Hematoma block or procedural sedation and analgesia, which is the most effective method of anesthesia in reduction of displaced distal radius fracture?

Abstract

BackgroundProcedure sedation and analgesia (PSA) is often used to alleviate discomfort and to facilitate fracture reduction for patients with distal radius fracture in emergency departments and clinics, but risks of respiratory distress and needs for different levels of monitoring under PSA are still under concern. Hematoma block (HB) is a simple alternative method of providing rapid pain relief during reduction of distal radius fracture. However, there is still in lack of strong evidence to promote HB over PSA in clinical practice. The aim of this study was to compare HB and PSA for adult and pediatric patients during reduction of displaced distal radius fracture to identify the level of pain relief, frequency of adverse effects (AEs), and reduction failure.MethodsThe PubMed, ScienceDirect, Cochrane Library, and ClinicalTrials.gov were searched for studies comparing HB or PSA in distal radius fracture reduction. The search revealed four randomized controlled trials and one non-randomized trial, which included two studies of pediatric subjects and three studies of adult subjects. Subgroup meta-analysis for adult and pediatric groups were specifically performed according to age difference to avoid potential bias.ResultsIn the adult group, the effect of HB on post-reduction pain severity was better than that of PSA with significant heterogeneity (Hedges’ g − 0.600, 95% confidence interval (CI) − 1.170 to − 0.029, p = 0.039), although there was no difference on the pain severity during reduction between these two groups with significant heterogeneity (Hedges’ g 0.356, 95% CI − 1.101 to 1.812, p = 0.632). In the pediatric group, the treatment effect on pain severity was significantly better by HB than that by PSA but without significant heterogeneity (Hedges’ g − 0.402, 95% CI − 0.718 to − 0.085, p = 0.013, I2 < 0.001%). Most of the reported adverse effects (AEs) include nausea, vomiting, and respiratory distress developed in adult patients treated by PSA. The rates of reported AEs did not significantly differ between HB and PSA in the pediatric group. Additionally, final outcomes of reduction failure did not significantly differ between HB and PSA in both adult and pediatric groups.ConclusionHematoma block is a safe and effective alternative of anesthesia in reduction of distal radius fracture without inferior pain relief compared with PSA among adult and pediatric patients.Electronic supplementary materialThe online version of this article (10.1186/s13018-018-0772-7) contains supplementary material, which is available to authorized users.

ticle Uncovering secrets of the beauty bone: A comprehensive review of anatomy and regional anesthesia techniques of clavicle surgeries

“…Thus, the deposited drug may not spread entirely around the clavicle. An additional injection over the periosteum of the clavicle at the fracture site (like "hematoma block") [43,44] may improve the quality of the block. Also, the skin over the clavicle can be included by giving an additional infiltration in the subcutaneous plane over the clavicle.…”

Comparison of hematoma block and sedoanalgesia for analgesia before reduction of distal radius fractures

“…Closed reduction and cast application is sufficient for minimal displaced fractures or pediatric fractures 3,4 . Excessive displaced, unstable fractures require closed reduction and maintaining the adequate alignment to reduce the pressure over the adjacent soft tissue as the first step 5,6 . Index treatment is generally applied at emergency service and leads to severe pain, and patient discomfort.…”

“…Index treatment is generally applied at emergency service and leads to severe pain, and patient discomfort. An effective analgesia is mandatory to acquire patient comfort and a high quality of reduction 3,5,7 .…”

“…However, none of these techniques appears to be optimal 8 . Sedoanalgesia is a wellknown technique which is feasible to perform and obtained by administration of benzodiazepines, or benzodiazepines combined with opioids 5 . Another simple method is the direct injection of lidocaine into the fracture hematoma and provides local anaesthesia which spares the systemic adverse effect of forementioned method 9 .…”

“…There are orthopedic surgeons who think that the risk of infection increases with the HB method 8 . In addition, complications such as respiratory depression can be seen with the SA method, especially in elderly patients 5 . In addition, few studies compared two analgesic modalities in the literature [10][11][12] .…”