Hematoma Block Research Articles

Anesthesia for Closed Reduction of Distal Radius Fractures in the Emergency Department

Objective/Hypothesis: Distal radius fractures (DRFs) are still treated conservatively with closed reduction in the emergency department (ED) for certain indications such as infirmity or patient preference. The quality of reduction depends on multiple variables such as inherent stability of the fracture, quality of casting, patient adherence, and the type of anesthesia used in the ED. The purpose of this study was to compare the quality of radiographic fracture reduction performed in the ED using sedation anesthesia with that of using hematoma block anesthesia. Materials and Methods: A retrospective case-control study of 240 DRF reductions was done. Thirty of them were treated with sedation and 210 with a hematoma block. Inclusion criteria included age greater than 18 years and availability of adequate radiographic series including pre- and post-reduction true posteroanterior (PA) and lateral radiographs. Exclusion criteria included immediate hospitalization for operative reduction and fixation, pregnancy, and chronic cognitive impairment. Pre- and post-reduction radiographs were reviewed for volar tilt, radial angulation, radial height, and ulnar variance. Patient charts were reviewed for demographic data, background disease, and experience of the reducing surgeon. Results: Both groups were similar in gender, background illnesses, concomitant injuries, surgeon experience, and fracture radiographic classification. Surgeon experience did not affect the quality of reduction. No complications related to the anesthesia were noted. The sedation group spent more time in the ED ( P = .001). Post-reduction 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). Conclusions:(1) Both types of anesthesia carried minimal complications and achieved reduction. (2) Sedation seemed to be more efficient than hematoma block in supporting closed reduction of DRF in the ED. However, it required certified personnel and the patient spent more time in the ED. (3) Because both types of anesthesia are acceptable, we suggest using sedation when the ED reduction is the final reduction, ie, when the patient is planned to continue with conservative treatment.

Anaesthetic management of forearm fractures using a combination of haematoma block and intravenous regional anaesthesia

BackgroundIntravenous regional anaesthesia (IVRA) has been successfully used as a sole technique for forearm fractures and has high success rates. However, it is uncomfortable for the patient when the fresh fracture is manipulated for conduct of IVRA. Haematoma block (HB) has also been demonstrated as an effective anaesthetic technique for treatment of radial fractures in the ER. Unfortunately, HB does not provide muscular relaxation and may not be sufficient for operative intervention. MethodsAn observational case series was designed with the hypothesis that a combination of HB and IVRA would overcome the aforementioned drawbacks. A standardized protocol was followed for HB with 0.1ml/kg of 0.5% bupivacaine preceding the conduct of IVRA, which permitted adequate exsanguination of the extremity (using compression bandage). For IVRA, 0.5% lignocaine at 3mg/kg was used with an electro-pneumatic tourniquet. Pain scores were noted after the HB, at exsanguination and during surgery. Results100 cases were studied. Average time of onset of block after HB was 2min 18s. By the time the IVRA procedure was performed, 99% of patients had a pain score of zero. The quality of surgical anaesthesia revealed that 94% of the patients did not have any pain of incision, tourniquet or positioning at any time during surgery. ConclusionThe use of dual technique of HB and IVRA improved patient acceptance and compliance, and the safety and efficacy of the IVRA. The combination anaesthesia was found to be easy to administer, effective and safe with no complications.

Percutaneous Pinning of Distal Radius Fractures Using Hematoma Block: Outcomes in Our Center

Surgical treatment is indicated for displaced and unstable distal radius fractures. Kapandji percutaneous pin fixation technique is widely practiced on account of its efficiency and relative reproducibility.

