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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]?

Clinical Scenario

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.

Search Strategy

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]

Search Outcome

46 papers identified of which 4 were clinical trials comparing biers block vs haematoma block. The remaining papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Cobb AG and Houghton GR, 1985, England	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, 1985, England	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, 1990, Sweden	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, 1997, England	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

Comment(s)

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.

References

1. Cobb AG, Houghton GR. Local anaesthetic infiltration versus Bier's block for Colles' fractures. BMJ 1985;291(6510):1683-4.
2. 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.
3. Abbaszadegan H, Jonsson U. Regional anesthesia preferable for Colles' fracture. Controlled comparison with local anesthesia. Acta Orthop Scand 1990;61(4):348-9.
4. 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.