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A pictorial how-to for performing local anesthetic

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A 43-year-old male presents after a mechanical fall down five stairs with a fall on outstretched hand injury to his left wrist. There is an obvious deformity (image 1). No other injuries were identified on complete physical exam and the patient’s neurovascular exam is intact. Plain film radiography reveals the distal radius and ulna fractures seen in image 2.
In consultation with your orthopedic colleagues by phone you determine that this fracture needs reduction and urgent outpatient follow up for consideration of operative fixation. Your orthopedist is not in house and you will need to perform the reduction. Analgesia will certainly be required, but how should this be delivered? You could employ conscious sedation, but this is time consuming during your busy shift and with associated risks. You decide to perform a hematoma block to anesthetize the fracture locally.

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Equipment

  • Sterile or non-sterile gloves
  • Cleansing solution (iodine, chlorhexidine solution, or alcohol wipes)
  • 12 cc syringe
  • Large bore needle to draw medications (blunt tip or 18-22 gauge)
  • Large bore needle for injection (18-22 gauge)
  • 8-12 cc 1 or 2% lidocaine


The injection site is identified through palpation of the dorsal aspect of the deformity and then cleansed with a cleansing solution (in this case a few alcohol wipes). Care must be taken to not contaminate this site after cleansing (image 3).

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The needle is then inserted into the fracture site. This may be accomplished blindly through readjustments until the needle “falls” into the fracture with loss of resistance or with the help of bedside imaging techniques such as ultrasound or bedside fluoroscopy (image 4).

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Confirmation of needle location within the fracture site can be obtained by drawing back on the syringe plunger and aspirating hematoma. In this case a flash of blood is evident at the base of the syringe (image 5). The hematoma can then be infiltrated with 8-12 cc of lidocaine.

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After allowing approximately 5-10 minutes for onset of anesthesia, reduction may be attempted. In this case excellent analgesia was obtained and the reduction was performed with assistance of bedside fluoroscopy (image 6).

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After immobilization with a Sugar-Tong splint, post-reduction radiographs were obtained which showed improved alignment of fracture fragments (image 7).

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Review of the literature shows that hematoma blocks are a safe method of obtaining analgesia without increased post-procedural infections when compared to other regional blocks1. They are equally efficacious to conscious sedation with intravenous Propofol in terms of both quality of reduction (equivalent reduction quality and equal rates of loss of reduction at one week) and pain control as measured by the Visual Analogue Scale before, during, and after the procedure2. Notably, mean time to reduction (0.9 vs. 2.6 hours) and time to leave hospital post procedure (0.74 vs 1.17 hours) were reduced with utilization of hematoma block compared to conscious sedation2. There is some evidence that hematoma blocks provide slightly inferior anesthesia and reductions when compared to intravenous regional anesthesia (i.e. Bier blocks) though were also noted to be quicker, easier, and less resource intensive in this study3. Contraindications include patients at high risk of bleeding (anti-coagulation, hemophilia), open fractures or contaminated injuries, and use in very young children.

Case Resolution
The patient in question was discharged to home splinted and non-weight bearing in his left upper extremity with prescription for pain medication and instructions to follow up in orthopedics clinic in 5-7 days. At the time of publication he had unfortunately been lost to follow up.

 

References
1. Bajracharya S, et al. Hematoma Block of Distal Forearm Fractures: Is it Safe? Orthop Rev 1991. 20(11):977-9.
2. Myderrizi N, Mema, B. The Hematoma Block: An Effective Alternative for Fracture Reduction in Distal Radius Fractures. MED ARH 2011; 65(4): 239-242.
3. Handoll H, Madhok R, Dodds C. Anaesthesia for Treating Distal Radial Fracture in Adults. Cochrane Database of Systematic Reviews 2002; 3, CD003320.

Dr. Peter Emiley is a 3rd year EM resident at the Denver Health EM Residency. Dr. Star Schreier is a 5th year Orthopedics Resident at Denver Health. Dr. Peter Pryor is a faculty member at Denver Health, an Assistant Professor of Emergency Medicine at the University of Colorado School of Medicine.


 

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