> Possibly I have never had any adverse effects using marcaine because I
> don't bother necessarily finding the 'haematoma'.  Firstly
> because there
> is often impaction and this makes it difficult unless you are really
> determined to scrunch through osteoporotic bone,  and
> secondly because I
> am a little scared of putting marcaine directly into such a vascular
> area.  However, by creating in effect a ring block around the fracture
> area,  I can almost always get a good block.  I would be interested to
> measure marcaine levels after this technique,  and wonder if
> they would
> be any higher than after putting equivalent amounts into a knee,  say.

That's interesting. I'd always thought that the key issue to success was
hitting the haematoma properly. I've seen ankles and ears blocked by ring
blocks but not wrists. I'd have thought that the interosseous nerves would
be too deep for this (in ankles and ears, it tends to be done because nobody
can remember where all the nerves are except that they're all subcut). Could
you give us some more details of your technique? Not sure about your
comments regarding the knee. I wouldn't inject anything like as much local
into a knee as I would into a haematoma block (factor of 10 at least)

> Plenty of sources disagree with you!
>

However, I think you'll find that Sir Abram agreed with me, so let's say
there's a plurality of views.

>
> http://www.jbjs.org/Comments/2003/cp_nov03_ladd.shtml

I'd note that this article seems to derive it's assumption that it was a low
energy injury from the following statement:
"Vehicular trauma (horse and carriage) was less common than simple falls in
pre-industrial Europe, (and thus) it is safe to assume the fracture
described by Colles was a low-energy injury."
The first part of the statement may or may not be true (I'm not sure it is-
horses and carriages were a lot less safe than cars), but is a bit
irrelevant as Colles described observations in post industrial Europe.
Colles' own statement: "The separation of these two bones from each other is
facilitated by a previous rupture of their capsular ligament; an event which
may readily be occasioned by the violence of the injury." would seem to
imply that he thought it was a violent mechanism of injury. If you look at
the demographics of Ireland around this time, there weren't a lot of
postmenopausal women around, and the population as a whole were more
physically active than these days, so it is likely that a lower proportion
of fractures than at present would be in osteoporotic bones. However, a key
issue is that it is inconceivable that Colles never saw a displaced radial
fracture in a young male. If he had intended to distinguish these, you'd
think he'd have said so at the time. BTW, I think the above article spells
his name wrong. I seem to remember it as being "Abram" not "Abraham"
I've come out with the statement that a Colles fracture is a low energy
fracture in osteoporotic bones myself. However, reading around it I've been
unable to find any evidence that Colles himself distinguished between low
and high energy fractures. I think it's one of these medical myths.

Matt Dunn

Warwick


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