Case: 64 yo F presents to the Emergency Department after tripping over a curb and suffering a FOOSH (fall on outstretched hand) injury. There is obvious deformity about the wrist with associated swelling and tenderness. X-ray imaging reveals the following:
Her exam and imaging are consistent with a distal radius fracture. How do you treat this?
Providing adequate analgesia, reduction of fracture, and proper splinting is well within the scope of EM practice, especially in the community setting. This post will review the technique of hematoma block for analgesia as well as the different techniques for reduction of distal radius fractures and application of splint.
- Can be used alone or in combination with other analgesic modalities such as IV narcotics or benzodiazepines
- Simple technique
- Very few complications
But is hematoma block effective?
- In 2011, prospective randomized controlled trial comparing hematoma block to conscious sedation with IV Propofol
- 96 patients underwent randomization and researchers compared patients’ pain using VAS (visual analog scale) during the procedure and after the procedure
- Patients who received Propofol had pain scores of 0 during the procedure compared to 0.97+/-0.7 in patients who received hematoma block
- After the procedure, patients who received Propofol had pain scores of 2.72+/-0.7 compared to 2.25+/-0.2 in patients who received hematoma block
- Patients who received hematoma block had significantly shorter ED stay times (0.9hrs vs 2.6 hrs)
Hematoma blocks result in similar analgesia as conscious sedation with IV Propofol AND leads to shorter ED stay times
Setting up for the procedure:
- 10cc 1% Lidocaine
- 10cc syringe with 2 large needles (one for drawing up Lidocaine, one for injecting)
- Skin cleanser (betadine, Chloraprep, or alcohol wipe)
- Identify the fracture site by palpating along the dorsal aspect of the forearm to feel for bony step-off. Cleanse this entire area thoroughly with skin cleanser.
- Insert needle attached to syringe filled with 10cc 1% Lidocaine at that site and advance needle along periosteum until needle falls into fracture site.
- Draw back on plunger to aspirate blood confirming the needle is in the fracture site.
- Inject 10cc Lidocaine into fracture site and remove needle.
- Allow 10-15min to pass to ensure full analgesic effect.
Finger trap: Involves passive traction with finger traps and weights applied to upper arm to provide counter traction. The patient sits in this position for 10-15 minutes and is then splinted while still in the finger traps.
Manual manipulation: Classically called the Jones Method. Involves hyperextension of the wrist to recreate the mechanism of injury followed by volar translation of the distal radial fragment. This is done while an assistant is providing counter-traction at the upper arm with the elbow flexed to 90 degrees. The reduction should be splinted with the hand held in ulnar deviation.
Is one technique superior to other?
In 2002, randomized controlled trial comparing finger trap vs manual manipulation. Two hundred twenty three patients were randomized with distal radius fractures to undergo finger trap reduction or manual manipulation. Both techniques achieved an 87% successful reduction rate initially. Long term reduction was decreased in both groups with only 57% (finger trap) and 50% (manual manipulation) achieving acceptable alignment after one week. This was not statistically significant. Both techniques appear to be safe and equally efficacious for closed reduction.
Other useful resources:
This post has been internally reviewed by Dr Jeffrey Feden, Attending and Assistant Professor, Division of Sports Medicine, Department of Emergency Medicine, Alpert Medical School of Brown University