4.9 vs. 6.6, P = 0.018), and 16-24 hours (4.7 vs. 6.6, P = 0.010), postoperatively. In addition, the opioid consumption (morphine milligram equivalents) was significantly lower in the treatment group compared with the control group over the first 24-hour postoperative period (43.6 vs. 65.9, P = 0.008). No adverse effects were observed secondary to the saline or ropivacaine infiltration.

CONCLUSIONS

Infiltrating the fracture hematoma with ropivacaine in adult femoral shaft fractures reduced postoperative pain and opioid consumption compared with saline control. This intervention presents a useful adjunct to multimodal analgesia to improve postoperative care in orthopaedic trauma patients.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Radial Nerve Supracondylar Block Versus Fracture Hematoma Block. Comparison of Their Efficacy in Cases of Fractures of the Distal Third of the Radius

Objective  The present study compares the analgesic efficacy of two techniques to perform non-surgical reduction: fracture hematoma block and radial nerve supracondylar block. Methods  Forty patients with fractures of the distal third of the radius, who required reduction, were selected in a quasi-randomized clinical trial to receive one of the anesthetic techniques. All patients signed the informed consent form, except for those who did not wish to participate in the study, had neurological injury, had contraindication to the procedure in the emergency room, or with contraindication to the use of lidocaine. To measure analgesia, the numerical pain rate scale was used at four different moments: preblock, postblock, during reduction, and after reduction; then three differences were calculated: the first between before and after blocking; the second between during reduction and after blockade; and the third between before blocking and after reduction. Results  The fracture hematoma and supracondylar block groups showed the following mean values, respectively: 3.90 (1-10) and 3.50 (-6-10) in difference 1; 4.35 (-5-10) and 5.00 (-3-10) in difference 2; and 4.65 (1-10) and 3.80 (-3-10) in difference 3. Conclusion  Both techniques proved to be efficient for analgesia, with mild superiority of hematoma block, but without statistical significance.

Regional Anesthesia in Upper-Limb Surgery

BACKGROUND

Local and regional anesthesia is associated with numerous clinical and institutional advantages relative to general anesthesia. As anesthesiologists and surgeons increasingly integrate local and regional anesthesia into their clinical practice, an understanding of the principles, evolution, and trends underpinning modern anesthetic techniques continues to be relevant.

METHODS

A review of the literature in databases Medline, PubMed, and EMBASE identified recent developments, ongoing trends, and historical milestones in upper-limb regional anesthesia.

RESULTS

Advances in regional anesthetic techniques in the last century have led to reduced postoperative pain, improved safety, and improved outcomes in upper-limb surgery. The development of ultrasound-guided techniques, as well as pharmacological advances in local anesthetic drugs and adjuncts, has further advanced the role of regional anesthesia. Wide-awake local anesthesia with no tourniquet has allowed certain procedures to be performed on select patients in outpatient and low-resource settings.

CONCLUSIONS

This review provides an overview of local and regional anesthesia in the upper-limb from its historical origins to its contemporary applications in upper-limb surgery, particularly during the COVID-19 pandemic.

Possibility of Avoiding Anesthesia in the Reduction of Greenstick and Angulated Forearm and Distal-End Radius Fractures in Children: A Comparative Study

Introduction Greenstick and angulated forearm bone fractures are the most common fractures in children and invariably require closed reduction under anesthesia. However, pediatric anesthesia is somewhat risky and not always available in developing countries like India. Therefore, this study aimed to evaluate the standard (quality) of closed reduction without anesthesia in children and to determine satisfaction among parents. Materials and methods The present study included 163 children with closed angulated fractures of the distal radius and fracture shafts of both forearm bones, who were treated by closed reduction. One hundred and thirteen were treated without any anesthesia (study group) on an outpatient department (OPD) basis, whereas 50 children of similar age and fracture type underwent reduction with anesthesia (control group). After reduction by both methods check X-ray was done to evaluate the quality of the reduction. Results The average age of the 113 children in the present study was 9.5 years (range: 3.5-16.2 years), of which 82 children had radius or ulna fractures, and 31 had isolated distal radius fractures. In 96.8% of children, ≤10° of residual angulation was achieved. Furthermore, 11 children (12.4%) used paracetamol or ibuprofen for pain control in the study group. Moreover, 97.3% of parents stated that they would like their children to be treated without anesthesia if any fracture occurred again. Conclusions Closed reduction of greenstick angulated forearm and distal-end radius fracture in children in the OPD without anesthesia achieved satisfactory reduction and high parent satisfaction while reducing the risks of pediatric anesthesia and its associated complications.

