Haematoma block vs sedation for manipulating distal radius fractures in the emergency department
Date First Published:
December 31, 2025
Last Updated:
December 31, 2025
Report by:
Dr Amy Fox and Dr Marrigje Nell, ACCS Anaesthetics CT4 Trainee and Core anaesthetics CT3 Trainee (Mersey and West Lancashire teaching hospitals NHS trust)
Search checked by:
Gregory Yates, SPR in emergency medicine
Three-Part Question:
In [adult patients presenting to ED with distal radius fractures requiring manipulation] is [the use of haematoma blocks] associated with [comparable procedural success rate to procedural sedation or a difference in likelihood of adverse events?]
Clinical Scenario:
An adult patient presents to the emergency department with a displaced distal radius fracture after a fall on an outstretched hand. The fracture requires manipulation, but the department is too busy to facilitate procedural sedation. You wonder what your likelihood of a successful reduction would be using a haematoma block and whether there is an increased risk of adverse events.
Search Strategy:
Embase and MEDLINE databases were searched using the Ovid interface with the following strategy:
[wrist fracture.mp. OR exp Wrist Fractures/ OR distal radi$ fracture$.mp. OR exp Colles' Fracture/ OR Colle$ fracture$.mp. OR smith fracture.mp. OR smith$ fracture$.mp. OR barton$ fracture$.mp. OR chauffeur$ fracture$.mp. OR die punch fracture.mp. OR die-punch fracture.mp. OR exp Radius Fractures/ OR fracture$ of the distal radius.mp. OR radi$ fracture.mp. OR exp distal radius fracture/ OR exp Barton fracture/] AND [haematoma block.mp. OR hematoma block.mp. OR haematoma injection.mp. OR hematoma injection.mp. OR haematoma infiltration.mp. OR hematoma infiltration.mp.]
[wrist fracture.mp. OR exp Wrist Fractures/ OR distal radi$ fracture$.mp. OR exp Colles' Fracture/ OR Colle$ fracture$.mp. OR smith fracture.mp. OR smith$ fracture$.mp. OR barton$ fracture$.mp. OR chauffeur$ fracture$.mp. OR die punch fracture.mp. OR die-punch fracture.mp. OR exp Radius Fractures/ OR fracture$ of the distal radius.mp. OR radi$ fracture.mp. OR exp distal radius fracture/ OR exp Barton fracture/] AND [haematoma block.mp. OR hematoma block.mp. OR haematoma injection.mp. OR hematoma injection.mp. OR haematoma infiltration.mp. OR hematoma infiltration.mp.]
Outcome:
This yielded 115 results which were screened independently by both authors. 14 papers were selected for full text review and 101 results excluded as they were either not relevant to the three-part question or were case reports/review articles/abstracts. 5 papers met inclusion criteria after full-text review and the references of these were searched for any papers missed by the keyword search. 1 additional paper was identified in this process. 1 other additional paper was found using the Google Scholar ‘cited by’ function.
The final sample (n=7) included two studies derived from the same dataset. They were combined in the BET table as one.
