Analgesia in the ED for reductions of distal radius fractures: Hematoma block vs conscious sedation
Date First Published:
February 6, 2020
Last Updated:
August 27, 2020
Report by:
Casey MacKenzie, Resident Physician (McMaster University)
Search checked by:
Kyle Saikaley, Christine King, McMaster University
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/)
Outcome:
163 papers were found of which 159 were irrelevant.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Hematoma block versus sedation for the reduction of distal radius fractures in children 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 | ||||
| Ultrasound-guided hematoma block in distal radial fracture reduction: A randomised clinical trial 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 | ||||
| The hematoma block an effective alternative for fracture reduction in distal radius fractures 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 | ||||
| Analgesia for the reduction of Colles fracture. A comparison of hematoma block and intravenous sedation. 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 |
Author Commentary:
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.
Bottom Line:
Hematoma block is as effective as conscious sedation for providing analgesia during reduction of distal radius fractures.
References:
- Bear et al. Hematoma block versus sedation for the reduction of distal radius fractures in children
- Fathi et al. Ultrasound-guided hematoma block in distal radial fracture reduction: A randomised clinical trial
- Myderrizi N and Mema B. The hematoma block an effective alternative for fracture reduction in distal radius fractures
- Singh et al. Analgesia for the reduction of Colles fracture. A comparison of hematoma block and intravenous sedation.