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

Comparison of 2 Types of Local Anesthetic Techniques in the Reduction of Distal Radius Fracture: A Prospective Cohort Study

BACKGROUND

The treatment of distal radius fractures may require manipulation of the fracture assisted by finger traction, causing pain both at the fracture site and at the fingers. The usual type of anesthesia used does not anesthetize the fingers.

METHODS

We conducted a prospective cohort study with two groups, hematoma block (HB) and hematoma with associated median nerve block (MHB). Characteristic variables of the patients were collected. The main variable for the analysis was pain, measured using the Visual Analogical Scale (VAS). It was measured prior to the injection (VAS1), during fracture reduction (VAS2), and 30 minutes after the injection (VAS3) in both groups.

RESULTS

The study included a total of 140 fractures (70 anesthetized with HB), 78% were women. There were no significant differences in the variables age, sex, Elixhauser index. and need for surgery between the groups. In the HB group, the VAS means were VAS1 5.23 cm (SD 2.31), VAS2 5.80 cm (SD 2.52), and VAS3 1.89 cm (SD 1.94); while in the MHB group, VAS1 5.13 cm (SD 2.36), VAS2 3.15 cm (SD 1.70), and VAS3 1.09 cm (SD 1.38). Area of greatest pain during fracture reduction in the HB group was finger traction in 78% cases (p < .05), while in the MHB group it was the manipulation of the fracture site in 71% cases (p < .05).

CONCLUSIONS

The study demonstrates that the use of hematoma with associated median nerve block decreases pain perception in patients with distal radius fracture that needs closed reduction, when compared to HB alone.

Analgesic Techniques for Managing Orthopedic Injuries: A Review for the Emergency Clinician

BACKGROUND

Orthopedic injuries are commonly managed in the emergency department (ED) setting. Fractures and dislocations may require reduction for proper management. There are a variety of analgesic and sedative strategies to provide patient comfort during reduction.

OBJECTIVE

This narrative review evaluates hematoma block, intra-articular injection, intravenous regional analgesia (IVRA) (also known as the Bier block), and periosteal block for orthopedic analgesia in the ED setting.

DISCUSSION

Analgesia is an essential component of management of orthopedic injuries, particularly when reduction is necessary. Options in the ED setting include hematoma blocks, intra-articular injections, IVRA, and periosteal blocks, which provide adequate analgesia without procedural sedation or opioid administration. When used in isolation, these analgesic techniques decrease complications from sedation and the need for other medications, such as opioids, while decreasing ED length of stay. Emergency clinicians can also use these techniques as analgesic adjuncts. However, training in these techniques is recommended prior to routine use, particularly with IVRA.

CONCLUSIONS

Knowledge of analgesic techniques for orthopedic procedures can assist clinicians in optimizing patient care.

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.

The hematoma block is not enough as method of anesthesia in reduction of displaced distal radius fractures

BACKGROUND

Two out of three wrist fractures seen in the emergency are displaced but most can be treated conservatively after closed reduction. Patient-reported pain during closed reduction of distal radius fractures varies widely and the best method to decrease the perceived pain has not been well established. The purpose of this study was to assess the pain during closed reduction of distal radius fractures after using the hematoma block as method of anaesthesia.

PATIENTS AND METHODS

Cross-sectional clinical study including all patients who presented an acute fracture of the distal radius requiring closed reduction and immobilization during a six-month period in two University Hospitals. Demographic data, fracture classification, perceived pain using a visual analog scale at different times of reduction and complications were registered.

RESULTS

Ninety-four consecutive patients were included. Mean age was 61 years. Mean pain score at initial assessment was 6 points. After the hematoma block, the perceived pain during the reduction manoeuvre improved to 5.1 points at the wrist, but increased to 7.3 points at the fingers. Pain decreased to 4.9 points during cast placement and reached 1.4 point after sling placement. The reported pain was higher in women at all times. There were no significant differences according to the according to the type of fracture. No neurological or skin complications were observed.

CONCLUSIONS

The hematoma block is only a mild effective method to reduce the wrist pain during closed reduction of distal radius fractures. This technique decreases slightly the perceived pain in the wrist and does not reduce the pain in the fingers. Other reduction methods or other analgesic techniques may be more effective options.

