Three Part Question
In [elderly patients with uncomplicated Colles fractures] is [Biers block or haematoma block better] at [reducing pain during manipulation, reducing the need for multiple manipulations and improving long term function]?
A 71 year old lady presents to the A+E department following a fall on the outstretched hand. X-rays reveal a Colles fracture with shortening and dorsal angulation requiring manipulation. Having worked in several different departments you have experience of reducing these fractures with either Biers block or a Haematoma block. The department is better and you think that it will be quicker to manipulate the fracture using a haematoma block but you wonder which is best for your patient.
MEDLINE using OVID interface on the world wide web 1966-December 1997.
[exp Colles fracture OR exp wrist injuries OR colles.ti,ab,sh] AND [biers.ti,ab,sh OR haematoma.ti,ab,sh OR exp nerve block OR exp anaesthesia, intravenous OR regional-anaesthesia.ti,ab,sh OR exp local anaesthesia OR local-anaesthesia.ti,ab,sh]
46 papers identified of which 4 were clinical trials comparing biers block vs haematoma block. The remaining papers are shown in the table.
|Author, date and country
||Study type (level of evidence)
|Cobb AG and Houghton GR,|
|100 consecutive patients with uncomplicated Colles fractures||PRCT||Pain during manipulation ||Less pain during manipulation with Biers block. No difference in pain in first few hours following manipulation||Outcome assessment not blinded
Inadequate basic data reporting
Randomisation procedures are not explicit
|Wardrope J et al,|
|79 (possibly 81 as some data missing) patients presenting with Colles' fractures. Aged over 45. Patients with previous fractures excluded.||PRCT||Need for remanipulation||Fewer remanipulations in Biers' block group||Outcome assessment not blind
Questionable randomisation procedures
No long term follow up
Some data missing on study subjects|
|Radiographic changes||No difference in radiographic appearances*|
|Pain during manipulation||Less pain during manipulation with Biers block|
|Abbaszadegan H and Jonsson U,|
|99 consecutive patients with Colles fractures requiring manipulation. Randomly assigned into treatment groups.||PRCT||Pain during manipulation & at 2,3, and 6 months||Pain during manipulation greater with haematoma block (no difference at subsequent follow up)||Outcome assessment not blinded
Inadequate basic data reporting
No account of Ahandedness made in assessment of grip strength
Randomisation procedures are not explicit|
|Grip strength and Range of wrist motion at 2,3 & 6 months||No difference in grip strength or range of motion|
|Radiographic changes||Radiographic appearances better in Biers block group|
|Kendall JM et al,|
|150 patients with colles fractures. More than 15 degrees dorsal angulation and 2mm shortening. 72 patients received Biers block, 70 haematoma block||PRCT||Radiological outcome||Better with IVRA in terms of initial angulation. -3.6 degrees vs. 2.1 degrees. 0=0.003||Data missing in 8 patients
Differences in position probably not clinically relevant.
No long term follow up of functional disability|
|Time spent within department||No significant difference found|
|Remanipulation rate||Less with IVRA. 17/70 vs. 4/72 p=0.003|
|Median pain score during block||Better for Biers block. 2.8 vs.5.3 p<0.001|
|Median pain scores during manipulation||Better for Biers. 1.5 vs. 3.0 p<0.01|
Pain and the need for remanipulation are very relevant patient outcomes but long term function is only addressed in one paper. The use of grip strength as an indicator of wrist function is only a crude assessment and further work is needed. Clearly there are other methods of reducing Colles fractures, (sedation, general anaesthesia, nerve blockade etc.) which have not been addressed here. However, Biers block and Haematoma block are the two most common methods of reducing this fracture in the UK with an increase in the proportion of departments using Haematoma block between 1989 and 1994 (see Cobb and Houghton).
Clinical Bottom Line
On the best evidence available at the present time Intravenous regional anaesthesia (Biers block) is preferable to local anaesthesia (haematoma block) for the reduction of uncomplicated Colles fractures in the elderly.
Level of Evidence
Level 2 - Studies considered were neither 1 or 3.
- Cobb AG, Houghton GR. Local anaesthetic infiltration versus Bier's block for Colles' fractures. BMJ 1985;291(6510):1683-4.
- Wardrope J, Flowers M, Wilson DH. Comparison of local anaesthetic techniques in the reduction of Colles' fracture. Archives of Emergency Medicine 1985;2(2):67-72.
- Abbaszadegan H, Jonsson U. Regional anesthesia preferable for Colles' fracture. Controlled comparison with local anesthesia. Acta Orthop Scand 1990;61(4):348-9.
- Kendall JM, Allen P, Younge P, et al. Haematoma block or Bier's block for Colles' fracture reduction in the accident and emergency department -- which is best? Emergency Medicine Journal 1997;14(6):352-6.