Procedural sedation and analgesia versus nerve blocks for reduction of fractures and dislocations in the emergency department: A systematic review and meta-analysis

Background

Procedural sedation and analgesia (PSA) and peripheral nerve blocks (NBs) are techniques to manage pain and facilitate reduction of dislocated joints or fractures. However, it is unclear if either approach provides any distinct advantage in the emergency department (ED). The aim of this systematic review is to compare these 2 techniques on pain scores, adverse events, patient satisfaction, and length of stay (LOS) in the ED.

Methods

We performed an electronic search of MEDLINE, EMBASE, and the Cochrane Library, and references were hand-searched. Randomized controlled trials (RCTs) comparing PSA with NBs for orthopedic reductions in the ED were included. Outcomes of interest included pain scores, adverse events, patient satisfaction, and LOS in the ED. A total of 2 reviewers independently screened abstracts and extracted data into a standardized form. The Cochrane risk-of-bias tool was used to evaluate study quality. The Grading of Recommendation Assessment Development and Evaluation approach was used to assess the certainty and strength of the evidence. Data on pain scores were pooled using a random-effects model and are reported as standardized mean differences (SMDs) with 95% confidence intervals (CIs).

Results

A total of 6 RCTs (n = 256) were included in a qualitative review, and 4 RCTs (n = 101) were included in the meta-analysis. There was no significant difference in pain scores between the PSA and NB groups (P = 0.47; SMD, 0.45; 95% CI, -0.78 to 1.69; I2 = 0.94). There were less adverse events in the NB group (0%-3.3%) compared with the PSA group (0%-20%; n = 256). LOS times were consistently shorter in the NB group (n = 215). Patient satisfaction was comparable in both groups (n = 196).

Conclusion

Based on the available evidence, NBs performed by emergency physicians are as effective as PSA in managing pain during orthopedic reductions in the ED. NBs are associated with fewer adverse events and shorter LOS in the ED. The quality of evidence is low.

"You're O.K. Anesthesia": Closed Reduction of Displaced Pediatric Forearm and Wrist Fractures in the Office Without Anesthesia

BACKGROUND

Angulated wrist and forearm fractures are among the most common pediatric fractures, and they often require closed reduction with anesthesia. There are several issues associated with pediatric anesthesia including the low but non-zero risk of significant complications, increased physician and staff time and effort, and increased cost. Despite these issues, there have not been any studies to prove that using anesthesia results in better outcomes or higher caregiver satisfaction in comparison to performing closed reductions without anesthesia. The purpose of this study was to evaluate the quality of closed reductions of angulated pediatric wrist and forearm fractures and to determine caregiver satisfaction with an anesthesia-free reduction technique.

METHODS

This study included 54 pediatric patients with closed, angulated fractures of the radius or combined radial and ulnar shafts. All closed reductions were performed by a single pediatric fellowship-trained orthopaedic surgeon in the office setting without any anesthesia. Radiographs were obtained to assess the quality of the reduction. At the first follow-up visit, caregivers were asked about their interim use of pain medications. Caregivers were later surveyed about patient use of analgesics and their satisfaction with an anesthesia-free reduction technique.

RESULTS

The average age of the 54 patients in this study was 9 years (1.8 to 16.8 y). Thirty-three fractures were combined radial and ulnar forearm shaft fractures, 18 were distal radius fractures, and 3 were radial shaft fractures. ≤10 degrees of residual angulation was achieved in 98% of patients. Nine percent (5/54) of the patients used ibuprofen or acetaminophen for pain control. Seventy eight percent (42/54) of the caregivers responded to the telephone and email surveys. All responding caregivers stated that the patients returned to full function and had satisfactory outcomes. Ninety eight percent (41/42) of the caregivers stated they would choose the same anesthesia-free reduction technique again.

