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Change of Injection site during Bier's block anaesthesia for colles' fracture

Three Part Question

In [patients with colles' fracture] does [injection proximal to the fracture site during Biers' block anaesthesia ] reduce [effectiveness of anaesthesia]

Clinical Scenario

A 70 year old women presents to the A&E department with fracture of the distal radius, which requires manipulation. During the administration of Biers' block you failed to cannulate a vein distal to the fracture site. You wonder whether cannulation of vein at antecubital fossa is safe and effective.

Search Strategy

Medline 1966 to 12.2001, using WebSPIRS
[exp Bier's block] AND [change of injection site]

Search Outcome

49 papers were found and only one was relevant

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Blyth Mj, Kinninmonth AW, Asante DK
100 patients with colles' fracture, randomly selected into two groups of 50. In the first group, the injection site was dorsum of the hand and in the second group, injection was into the antecubital fossa.PRCTPain at fracture site No significant differenceNo power calculation
Pain at cuff No significant difference
Injection site bleedingHand-5 Antecubital fossa-0
Injection site haematomaHand-5 Antecubital fossa-0


The onset of sufficient anaesthesia was delayed by an average of about 5 minutes in the proximally injected group. The theoretical danger of cuff leak with proximal injection is not borne out clinically, if the slow injection speed is maintained with cuff pressure of 300 mmHg.

Clinical Bottom Line

Injection proximal to the fracture site during Biers' block anaesthesia is safe and as effective as distally placed injection.


  1. Blyth MJ, Kinninmonth AW, Asante DK. Bier's Block: A change of injection site. The Journal of Trauma-Injury Infection and Critical care. 1995;39(4):726-728.