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Three Part Question

For [patients presenting to the ED with closed distal radius fractures requiring reduction], is the [hematoma block better than conscious sedation] at providing [analgesia]?

Clinical Scenario

A 45-year-old woman presents to the emergency department with a displaced Colles fracture two hours after slipping on ice. As you prepare for the reduction, you wonder whether a hematoma block would be adequate for analgesia versus conscious sedation.

Search Strategy

(exp Colles' Fracture/ or exp Radius Fracture/ or Colles.mp. OR (smith$ fracture or barton$ fracture).mp. OR radial fracture.mp.) AND ((hematoma block or haematoma block).mp. OR anesthetics, local/ OR (local anesthetic or local anaesthetic).mp. OR exp Lidocaine/ or lidocaine.mp. OR lignocaine.mp. OR exp bupivacaine/ OR bupivacaine.mp. OR (regional anaesthesia or regional anesthesia).mp.) AND (exp Conscious Sedation/ or sedation.mp. OR anesthetics, dissociative/ or anesthetics, intravenous/ OR ketamine.mp. or ketamine/ OR propofol.mp. or propofol/ OR midazolam.mp. or midazolam/ OR etomidate.mp. or etomidate/)

Search Outcome

163 papers were found of which 159 were irrelevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bear et al 2015 USA	52 pediatric patients with displaced DRFs requiring reduction. Conscious sedation (26) vs hematoma block (26).	Prospective study	Satisfaction survey	No statistical difference in satisfaction	(1) Not generalizable to adult patients or patients younger than ten years old, (2) Selection bias, (3) Not randomized, and (4) Time to ED/reduction not specified for groups
			Level of discomfort	No statistical difference in level of discomfort
			Length of stay	Time spent in ED significantly less in the hematoma block group
			Complications	No statistical difference in complications including reduction failure
Fathi et al 2014 Iran	143 patients with displaced DRFs requiring reduction. Conscious sedation (72) vs hematoma block (71).	RCT	Pain before reduction, during reduction and at 5, 10 and 15 minutes after reduction	No statistical difference between the two groups	(1) Polytrauma and critically ill patients excluded, (2) Multiple trauma and critically ill patients were not included, (3) Pain of local anaesthetic injection was not considered significant in the US-HB group, and (4) Physicians and patients not blinded to treatments
			Patient satisfaction	No statistical difference between the two groups
			Physician satisfaction	No statistical difference between the two groups
			Time to discharge	Time to discharge was significantly lower in the hematoma group
			Early adverse effects	Four patients in the conscious sedation group showed early adverse effects
			Late complications	No patient in either group showed late complications
Myderrizi N and Mema B 2011 Albania	96 patients with displaced Colles fractures requiring reduction. Conscious sedation (48) vs hematoma block (48).	RCT	Pain by visual analogue scale (VAS) before, during, after reduction	Pain during reduction was minimally more in the hematoma block group but less after reduction	Waiting time before manipulation for hematoma block and conscious groups not standardized
			Time to ED, manipulation, and discharge	Time to ED was similar between groups, but time to manipulation and discharge was significantly less in the hematoma block group
			Loss of reduction one week after procedure	No difference in loss of reduction between the groups
Singh et al 1992 India	66 patients with displaced Colles fracture. Conscious sedation (33) vs hematoma block (33).	RCT	Pain by VAS during reduction	Pain during reduction was significantly less in the hematoma block group	Full text not available online to assess for weaknesses

Comment(s)

Lack of blinding and randomization in some studies. Time to presentation at ED not factored into all studies. Intervention of studies was varied (US-guided vs non-US guided, type/concentration of local anesthetic). Quality of fracture reduction not assessed.

Clinical Bottom Line

Hematoma block is as effective as conscious sedation for providing analgesia during reduction of distal radius fractures.

References

1. Bear et al Hematoma block versus sedation for the reduction of distal radius fractures in children Journal of Hand Surgery
2. Fathi et al Ultrasound-guided hematoma block in distal radial fracture reduction: A randomised clinical trial Emergency Medicine Journal
3. Myderrizi N and Mema B The hematoma block an effective alternative for fracture reduction in distal radius fractures Medical Archives 2011; 239-242
4. Singh et al Analgesia for the reduction of Colles fracture. A comparison of hematoma block and intravenous sedation. The Online journal of current clinical trials. 1992