Percutaneous Pinning of Distal Radius Fractures Using Hematoma Block: Outcomes in Our Center

Percutaneous Pinning of Distal Radius Fractures Using Hematoma Block: Outcomes in Our Center

Ultrasound-guided Hematoma Block for Distal Radial and Ulnar Fractures

BackgroundHematoma blocks of the radius can provide excellent analgesia for simple distal radius fractures. However, the landmark-based approach can be difficult, and ultrasound guidance may improve success of the block and analgesia during reduction. There is limited literature describing the ultrasound-guided approach, and prior case descriptions have not involved comminuted fractures or concomitant ulnar styloid fractures. ObjectivesThis report reviews the technique of the ultrasound-guided hematoma block for distal radius fractures and introduces a second step, which can be used in the case of concomitant distal ulna fractures. DiscussionThe use of the ultrasound-guided hematoma block allows for direct visualization of needle advancement, as well as a simple approach to anesthetizing most distal radial and ulnar fractures. ConclusionThe ultrasound-guided hematoma block may be helpful in improving anesthesia of complicated distal radial and ulnar fractures, especially when landmark-based localization is difficult.

Hematoma Block Versus Sedation for the Reduction of Distal Radius Fractures in Children

To determine which mode of anesthesia, hematoma block (HB) or procedural sedation (PS), was preferable for distal radius fracture (DRF) reduction in children. Fifty-two children (mean age, 12 y; range, 5-16 y) presenting with DRFs requiring reduction were prospectively enrolled and offered either PS or HB for anesthesia. Following reduction, families completed a satisfaction survey regarding mode of anesthesia and overall care (rated 0-10, with 10 being the best score) and an assessment of discomfort (rated 0-10, with 0 being no pain). Length of stay in the emergency department (ED) and complications related to procedure and method of anesthesia were recorded. Radiographic alignment was evaluated before and after reduction. Twenty-six patients underwent reduction with either PS or HB. Midazolam was used in addition to HB in 8 patients. One patient was converted from HB to PS due to inadequate block. There was no significant difference in prereduction and postreduction angulation between the groups, and reductions maintained satisfactory alignment. Overall satisfaction and satisfaction with anesthesia were excellent for both groups, with respective means of 9.5 and 9.5 for PS and 9.3 and 9.6 for HB. Patient discomfort was minimal in both groups, with a mean of 1.6 for PS and 2.2 for HB. Length of stay was significantly shorter for HB patients, with patients spending a mean of 2.2 hours less in the ED. Three patients required further intervention following initial reduction. One patient in each group required revision reduction, and 1 PS patient underwent closed reduction and pinning. Use of HB for the reduction of pediatric DRFs provided radiographic alignment, patient satisfaction, and pain control comparable with that of PS, while significantly decreasing ED time and resources.

Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial

ObjectiveWe compared the efficacy and safety of ultrasound-guided haematoma block with that of procedural sedation and analgesia in patients with acute distal radial fracture reduction pain control.MethodsThis was a randomised...

Evaluating the hematoma block as an adjunct to procedural sedation for closed reduction of distal forearm fractures.

Although procedural sedation using intravenous agents is highly effective for forearm fracture reduction, the process is both resource and time intensive. Our objective was to determine whether the use of a hematoma block as an adjunct to procedural sedation with ketamine and midazolam reduces (1) pain during the procedure (scored using the Observational Score for Behavioral Distress-Revised score) or (2) the excess sedation time, defined by the time between procedure completion and discharge from sedation. Our secondary outcome measure was total ketamine dose administered during the procedure. A randomized, double-blind, placebo-controlled clinical trial was conducted. Before fracture reduction, children 3 to 17 years of age randomly received 2% lidocaine (L) or normal saline (NS) into the hematoma of their fracture site during sedation with intravenous ketamine and midazolam. Ninety patients were randomized: 50 to L and 40 to NS. The groups were similar with regard to age, sex, type of fracture, and prior administration of pain medication. Median Observational Score for Behavioral Distress-Revised scores were 1.11 and 1.69 for the L and NS groups, respectively (P = 0.23). Excess sedation time was not significantly different between the groups (P = 0.36), with a median excess sedation time of 33.0 and 36.0 minutes for the L and NS groups, respectively. Mean ketamine dose administered was not different between the groups (P = 0.42). The mean total dose administered was 1.00 mg/kg and 1.07 mg/kg in the L and NS groups, respectively. Mean midazolam dose was 0.05 mg/kg for both groups. The use of a hematoma block as an adjunct to procedural sedation with ketamine and midazolam for forearm fracture reduction conferred no additional benefit and did not decrease observed pain scores, excess sedation time, or total ketamine dose administered.