CONCLUSIONS

Closed reduction of angulated pediatric wrist and forearm fractures in the office without anesthesia can achieve satisfactory reductions and high caregiver satisfaction while eliminating the risks and complications associated with pediatric anesthesia.

LEVEL OF EVIDENCE

Level IV Case series.

Pain management of upper limb fractures in pediatric emergency department versus general orthopedics emergency department

Under treatment of pain is frequently reported in children even in conditions associated with severe pain such as fractures. Recent literature supports adequate and early pain treatment because extreme and uncontrolled pain can lead to hyperalgesia. Since 2017, the treatment of pediatric orthopedic cases in the "Meir" Medical Center was gradually shifted from the orthopedic general emergency department to the pediatric emergency department. The objective was to examine the differences in pain management between the orthopedic and pediatric emergency departments. Upper limb fractures were chosen as a representing case. This retrospective cohort study included children aged 0-18 years that suffered from an upper limb fracture and were admitted to the emergency department in the years 2016 and 2018. In our study, a total of 2520 children suffered from an upper limb fracture and were treated at the Meir Medical Center during the study period. 959 of these children were treated during 2016 in the general emergency department, and 1561 were treated in the pediatric emergency department during 2018. The group characteristics were similar. In the pediatric emergency department compared to general emergency department group, more children received analgesic treatment (47.85% versus 30.4%, p < .001), more opiates were given (13.9% versus 5.3%, p < .001), and the analgesic treatment was more adequate to pain severity. Additionally, sedation was performed more frequently in the pediatric emergency department (21.6% versus 9.5%, p < .001), especially for dislocated fractures (81.5% versus 31.4%, p < .001).

COMPLICATIONS

Length of stay, surgery, hospitalization, and recurrent referral rates were similar between the two groups.

CONCLUSIONS

 The transfer of orthopedic pediatric cases to the pediatric emergency department showed a notable improvement in pain management without an increase in complications or emergency department length of stay.

WHAT IS KNOWN

• Pain management and control is a major issue to address in their treatment. • Traumatic injuries and especially fractures are common causes for ED admissions.

WHAT IS NEW

• Comparing pain management and upper limb fractures treatment between general and pediatric ED. • Pain is better treated in the PED than in the GED, without an increased rate of complications.

Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review

BACKGROUND

Forearm fractures in children often require closed reduction in the emergency setting. The choice of anaesthesia influences the degree of pain relief, which determines the success of reduction. Main methods of anaesthesia include procedural sedation and analgesia, haematoma block, intravenous regional anaesthesia (IVRA) and regional nerve blocks. However, their comparative effectiveness is unclear. This study aims to synthesise peer-reviewed evidence and identify the most effective, in terms of pain reduction, and safest anaesthetic method.

METHODS

MEDLINE, Embase and the Cochrane Library were searched from inception to 15 June 2021. Randomised controlled trials comparing anaesthetic methods for the closed reduction of paediatric forearm fractures in the emergency setting were included. Two reviewers independently screened, collected data and assessed the risk of bias for the selected outcomes. The primary outcome was pain during reduction. Secondary outcomes included pain after reduction, adverse effects, satisfaction, adequacy of sedation/anaesthesia, success of reduction and resource use.

RESULTS

1288 records were screened and 9 trials, which studied 936 patients in total, were included. Four trials compared the main methods of anaesthesia. Within the same method of anaesthesia, one compared administrative routes, one compared procedural techniques, one compared different drugs, one compared the use of adjuncts and one compared different doses of the same drug. One study found better pain outcomes with infraclavicular blocks compared with procedural sedation and analgesia. Lidocaine was superior in analgesic effect to prilocaine in IVRA in one study. One study found lower pain scores with moderate-dose than low-dose lidocaine in IVRA.

CONCLUSION

Few randomised controlled trials compared anaesthetic methods in the closed reduction of paediatric forearm fractures. High heterogeneity precluded meta-analysis. Overall, current data are insufficient to guide the choice of anaesthetic method in emergency settings. More adequately powered trials, conducted using standardised methods, are required.