LEVEL OF EVIDENCE

Therapeutic study. Cross-sectional study - Level IV.

[Translated article] The haematoma block is not enough as method of anaesthesia in reduction of displaced distal radius fractures

BACKGROUND

Two out of three wrist fractures seen in an emergency department are displaced but most can be treated conservatively after closed reduction. Patient-reported pain during closed reduction of distal radius fractures varies widely and the best method to decrease the perceived pain has not been well established. The purpose of this study was to assess pain during closed reduction of distal radius fractures after using haematoma block as method of anaesthesia.

PATIENTS AND METHODS

Cross-sectional clinical study including all patients who presented an acute fracture of the distal radius requiring closed reduction and immobilisation during a six-month period in two University Hospitals. Demographic data, fracture classification, perceived pain using a visual analogue scale at different times of reduction and complications were registered.

RESULTS

Ninety-four consecutive patients were included. Mean age was 61 years. Mean pain score at initial assessment was 6 points. After the haematoma block, the perceived pain during the reduction manoeuvre improved to 5.1 points at the wrist, but increased to 7.3 points at the fingers. Pain decreased to 4.9 points during cast placement and reached 1.4 point after sling placement. The reported pain was higher in women at all times. There were no significant differences according to the according to the type of fracture. No neurological or skin complications were observed.

CONCLUSIONS

Haematoma block is only a mildly effective method to reduce wrist pain during closed reduction of distal radius fractures. This technique slightly decreases the perceived pain in the wrist and does not reduce the pain in the fingers. Other reduction methods or other analgesic techniques may be more effective options.

LEVEL OF EVIDENCE

Therapeutic study. Cross-sectional study - Level IV.

A Hematoma Block in the Wrist for a Displaced Distal Radius Fracture Induces Systemic Neurological Symptoms: A Case Report

Hematoma blocks are considered a relatively simple, safe, and effective technique in the acute setting to provide sufficient anesthesia and allow for closed reduction of displaced distal radius fractures. Complications associated with the utilization of local anesthetics in this setting are rare. We present the case of a patient who had a hematoma block in the wrist and developed short-term systemic neurologic complications likely secondary to systemic absorption of 20 mL of 1% lidocaine without epinephrine via the cancellous bone channels.

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.

The radiographic quality of conservatively managed distal radius fractures in adults using haematoma block versus intravenous sedation

OBJECTIVE

We compared the radiographic quality of initial reduction of distal radius fractures reduced using haematoma block to those reduced with intravenous sedation. The overall rate of re-manipulation and complications were noted.

METHODS

A prospective study carried out at the emergency unit of our hospital between 1st September, 2017 and 31st December, 2018. Patients were consecutively recruited into Haematoma Block (HB) and Sedation(S) groups using the simple balloting method. After 5-10 min of administering anaesthesia, the fracture was reduced and immobilized in a below-to-elbow Plaster of Paris (P.O.P) cast for 6 weeks. The pre- and post-reduction radiographs were reviewed for volar tilt, radial angulation, radial deviation and radial shortening.

RESULTS

Sixty-seven patients completed the study with 33 patients in HB group and 34 patients in S group. There was no significant difference in the radiographic quality of initial reduction between the two groups using the Sarmiento's modification of Lindström criteria (p = 0.49). Five out of 34 patients among the sedated group had gastrointestinal symptoms. The overall rate of re-manipulation was low and the complications recorded were wrist stiffness and residual wrist deformity.

CONCLUSION

Our study revealed that there was no significant difference in the radiographic quality of initial reduction between the groups. Excellent to good reduction was achieved with both anaesthetic options. The choice of anaesthesia should be individualized and based on surgeons' preference.

Circumferential periosteal block versus hematoma block for the reduction of distal radius and ulna fractures: a randomized controlled trial

PURPOSE

To assess the analgesic efficacy of the circumferential periosteal block (CPB) and compare it with the conventional fracture hematoma block (HB).