Effectiveness of butorphanol as an adjuvant to lidocaine for haematoma or periosteal block: A prospective, randomised, double blind study

Background:The peripheral nerve endings carrying pain contains opiod receptors. Blocking these receptors during haematoma block or periosteal block may provide better analgesia.Aim:Evaluation of effectiveness and safety of butorphanol as an adjuvant to lidocaine for haematoma block.Settings and Design:This is a two centre, prospective, individually randomised, two group, parallel, double-blind clinical trial.Methods:In this study, 115 American society of anaesthesiologist grade I and II adult patients scheduled for closed reduction of fractures were randomly allocated into two groups; Group A received 1% lidocaine (2 mg/kg) where as Group B received 1% lidocaine (2 mg/kg) with butorphanol (0.02 mg/kg) during haematoma block. Pain was assessed before, during and after manipulation of fracture by using visual analogue scale (VAS 0-10). Onset time of block, time for first rescue analgesic, 24 hour analgesic requirement and sedation levels were noted.Statistical Analysis:Data analysed with the unpaired t-test with Welch correction assuming unequal variances and Fisher's exact test using Graph pad Prism 5.02 version.Results:Onset time of haematoma block was significantly less in the butorphanol group compared to the lidocaine group (P=0.0003). The mean time for first rescue analgesic was significantly higher and total analgesic requirement was significantly lower in the butorphanol group (P<0.0001). Mean VAS scores were lower and sedation scores were higher in the butorphanol group.Conclusions:Addition of butorphanol to lidocaine quickens onset of haematoma block, provides excellent post manipulation analgesia and decreases 24 hour total analgesic requirement without excessive sedation.

Fractures of the Distal Radius

Distal radius fractures represent 1 of every 6 fractures treated in emergency departments (EDs) each year. This injury has a peak incidence within both the 5- to 24-year-old age group and the elderly female population aged 65 years and older. An understanding of the functional anatomy of the wrist fracture will greatly aid the practitioner in proper treatment and referral for these injuries. After obtaining wrist radiographs, a thorough examination must be performed. Once anesthesia is achieved (via hematoma block, sedation, or Bier block), the first line of treatment of distal radius fractures is to reduce the fracture and stabilize the bone alignment, even if it is expected that the patient will require surgical intervention. Up to 50% of patients are at risk of losing reduction, and 20%-50% of distal radius fractures will eventually require surgical fixation. Referral to an orthopedist can be made during the ED visit or done on an outpatient status.

Use of Combined Transmucosal Fentanyl, Nitrous Oxide, and Hematoma Block for Fracture Reduction in a Pediatric Emergency Department

The objective of this study was to evaluate the use of combined inhaled nitrous oxide (NO), hematoma block (HB), and transmucosal fentanyl (TMF) as sedoanalgesia in the reduction of radioulnar fractures in children in a pediatric emergency department (PED). A retrospective, analytical observational study examining the cases of radioulnar fracture reduction in PED from 2007 to 2009 in children from 4 to 15 years old. The cases were divided into 2 groups: those in which only NO + HB was used and those in which TMF was combined with NO + HB. The pain perceived by the child, the doctor, and the nurse was studied during the procedure with 0- to 10-point scales (10 being severe pain). Satisfaction of the medical professionals, duration of the procedure, and the adverse effects that appeared were also studied. Eighty-one children were included. Sixty-four children (79%) received NO + TMF + HB, and 17 children (21%) received NO + HB only. The pain perceived by the child during the procedure in the group receiving NO + TMF + HB was 2.5 (95% confidence interval [CI], 1.8-3.1) compared with 3.9 (95% CI, 2.3-5.5) in the NO + HB group (P = 0.035), the pain perceived by the doctor was 2.6 (95% CI, 2-3.2) compared with 4 (95% CI, 1.6-4), and by the nurse was 2.7 (95% CI, 2-3.3) compared with 3.9 (95% CI, 2.3-5.5), respectively. Adverse events appeared in 15.3% of the NO + TMF + HB group and in 40% of the NO + HB group. The association of NO + TMF + HB in the reduction of radioulnar fractures in PED improves pain control compared with the NO + HB combination. New studies are required to confirm the benefit and safety of this drug combination.