Point-of-Care Ultrasound-Guided Hematoma Block for Forearm Fracture Reduction

ABSTRACT

Fractures of the radius and ulna are very common in pediatric patients. Procedural sedation or general anesthesia is typically required to perform orthopedic reductions. There are several studies in the adult literature that conclude that point-of-care ultrasound-guided hematoma blocks are faster and just as efficacious as procedural sedation for reducing fractures in the emergency department. There is currently no literature examining point-of-care ultrasound-guided hematoma blocks in pediatric patients. This case describes a pediatric patient with a distal radius fracture who underwent a hematoma block under ultrasound guidance and had a successful bedside reduction without the need for sedation.

Length of stay outcomes in patients receiving ketamine sedation versus Bier's block anaesthesia for procedural closed fracture reduction: A retrospective audit of paediatric emergency department patients

OBJECTIVE

To compare length of stay (LOS) for paediatric patients receiving ketamine sedation or Bier's block anaesthesia for procedural closed fracture reduction.

METHODS

We conducted a retrospective audit of paediatric ED patients aged 3-18 years presenting at one of three metropolitan hospitals in Victoria, Australia (2012-2017). Outcomes were post-procedural LOS (PPLOS), total LOS, incidence of ketamine and Bier's block procedures, and recorded adverse effects. Groups were compared using t-tests. Association between treatment group and admission to a short stay unit (SSU) was assessed using univariate logistic regression.

RESULTS

Across all three sites, 449 patients were included, 379 of whom received ketamine sedation and 73 of whom underwent Bier's block anaesthesia. Mean age was 9.1 years (ketamine group: 8.3 years; Bier's block group: 13.1 years). Median PPLOS was 75 min shorter for patients who received a Bier's block than for those sedated with ketamine (P < 0.001). Patients sedated with ketamine were also 9.01 times more likely to be admitted to an SSU than those who received Bier's block anaesthesia (95% confidence interval 3.82-21.31, P < 0.001). Ketamine sedation was more common than Bier's block across the three sites. No major adverse events occurred in either group.

CONCLUSION

Bier's block anaesthesia is a safe alternative to ketamine sedation for paediatric patients presenting to the ED with closed fractures. It is associated with reduced LOS and need for post-procedural observation. However, ketamine may remain preferable for younger paediatric patients, on whom it places fewer demands for cooperation.

The emergency medicine management of clavicle fractures

BACKGROUND

Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated.

OBJECTIVE OF THE REVIEW

To provide an evidence-based review of clavicle fracture management in the emergency department.

DISCUSSION

Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults.

CONCLUSIONS

When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.

Hematoma Block: An Effective Alternative for Pain Management and Procedural Sedation

Management of traumatic extremity injuries in the emergency department is typically time consuming, often requiring multiple resources including pain control and procedural sedation. A hematoma block is a safe and effective alternative treatment of pain and may eliminate the need for procedural sedation. The hematoma block requires fewer emergency department resources and may decrease time and costs that are associated with procedural sedation and analgesia. This technique is easily performed by the emergency nurse practitioner, and complications are rare. This article presents the appropriate technique required to perform a hematoma block for pain control and fracture reduction in patients with closed traumatic injuries.

Haematoma block: a safe method for pre-surgical reduction of distal radius fractures

BACKGROUND

The haematoma block (HB) has been successfully used to minimise pain prior to otherwise painful closed reduction manoeuvres for distal radius fractures. However, the invasive manner of the procedure, which technically produces an open fracture, still raises the question, whether HBs increase the risk of infection compared to conventional intravenous analgesia (IA). The purpose of this study was to assess complication rates and safety of the HB procedure for the closed reduction of surgically treated distal radius fractures.

METHODS

We included 176 distal radius fractures in 170 patients in a retrospective mono-centric study, who underwent closed reduction and casting followed by definitive surgical care over a period of two years. Patients either received a HB or IA before closed reduction and were evaluated for minor and major complications over a follow-up period of four years.

RESULTS

Overall, 42 distal radius fractures were treated with a HB (23.9%) and 134 with IA (76.1%) before closed reduction. There were a single major (2.3%) and eight minor (19%) complications observed in the HB group compared to two major (1.4%) and 24 minor (17.9%) complications in the IA group. No significant differences were identified between the two groups. Sex and type of fracture had no effect on complication rates, however, younger patients experienced higher complication rates in comparison to older ones (p = 0.035).

CONCLUSION

According to our data, the apprehensions that clinicians may have of creating open fractures through HB procedures, are unnecessary and may be abandoned confidently.

Local Hematoma Block as Postoperative Analgesia in Pediatric Supracondylar Humerus Fractures

Purpose

Supracondylar humerus fracture (SHF) is the most common type of fracture in children. The aim of this study was to evaluate the efficacy of local hematoma block with 0.25% bupivacaine as postoperative pain control in patients with pediatric SHF who underwent closed reduction pin fixation.

Methods

We performed an institutional review board–approved, prospective cohort study of 65 patients with SHF treated with closed reduction percutaneous pin fixation. For 6 months, all patients were randomly divided into 2 groups. The treatment group (35 patients) received an intraoperative local hematoma block using 0.25% bupivacaine whereas the control group (30 patients) did not receive a local hematoma block as postoperative pain management adjuvant. After surgery, all patients were prescribed opioid pain medication. To evaluate the efficacy of the hematoma block, postoperative morphine equivalent consumption and the Faces Pain Scale–Revised (FPS-R) survey were blindly recorded during postoperative day 1. Demographic data, surgical details, clinical neurovascular examination during the hospital stay, and complications were also evaluated.

Results

Comparison of the control group with the treatment group showed similar morphine equivalent consumption and Face Pain Scale–Revised Survey results. No hematoma block-associated complications were reported.

Conclusions

The result of this study do not favor the use of local hematoma block to improve pain control and decrease the need for opioid use on postoperative day 1 in pediatric SHF after patients undergo closed reduction percutaneous pin fixation. These results can lay the foundation for future studies while suggesting new, novel opioid-free pain control strategies in patients with SHF.

Type of study/level of evidence

Therapeutic II.

Pain Management for Orthopedic Injuries

Pain management in acute orthopedic injury needs to be tailored to the presentation and patient. Subjective and objective assessment, in conjunction with pathophysiology, should be used to provide symptom control. Ideally, treatment should be administered in an escalating fashion, attempting to manage pain with the lowest dose of the safest medication available. There are also adjunctive therapies, including those that are nonpharmacologic, that can provide additional relief.

Risk factors for fracture redisplacement after reduction and cast immobilization of displaced distal radius fractures in children: a meta-analysis

PURPOSE

Displaced distal radius fractures in children are common and often reduced if necessary and immobilized in cast. Still, fracture redisplacement frequently occurs. This can be prevented by fixation of fracture fragments with K-wires, but until now, there are no clear guidelines for treatment with primary K-wire fixation. This meta-analysis aimed to identify risk factors for redisplacement after reduction and cast immobilization of displaced distal radius fractures in children, and thereby determine which children will benefit most of primary additional K-wire fixation.

METHODS

Eight databases were searched to identify studies and extract data on the incidence of and risk factors for redisplacement of distal radius fractures after initial reduction and cast immobilization in children.

RESULTS

Twelve studies, including 1256 patients, showed that initial complete displacement (odds ratio [OR] 4.69, 95% confidence interval [CI] 2.98-7.39) and presence of a both-bone fracture (OR 1.95, 95% CI 1.34-2.85) were independent risk factors for redisplacement. Anatomical reduction reduced the redisplacement risk (OR 0.14, 95% CI 0.05-0.40). No significant influence on redisplacement risk could be established for female sex, experience level of the attending surgeon, Cast Index < 0.8, Three-Point Index < 0.8 and patient's age.

CONCLUSIONS

For children with a displaced distal radius fracture, the presence of a both-bone fracture, complete displacement of the distal radius and non-anatomical reduction are risk factors for redisplacement after reduction of their initially displaced distal radius fracture. Children with one or more of these risk factors probably benefit most of reduction combined with primary K-wire fixation.

The Community Orthopedic Surgeon Taking Trauma Call: Pediatric Distal Radius and Ulna Fracture Pearls and Pitfalls

Distal radius and ulna fractures are common injuries in children. Fractures typically involve the distal radius and ulna metaphysis or physis or a combination of the 2. The goals of treatment are aimed at achieving satisfactory anatomic alignment within defined parameters based on growth remaining. Nonoperative treatment approaches are recommended for most fractures, whereas surgical intervention is indicated for select cases. Potential issues with skeletal growth and bone remodeling are common. This article will offer evidence- and experience-based pearls regarding common closed fractures of the distal radius and ulna intended to benefit the community orthopaedic surgeon caring for children during the course of their on-call duties.

The efficacy, safety, and cost benefits of splints for fractures of the distal radius in children: A systematic review and meta-analysis protocol

BACKGROUND

Distal radius fractures (DRFs) is one of the most common bone injuries in children, which may lead to deformity and other complications if the treatment is not prompt or appropriate. Splints external fixation is a common conservative treatment for such fractures. Therefore, we conducted a systematic review and meta-analysis to explore the efficacy, safety and cost benefits of splints in the treatment of DRFs in children.

METHODS

PubMed, Web of Science, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov, Chinese National Knowledge Infrastructure Database (CNKI), Wanfang Database, and VIP Database were searched for eligible randomized controlled trials (RCTs). The methodological quality of the included studies and the level of evidence for results were assessed, respectively, using the risk bias assessment tool of Cochrane and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Statistical analysis was conducted with Revman 5.3.

RESULTS

This study will analyze and integrate the existing evidence for effectiveness, safety and cost benefits of splints on DRFs in children.

CONCLUSION

The conclusion of this study will provide evidence to effectiveness, safety and cost benefits of splints on DRFs in children, which can further guide the selection of appropriate interventions.

PROSPERO REGISTRATION NUMBER

CRD42019123429.

Ultrasound-Guided Nerve Blocks as Analgesia for Nonoperative Management of Distal Radius Fractures-Two Consecutive Randomized Controlled Trials

OBJECTIVES

To investigate whether a conventional fracture hematoma block (FHB) or an ultrasound-guided peripheral nerve block has more superior analgesic effect during nonoperative management of distal radius fractures in an emergency department setting. Two peripheral nerve block types were investigated, one at the level of the elbow, or cubital nerve block (CNB), and another an axillary nerve block (ANB).

DESIGN

Two prospective randomized controlled studies were performed to compare the difference in pain intensity during closed reduction of a distal radius fracture between FHB-, CNB-, and, ANB-treated patients.

SETTING

Level 2 trauma center.

PATIENTS

One hundred ten patients with radiographic displaced distal radius fractures were randomized. Fifty patients were randomized between FHB and CNB, and 60 patients were randomized between CNB and ANB.

INTERVENTION

FHB, CNB, or ANB. These were performed by 3 physicians new to ultrasound-guided peripheral nerve blocks and trained before onset of this study.

MAIN OUTCOME MEASUREMENT

Pain was sequentially measured using an NRS during closed distal radius fracture reduction.

RESULTS

CNB patients experienced less pain during block procedure (P = 0.002), finger trap traction (P = 0.007), fracture reduction (P = 0.00001), after plaster cast application (P = 0.01), and after control radiography (P = 0.01). In our second study, ANB-treated patients reported less pain during block procedure (P = 0.04), during finger trap traction (P < 0.0001), fracture reduction (P < 0.0001), after plaster cast application (P = 0.0001), and after control radiography (P = 0.0005).

CONCLUSIONS

Although participating clinicians had minimal expertise using ultrasound-guided peripheral nerve blocks, nonoperative management of distal radius fracture using an ANB was less painful. These block types are expected to completely eradicate sensation the best. Future studies should address technical factors including adequate placement and time to let the block set up, as well as issues such as resource utilization including time and clinician availability to better determine the relative advantages and disadvantages to other analgesia techniques such as the FHB.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Reduced Length of Stay and Adverse Events Using Bier Block for Forearm Fracture Reduction in the Pediatric Emergency Department

OBJECTIVES

Forearm fractures are among the most common pediatric injuries. Procedural sedation is frequently used for analgesia during fracture reduction but requires a prolonged recovery period and can be associated with adverse events. Bier block is a safe alternative for fracture reduction analgesia. This study sought to compare Bier block and procedural sedation for forearm fracture reduction.