The final sample (n=7) included two studies derived from the same dataset. They were combined in the BET table as one.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Use and efficacy of haematoma blocks in managing closed reduction of distal radial fractures by emergency nurse practitioners: a matched case-control study design. Hagness C, Golding M, Varndell W 2025 Australia | Single, isolated displaced DRF managed with HB or PS N = 100 in each group Male – 29% for both groups Average age: HB – 63, PS - 61 | Single centre Retrospective Matched case-control Observational study Level 3 |
Pain score (0-10/10) post reduction | Pain score: | Retrospective non-randomised design Significant variability in sedation technique Nitrous oxide given to some patients in HB group during manipulation introducing confounding No long-term follow up |
| Radiographic outcome | HB = 0/10 | ||||
| Adverse events | PS = 4/10 * | ||||
| Radiographic outcome: | |||||
| No significant difference between both groups | |||||
| Adverse events: | |||||
| HB = 0 cases PS = 23 cases | |||||
| The radiographic quality of distal radius fracture reduction using sedation versus hematoma block Koren L, Ginesin E, Elias S, Wollstein R, Israelit S 2018 Israel | Single, isolated displaced DRF managed with either HB or PS N = HB 210, PS 30 Male – HB 29.6%, PS 30% Average age – HB 59.6, PS 53.8 | Single centre Retrospective Matched case-control Observational study Level 3 |
Radiographic outcome | Radiographic outcome: | Retrospective non-randomised design Large difference in number of participants between each group Patients needing multiple reductions excluded leading to possible attrition bias No long-term follow up |
| Adverse events | PS group had a lower rate of reduction failures* | ||||
| Adverse events: | |||||
| None in either group | |||||
| Comparing the effects of haematoma block and conscious sedation in adults with distal radius fractures Onuoha KM, Orimolade EA, Onuoha CEO, Adegbehingbe OO, Ikem IC 2017 Nigeria | Single, isolated DRF presenting within 72h of injury randomised to either HB or PS N = HB 35, PS 35 Male – HB 29%, PS 22% Average age - 50 | Single centre Prospective Randomised controlled trial Level 3 |
Radiographic outcome | Radiographic outcome: | Small sample size Randomisation method not robust Palmar tilt only parameter measured to indicate adequate reduction No long-term follow up |
| Post-reduction pain severity | No significant difference | ||||
| Post-reduction pain severity: | |||||
| No significant difference | |||||
| The radiographic quality of conservatively managed distal radius fractures in adults using haematoma block versus intravenous sedation Alatishe KA, Ajiboye LO, Choji C, Olanrewaju OS, Lawal WO 2023 Nigeria | Single, extra-articular only DRF presenting within 72h randomised to either HB or PS N = HB 33, PS 34 Male – HB 30%, PS 41% Average age – HB 46.6, PS 51.2, overall = 48.9 | Single centre prospective Randomised controlled trial Level 2 |
Radiographic outcome | Radiographic outcome: | Randomisation method not robust Small sample size Excluded patients with significant re-displacement at 1 week introducing attrition bias Included patients re-manipulated with sedation irrespective of initial group diluting differences between groups |
| Rate of re-manipulation | No significant difference | ||||
| Adverse events | |||||
| Pain levels during and post reduction** | Rate of re-manipulation: | ||||
| No significant difference | |||||
| Adverse events: | |||||
| No significant difference | |||||
| Pain levels during and post reduction: | |||||
| No significant difference | |||||
| Haematoma block: a safe method for pre-surgical reduction of distal radius fractures Maleitzke T, Plachel F, Fleckenstein FN, Wichlas F, Tsitsilonis S 2020 Germany | DRF requiring initial closed reduction with either PS or HB followed by definitive surgical management N = HB 42, PS 134 Male – HB 31%, PS 33% Average age – HB 57.6, PS 60.6 | Single centre Retrospective cohort Observational study Level 3 |
Adverse events | No significant difference | Only included patients who went on to have surgical management after reduction in the ED and excluded those conservatively managed Retrospective non-randomised design Reported on adverse events only, not adequacy of reduction X-ray used to guide needle position for haematoma block which limits generalisability |
| Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial 7. Fathi M, Moezzi M, Abbasi S, Farsi D, Zare MA, Hafezimoghadam P 2015 Iran | DRF with ASA score 1 or 2 randomised to either HB or PS N = HB 71, PS 72 Male – HB 53.5%, PS 52.8% Average age – HB 38.9, PS 41.1 | Two-centre Prospective Randomised controlled trial Level 2 |
Efficacy of pain control at 5,10 and 15 minutes after reduction | Efficacy of pain control at 5,10 and 15 minutes after reduction: | Haematoma blocks done with USS so not generalisable to centres where this skill/equipment isn’t available Excluded ASA 3 and 4 patients limiting generalisability Didn’t report on adequacy of reduction |
| Mean difference not statistically significant | |||||
| Adverse events | Adverse events: | ||||
| 11% in PS group and 0 in USS-HB |
Author Commentary:
Regarding procedural success rate when using sedation versus haematoma block, the highest quality evidence in the table from two randomised controlled trials found no difference in radiographic outcome [3,4]. Regarding the likelihood of adverse events when comparing haematoma block versus sedation, one study found less pain in the haematoma block group [1]. None of the other studies detected a statistically significant difference [2,3,4,5,6,7]. However, it is worth highlighting that there was significant heterogeneity in the adverse outcomes the researchers were looking for.