Management of distal radius fractures in emergency departments in England and Wales

AimsTo examine variations and consistencies in the emergency management of distal radial fractures across England and Wales.MethodsA survey was conducted of emergency departments (ED) in England and Wales regarding the...

Radiological dorsal tilt analysis of AO type A, B, and C fractures of the distal radius treated conservatively or with extra-focal K-wire plus external fixateur

Fractures of the distal radius are amongst the most common injury patterns. The dorsal tilt represents an important co-factor determining functional outcome. The purpose of this study was to analyze the radiological dorsal tilt and identify critical time frames in conservative and operative treatment of distal radius fractures. Eighty-seven conservatively treated (hematoma block assisted reduction and splinting) and 37 operatively treated (reduction, extra-focal K-wire fixation, bridging external fixateur) AO type A, B, and C fractures of the distal radius in 124 females were retrospectively analyzed. The dorsal tilt at the initial, post-reduction, and 2 weeks post-reduction stages was correlated with the final radiographic outcome at 6 weeks. Mean initial dorsal tilt was 16.53° in the conservatively treated group and 26.76° in the operatively treated group. Mean dorsal tilt after 6 weeks showed significant differences from the mean initial dorsal tilt at time of presentation within both groups (both groups p < 0.000). No significant differences between the two groups were found after 6 weeks of treatment (p = 0.194) regardless of the underlying AO fracture type. Conservatively treated radius fractures showed a significantly higher slip rate within the first 2 weeks (primary slip rate), whereas the operative group presented a significantly higher slip rate between the 2-week and 6-week radiographic checks (secondary slip rate). In terms of dorsal tilt, conservative (cast immobilization) and operative (K-wire fixation plus external fixateur) treatment demonstrated no significant differences at the final radiographic examination (6 weeks) regardless of the underlying AO fracture type. Both treatment groups showed treatment-associated different primary and secondary slip rates, indicating a need for more frequent radiographic checks within these critical time frames.

Distal radius fracture manipulation under haematoma block: A first year trainee's first hundred patients

Distal radius fracture manipulation under haematoma block: A first year trainee's first hundred patients

The Hematoma Block: A Simple, Effective Technique for Closed Reduction of Ankle Fracture Dislocations

Management of a dislocated ankle fracture can be challenging because of instability of the ankle mortise, a compromised soft tissue envelope, and the potential neurovascular compromise. Every effort should be made to quickly and efficiently relocate the disrupted ankle joint. Within the emergency department setting, narcotics and benzodiazepines can be used to sedate the patient before attempting closed reduction. The combination of narcotics and benzodiazepines provides relief of pain and muscle guarding; however, it conveys a risk of seizure as well as respiratory arrest. An alternative to conscious sedation is the hematoma block, or an intra-articular local anesthetic injection in the ankle joint and the associated fracture hematoma. The hematoma block offers a comparable amount of analgesia to conscious sedation without the additional cardiovascular risk, hospital cost, and procedure time.

The Hematoma Block an Effective Alternative for Fracture Reduction in Distal Radius Fractures