METHODS

We performed a retrospective study of patients aged 6 to 18 years, presenting with forearm fractures requiring closed reduction from June 2012 to March 2014. Outcomes assessed were emergency department length of stay, reduction success rates, adverse events, and unscheduled return visits.

RESULTS

Overall, 274 patients were included (Bier block, n = 109; procedural sedation, n = 165). Mean length of stay was 82 minutes shorter for Bier block patients (279 vs 361 minutes, P < 0.001). Subanalysis revealed a reduced length of stay among Bier block patients with forearm fractures involving a single bone (286 vs 388 minutes, P < 0.001) and both bones (259 vs 321 minutes, P < 0.05). Reduction success did not differ between Bier block and procedural sedation (98.2% vs 97.6%, P = 0.74). There were no major adverse events in either group, but Bier block patients experienced fewer minor adverse events (2.7% vs 14.5%, P < 0.001). Return visit rates were similar between Bier block and procedural sedation (17.6% vs 16.9%, P = 0.92).

CONCLUSIONS

Compared with procedural sedation, forearm fracture reduction performed with Bier block was associated with a reduced emergency department length of stay and fewer adverse events, with no differences in reduction success or return visits.

Pain Management in the Emergency Department: a Review Article on Options and Methods

CONTEXT

The aim of this review is to recognizing different methods of analgesia for emergency medicine physicians (EMPs) allows them to have various pain relief methods to reduce pain and to be able to use it according to the patient's condition and to improve the quality of their services.

EVIDENCE ACQUISITION

In this review article, the search engines and scientific databases of Google Scholar, Science Direct, PubMed, Medline, Scopus, and Cochrane for emergency pain management methods were reviewed. Among the findings, high quality articles were eventually selected from 2000 to 2018, and after reviewing them, we have conducted a comprehensive comparison of the usual methods of pain control in the emergency department (ED).

RESULTS

For better understanding, the results are reported in to separate subheadings including "Parenteral agents" and "Regional blocks". Non-opioids analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are commonly used in the treatment of acute pain. However, the relief of acute moderate to severe pain usually requires opioid agents. Considering the side effects of systemic drugs and the restrictions on the use of analgesics, especially opioids, regional blocks of pain as part of a multimodal analgesic strategy can be helpful.

CONCLUSION

This study was designed to investigate and identify the disadvantages and advantages of using each drug to be able to make the right choices in different clinical situations for patients while paying attention to the limitations of the use of these analgesic drugs.

The Radiographic Quality of Distal Radius Fracture Reduction Using Sedation Versus Hematoma Block

Introduction

Distal radius fractures (DRFs) are treated in the emergency department (ED) with a closed reduction in order to decrease neurovascular and soft tissue injury and as a first definitive step in conservative treatment. The type of anesthesia used may affect the ability to reduce the fracture and remains controversial.

Objective

The purpose of this study was to compare the quality of radiographic reduction achieved in the ED of DRF reduced using sedation anesthesia to those reduced with hematoma block anesthesia.

Methods

A retrospective case-control study of 240 DRF reductions, 30 treated with sedation and 210 with a hematoma block, was performed. Complications and time spent in the ED were documented. Pre- and postreduction radiographs were reviewed for volar tilt, radial angulation, radial height, and ulnar variance.

Results

Both groups were similar in gender, background illnesses, concomitant injuries, surgeon experience, and fracture radiographic classification. Postreduction values of volar tilt were better in the sedation group (P = .03). Volar tilt and ulnar variance improved more in the sedation group (P = .001). The sedation group spent more time in the ED (P = .001).

Discussion

Sedation seemed to be more efficient than hematoma block in supporting closed reduction of distal radius fractures in the ED. However, this method requires specialized personnel and more time spent in the ED.

Conclusion

We suggest using this method when the patient is planned to continue with conservative treatment.

Hematoma block or procedural sedation and analgesia, which is the most effective method of anesthesia in reduction of displaced distal radius fracture?