There are no current RCEM (Royal College of Emergency Medicine) guidelines recommending a particular analgesic or anaesthetic technique for reducing distal radius fractures. There is a 2016 NICE (National Institute for Health and Care Excellence) guideline that recommends considering reduction with intravenous regional anaesthesia [8]. In their full review they mention no studies were found that investigated conscious sedation or haematoma block with sedation. They did not compare haematoma block with sedation directly. They also suggested there was insufficient evidence to comment on procedural sedation as a technique and its associated risks. These national guidelines could be updated with the evidence found by this BET, which at least suggests non-inferiority of haematoma block to procedural sedation.
With this in mind, it is worth highlighting some of the potential benefits of haematoma blocks. They require fewer personnel to facilitate, less monitoring, less equipment and may facilitate earlier discharge. They could also be an underutilised alternative to giving frail and comorbid patients sedative agents. All these factors could reflect a more prominent role for haematoma blocks in reducing distal radius fractures, particularly in the context of a busy emergency department.
There are no current RCEM (Royal College of Emergency Medicine) guidelines recommending a particular analgesic or anaesthetic technique for reducing distal radius fractures. There is a 2016 NICE (National Institute for Health and Care Excellence) guideline that recommends considering reduction with intravenous regional anaesthesia [8]. In their full review they mention no studies were found that investigated conscious sedation or haematoma block with sedation. They did not compare haematoma block with sedation directly. They also suggested there was insufficient evidence to comment on procedural sedation as a technique and its associated risks. These national guidelines could be updated with the evidence found by this BET, which at least suggests non-inferiority of haematoma block to procedural sedation.
With this in mind, it is worth highlighting some of the potential benefits of haematoma blocks. They require fewer personnel to facilitate, less monitoring, less equipment and may facilitate earlier discharge. They could also be an underutilised alternative to giving frail and comorbid patients sedative agents. All these factors could reflect a more prominent role for haematoma blocks in reducing distal radius fractures, particularly in the context of a busy emergency department.
Bottom Line:
In adult patients presenting to the emergency department with distal radius fractures requiring manipulation, the use of haematoma blocks appears to be associated with comparable procedural success rate to procedural sedation, without strong evidence of a difference in likelihood of adverse events.
Level of Evidence:
Level 1: Recent well-done systematic review was considered or a study of high quality is available
References:
- Hagness C, Golding M, Varndell W. Use and efficacy of haematoma blocks in managing closed reduction of distal radial fractures by emergency nurse practitioners: a matched case-control study design.
- Koren L, Ginesin E, Elias S, Wollstein R, Israelit S. The radiographic quality of distal radius fracture reduction using sedation versus hematoma block
- Onuoha KM, Orimolade EA, Onuoha CEO, Adegbehingbe OO, Ikem IC. Comparing the effects of haematoma block and conscious sedation in adults with distal radius fractures
- Alatishe KA, Ajiboye LO, Choji C, Olanrewaju OS, Lawal WO. The radiographic quality of conservatively managed distal radius fractures in adults using haematoma block versus intravenous sedation
- Maleitzke T, Plachel F, Fleckenstein FN, Wichlas F, Tsitsilonis S. Haematoma block: a safe method for pre-surgical reduction of distal radius fractures
- 7. Fathi M, Moezzi M, Abbasi S, Farsi D, Zare MA, Hafezimoghadam P. Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial