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Analgesia in the ED for reductions of distal radius fractures: Hematoma block vs conscious sedation

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 OR (smith$ fracture or barton$ fracture).mp. OR radial AND ((hematoma block or haematoma block).mp. OR anesthetics, local/ OR (local anesthetic or local anaesthetic).mp. OR exp Lidocaine/ or OR OR exp bupivacaine/ OR OR (regional anaesthesia or regional anesthesia).mp.) AND (exp Conscious Sedation/ or OR anesthetics, dissociative/ or anesthetics, intravenous/ OR or ketamine/ OR or propofol/ OR or midazolam/ OR 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
52 pediatric patients with displaced DRFs requiring reduction. Conscious sedation (26) vs hematoma block (26).Prospective studySatisfaction surveyNo 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 discomfortNo statistical difference in level of discomfort
Length of stayTime spent in ED significantly less in the hematoma block group
ComplicationsNo statistical difference in complications including reduction failure
Fathi et al
143 patients with displaced DRFs requiring reduction. Conscious sedation (72) vs hematoma block (71).RCTPain before reduction, during reduction and at 5, 10 and 15 minutes after reductionNo 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 satisfactionNo statistical difference between the two groups
Physician satisfactionNo statistical difference between the two groups
Time to dischargeTime to discharge was significantly lower in the hematoma group
Early adverse effectsFour patients in the conscious sedation group showed early adverse effects
Late complicationsNo patient in either group showed late complications
Myderrizi N and Mema B
96 patients with displaced Colles fractures requiring reduction. Conscious sedation (48) vs hematoma block (48).RCTPain by visual analogue scale (VAS) before, during, after reductionPain during reduction was minimally more in the hematoma block group but less after reductionWaiting time before manipulation for hematoma block and conscious groups not standardized
Time to ED, manipulation, and dischargeTime 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 procedureNo difference in loss of reduction between the groups
Singh et al
66 patients with displaced Colles fracture. Conscious sedation (33) vs hematoma block (33).RCTPain by VAS during reductionPain during reduction was significantly less in the hematoma block groupFull text not available online to assess for weaknesses


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.


  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