An alternative to general anesthesia was tested against hematoma block by a double-blind, randomized clinical trial in reduction of Colles fracture. 96 patients more than 18 years old with displaced fractures of distal radius were selected from 2007-2009 on the basis of: 1) informed consent; 2) no contraindication to any method of analgesia; 3) no associated injury. Patients were randomized into 2 equal groups. The A group received Propofol intravenously, whereas the B group received 10 ml of 2% Lidocaine Hydrochloride into the fracture hematoma. Fractures are reduced under acceptable criteria. Pain measured by Visual Analogue Scale (VAS) was recorded before, during, and after reduction. Time to Emergency department, to manipulation and to hospital discharge is measured. In radiographic before, after reduction and a week later the radial tilt, ulnar migration and dorsal tilt are measured. Loss of these parameters were study statistically data analysis by KW statistics. 96 patients with displaced fractures of distal radius at mean age 54.3 (19-84) years old, M/F rate 37/59, left/right hand 37/58., from 2005-2008. VAS during reduction was 0 in group A and 0.97 +/- 0.7 in group B and VAS after reduction was 2.72 +/- 0.7 in group A and 2.25 +/- 0.2 in group B. Time to reduction was 2.63 +/- 0.96 hr in A and 0.90 +/- 0.47 hr in B After a week, 21 fractures lose reduction in group A and 22 in group B. Hematoma block by local anesthetic is a safe and effective alternative to intravenous general anesthesia in reduction of Colles fracture.

A Prospective Clinical Trial Comparing Self‐Administered Nitrous Oxide and Haematoma Block for Analgesia in Reducing Fracture of the Distal Radius in an Emergency Department

ObjectiveTo compare the effectiveness and efficacy of self‐administered nitrous oxide and haematoma block in pain relief during close reduction of fractured distal radius in adult patients.MethodsThis was a prospective clinical trial. All adult patients aged 18 years or above with fracture of the distal radius within 24 hours requiring close reduction in the Accident and Emergency Department of Kwong Wah Hospital were included. Patients with known contraindications were excluded. A consecutive series of patients were randomised into the two groups in alternating fashion. Pain perception (VAS score), procedure time, patient acceptance and complications were measured and monitored.ResultsA total of 67 patients (53 females and 14 males) with age ranging from 26 to 94 years were enrolled during the period from April 2008 to December 2008; 33 patients received Entonox and 34 received haematoma block. The average VAS score before reduction was 6.97 cm for the Entonox group and 6.76 cm for the haematoma block group (p=0.61). The average VAS score during reduction was 7.19 cm for the Entonox group and 2.80 cm for the haematoma block group (p&lt;0.0001). For the difference of average VAS scores during and before reduction, there was 0.22 cm increase in the Entonox group and 3.95 cm decrease in the haematoma block group (p&lt;0.0001). The relative change of mean VAS score was 3% increase in the Entonox group and 58% decrease in the haematoma block group (p&lt;0.0001). The average procedure time was 6.29 min for the Entonox group and 6.44 min for the haematoma block group (p=1). In the Entonox group, 64% patients agreed to use the same analgesia method under similar circumstances whereas in the haematoma block group, it was 91% (p=0.009). There were no complications or failed reductions in both groups.ConclusionHaematoma block is a safe and effective analgesia in the reduction of fractured distal radius with less pain perception, more patient acceptance and similar procedure time compared with Entonox.

Ultrasound-guided hematoma block and fracture reduction: a new way to go forward

The conventional treatment for most distal radial fractures is closed reduction and cast immobilization. Conventionally the hematoma block is used to reduce the fractures but it is done blindly and radiographic techniques have been essential and effective in monitoring these reductions [1]. Radiation-free ultrasonography, however, can provide both real-time and dynamic multiple-plane images with a small and simple-to-use transducer that can be operated with only one hand. We therefore wanted to see whether the real-time and dynamic multiple-plane observation capabilities of ultrasonography would allow an ED physician to perform under direct vision a hematoma block and closed reduction without multiple attempts of either as are frequently required when only conventional techniques are used.