METHODS

This study was a prospective single-center randomized controlled trial performed in a national orthopedic hospital. Fifty patients with displaced distal radius (with or without concomitant ulna) fractures requiring reduction were randomized to receive either CPB or HB prior to the reduction. Pain was sequentially measured using the visual analogue scale (VAS) across three stages; before administration of local anesthesia (baseline), during administration (injection) and during manipulation and immobilization (manipulation). Further, the effect of demographic factors on the severity of pain was analyzed in multivariate regression. Finally, complications and end outcomes were compared across both techniques.

RESULTS

Patients receiving CPB experienced significantly less pain scores during manipulation (VAS = 0.64) compared with HB (VAS = 2.44) (p =  < 0.0001). There were no significant differences between groups at baseline (P = 0.55) and injection (P = 0.40) stages.

CONCLUSION

The CPB provides a superior analgesic effect over the conventional HB with no documented complications in either technique.

LEVEL OF EVIDENCE

Therapeutic Level II.

"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.

Review article: Ankle intra-articular haematoma block for reduction of unstable ankle fractures in the emergency department: An integrative review

A review was conducted to assess the efficacy and safety of the intra-articular haematoma block (IAHB) for manipulation of ankle fractures in ED. Any study investigating the success of IAHB for ankle fracture reduction published in English was sought. Seven databases were searched. The Cochrane Risk of Bias tool was used to quality assess the included studies. Three studies met the inclusion criteria (n = 436 patients). Just one study was a randomised controlled trial (n = 42). The two non-randomised studies that included the majority of patients were assessed as at high overall risk of bias. The studies reported no significant difference in the overall rate of successful reduction or patient-reported pain scores between IAHB and procedural sedation groups. A subgroup analysis in one study suggested timelier reduction by 51.4 min (P = 0.01) for fractures involving subluxation when using IAHB, but that more patients with dislocation were reduced on first attempt when using procedural sedation compared to IAHB (74.0% vs 54.8%, P < 0.01). No adverse events were reported from using IAHB, although no study measured events such as joint sepsis or chondrolysis. Findings suggest that IAHB might be safe and effective but the evidence is very limited. High-quality research is required before IAHB can be considered a routine alternative. However, IAHB could be considered in situations where the risk of procedural sedation outweighs the likely very low risk of chondrolysis.

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.

Adult Distal Radius Fracture Management

Distal radius fractures (DRFs) are some of the most commonly encountered fractures, and the incidence is increasing. Optimal treatment remains controversial. Critical evaluation of the initial imaging is necessary to recognize fracture characteristics and stability. The fracture pattern, injury mechanism, soft-tissue injury, patient characteristics, and surgeon preference are generally taken into consideration when choosing the most appropriate modality. Volar plating has become the workhorse of surgical DRF management but is not without complications. The surgeon should be comfortable using a wide variety of techniques to customize the fixation to the fracture pattern. Recognition of potential dangers and use of intraoperative imaging techniques can mitigate complications. Goals of rehabilitation after the initial treatment of DRF include regaining motion, strength, and ultimately function while managing pain.

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.

Perioperative management of distal radius fractures

Fractures of the distal radius are the most common upper limb fracture and account for over a sixth of all fractures seen in emergency departments. Although most of these fractures are managed non-operatively, a significant number of complex injuries undergo operative management. This educational review of up to date guidelines discusses the perioperative management of distal radius fractures and provides readers with continuing professional development activities.

Management of Pain Associated with Fractures

PURPOSE OF REVIEW

The purpose is to review current literature on pain management strategies from initial presentation to postoperative care on common fracture types.

RECENT FINDINGS

- Hip fractures benefit from use of multimodal pain control for early mobility and decreased narcotic requirement. - Distal radius fracture pain during reduction can be managed with hematoma block. Postoperatively, a soft dressing is adequate, and use of a compression glove may improve pain control and edema. - Ankle fractures can be reduced with hematoma block, though use of procedural sedation may reduce reduction attempts for fracture dislocations. - Long bone fracture pain management is trending toward multimodal pain control. Though there is no high-quality evidence, concern that regional anesthesia may mask compartment syndrome has limited its use in high-risk fractures. - The effect of NSAIDs on bone healing has not been conclusively demonstrated. The literature is still inconclusive regarding superiority of either spinal or general anesthesia during operative treatment. Fracture pain control is complex and multifactorial, requiring nuanced clinical judgment in the face of mixed clinical findings.

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.