Background

Procedure sedation and analgesia (PSA) is often used to alleviate discomfort and to facilitate fracture reduction for patients with distal radius fracture in emergency departments and clinics, but risks of respiratory distress and needs for different levels of monitoring under PSA are still under concern. Hematoma block (HB) is a simple alternative method of providing rapid pain relief during reduction of distal radius fracture. However, there is still in lack of strong evidence to promote HB over PSA in clinical practice. The aim of this study was to compare HB and PSA for adult and pediatric patients during reduction of displaced distal radius fracture to identify the level of pain relief, frequency of adverse effects (AEs), and reduction failure.

Methods

The PubMed, ScienceDirect, Cochrane Library, and ClinicalTrials.gov were searched for studies comparing HB or PSA in distal radius fracture reduction. The search revealed four randomized controlled trials and one non-randomized trial, which included two studies of pediatric subjects and three studies of adult subjects. Subgroup meta-analysis for adult and pediatric groups were specifically performed according to age difference to avoid potential bias.

Results

In the adult group, the effect of HB on post-reduction pain severity was better than that of PSA with significant heterogeneity (Hedges’ g − 0.600, 95% confidence interval (CI) − 1.170 to − 0.029, p = 0.039), although there was no difference on the pain severity during reduction between these two groups with significant heterogeneity (Hedges’ g 0.356, 95% CI − 1.101 to 1.812, p = 0.632). In the pediatric group, the treatment effect on pain severity was significantly better by HB than that by PSA but without significant heterogeneity (Hedges’ g − 0.402, 95% CI − 0.718 to − 0.085, p = 0.013, I² < 0.001%). Most of the reported adverse effects (AEs) include nausea, vomiting, and respiratory distress developed in adult patients treated by PSA. The rates of reported AEs did not significantly differ between HB and PSA in the pediatric group. Additionally, final outcomes of reduction failure did not significantly differ between HB and PSA in both adult and pediatric groups.

Conclusion

Hematoma block is a safe and effective alternative of anesthesia in reduction of distal radius fracture without inferior pain relief compared with PSA among adult and pediatric patients.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0772-7) contains supplementary material, which is available to authorized users.

Current Trends in the Management of Distal Radius Fractures

This article discusses recent reports on distal radius fractures. The keyword "distal radius fracture" was used to query the PubMed database of the US National Library of Medicine. From the resulting list, articles published in the Journal of Hand Surgery (American Volume), the Journal of Hand Surgery (European Volume), and the Journal of Orthopaedic Trauma from April 2014 through December 2015 were reviewed. Related commentaries were also evaluated. Case series of fewer than 5 patients were excluded. The 65 studies and commentaries identified are categorized and summarized. [Orthopedics. 2017; 40(3):145-152.].

Hematoma Block Versus General Anesthesia in Distal Radius Fractures in Patients Over 60 Years in Trauma Emergency

Background

Distal radius fractures are among common fractures in the elderly. Regarding the age, background diseases, and possible risks, analgesia method is of great importance in this group.

Objectives

The aim of this study was to compare two analgesia methods including hematoma block and general anesthesia in people over 60 years in the orthopedic emergency department.

Methods

68 elderly patients referring to the emergency department of a medical teaching center were selected based on the inclusion criteria for a non-randomized clinical trial. The patients were placed in two groups of 34, which were matched for age and sex. Hematoma block was used as the analgesic method in one group and general anesthesia was used in the other group. These two groups were compared for pain intensity, analgesia duration, and anesthesia side effects. The SPSS software (Statistical Package for the Social Sciences, version 17.0, SPSS Inc., Chicago, Ill, USA) was used for data analysis.

Results

68 elderly patients (mean age of 70.3 ± 6.6) with a dislocated distal radius fracture which required closed reduction were examined. The duration of manipulation and surgery and discharging time were significantly different between two groups and they were all lower in the hematoma blocked group. Pain intensity evaluation indicated a statistically significant difference during initial hours after fracture reduction and fixation so that pain intensity was less in elderly patients under hematoma block than patients who underwent general anesthesia in one and six hours after surgery. Need for narcotic was 35.2% in the general anesthesia group which also showed a significant between-group difference.

Conclusions

Hematoma block analgesia used in distal radius fractures of the elderly is a very safe and effective method that seems preferable to general anesthesia in emergency departments.