Predicting initial treatment failure of fiberglass casts in pediatric distal radius fractures: Utility of the second metacarpal-radius angle

PurposeRecent literature comparing the effectiveness of above-elbow and below-elbow plaster casts appears to suggest that either cast type offers adequate immobilization for distal radius and ulna fractures. The idea that an appropriate mold placed on the cast is the most significant determinant of successful immobilization and, thereby, patient outcome has also been elucidated. The purpose of this study was to compare the effectiveness of above-elbow versus below-elbow fiberglass casts in maintaining distal radius/ulna fracture reduction and to identify factors associated with treatment failures.MethodsWe reviewed the radiographs and clinical data of 253 children with distal third forearm fractures requiring reduction under conscious sedation or a hematoma block. Outcome measures included rates of re-manipulation, loss of reduction, and cast complications.ResultsOne hundred and nineteen children were treated with below-elbow fiberglass casts and 134 were treated with above-elbow fiberglass casts based on a clinical pathway created before the study period. There were no differences between the two groups in age, weight, fracture pattern, percentage of both-bone fractures, and initial fracture angulation. Of the 253 fractures in the study, 38 (15%) were considered to have less than ideal outcomes. There were no differences between the ‘ideal’ and ‘non-ideal’ groups in age, fracture pattern, presence of ulna fracture, cast index, or cast type. All immediate post-reduction measures (anterior-posterior [AP] and lateral displacement/angulation) were significantly correlated with treatment outcome, except angulation on AP films. The magnitude of reduction as measured by a newly described variable, the angle between the second metacarpal and long axis of the radius in the AP projection, was significantly correlated with treatment failure (r = −0.139, P = 0.027). Binary logistic regression was performed and demonstrated that the success of the reduction, as determined by the AP radiograph second metacarpal-radius angle, was a significant predictor of treatment success (odds ratio 1.6, P < 0.001). Also, the change in lateral view angulation post-reduction was a significant predictor of treatment failure based on regression (odds ratio 1.2, P = 0.004). The above-elbow cast group had a slightly greater cast index (0.80) compared to the below-elbow cast group (0.77) (P = 0.003). Whereas below-elbow fiberglass casts appear to be equally effective in immobilizing pediatric distal third forearm fractures as above-elbow fiberglass casts, it seems that they have an increased risk for poor molding, particularly with regards to ulnar deviation. We did not find an association between the treatment ‘failure’ and cast index, likely because the number of poor molds (cast index >0.8) was nearly equal in each group (above-elbow with 61 and below-elbow with 45). However, the mold seen on the AP radiograph as determined by the second metacarpal-radius angle was a reproducible radiographic predictor of treatment success. If molded with ulnar deviation (second metacarpal-radius angle >0°), the outcome was considered to be ideal in 86.7% of cases compared to only 74.4% when it was <0°.ConclusionWe agree with prior studies suggesting the equal efficacy of below-elbow versus above-elbow casts in distal radius and ulna fracture treatment using either plaster or fiberglass, but wish to emphasize the importance of not only the cast index, but also the ulnar deviation mold (for most dorsally displaced fractures), as measured by the second metacarpal-radius angle.

Alternatives to Sedation for Painful Procedures

Conscious sedation is used frequently to perform procedures that may be undertaken with or without minimal sedation. Fracture manipulation can be performed with minimal discomfort in the awake patient using various techniques-for example, intravenous regional anesthesia, nerve blocks, and hematoma blocks. These have been used for many years and are very safe. They may require some specific equipment (eg, automatic tourniquet) to perform the anesthesia but patients have the same results and are able to go home much quicker because sedation is not used.Use of topical anesthesia for both intact skin and wounds has been used over many years. Its use now should be standard. Nerve blocks can also be used to anesthetize specific areas which may be difficult to use topical anesthesia (eg, lip, hand, etc) or are painful because of injection directly into the wound. These may include infraorbital nerve blocks for lip lacerations, ulna or median nerve blocks for hand injuries, and so on. Other novel approaches to topical anesthesia have seen the use of iontophoresis (again requires specific expensive equipment), jet injection of lidocaine, or "freeze sprays." Each has its own advantages and disadvantages.Femoral nerve block is a useful intervention for analgesia in patients with femoral fractures and can obviate the need for parenteral analgesia and allows excellent analgesia particularly during x-ray examination.Thus, it is important to remember that there are alternatives to conscious sedation which gives good analgesia during the procedure and allows the patient to be discharged sooner.