Indeed, that's certainly how Charnley taught it: reproduce the original 
deformity, so dorsal angulation effectively disimpacts the volar area of 
impaction and allows a better reduction, without using traction.

Interesting about sickle cell: I've often wondered why this fracture seems 
vanishingly rare in African races, but it is. It's not that common in Asian 
races either. We have a very mixed population here but this fracture seems 
almost exclusively the preserve of Caucasians.

Back to the procedure: I think someone said they were using 7-8 ml of 2% 
lignocaine. Surely that runs a risk of toxicity, doesn't it? I've certainly 
seem some haematoma patients complain of peri-oral paraesthesia 
post-injection. I mean, you're injecting straight into a vascular surface, 
aren't you? At least with my Bier's I'm using prilocaine and I trust my 
double cuff!

I can understand those who've argued for the "factory" approach of running 
multiple rooms by using haematoma blocks, but even in our worst days we've 
always managed to push everyone through a single room, with a single 
operator with his single cuff. That system can certainly manage three 
patients an hour and I can't really envisage the need to work faster than 
that.

Finally, I agree with Doc about handedness. I firmly believe we're all 
ambidextrous, particularly those of us who touch-type and rarely write 
anymore. And even strongly right-handed folks do many things with their 
non-dominant hand that they couldn't do with their so-called dominant hand. 
So I don't ask about handedness either - well I don't record it, but I 
sometimes ask as a conversation topic. Our Colles patients are the one group 
we can have long chats with, other than just taking a history!

AF


----- Original Message ----- 
From: "Dunn Matthew (South Warwickshire General Hospitals NHS Trust)" 
<[log in to unmask]>
To: <[log in to unmask]>
Sent: Tuesday, December 22, 2009 4:23 PM
Subject: Re: Haematoma blocks

With regard to time to do procedure, there's no difference between haematoma 
and Biers block (paper on this from Bristol about 10 years back). IVRA is 
contraindicated in some patients particularly sickle cell trait; but 
populations with a high incidence of sickle cell trait have a low incidence 
of Colles' fractures at present although this may change in future (also a 
very low incidence of FNOF, but that's due to different bone angles, not to 
low incidence of osteorporosis). Haemtoma block has an advantage in that you 
can put half a dozen in and by the time you've put the last one in, the 
first one has worked. I think the "two doctor" bit with IVRA dates back to 
use of Marcaine.
With regard to long term results, not much published, but I knew someone 
looked at it for a thesis in the early 90s. No matter what you do, 
osteoporotic fractures slip. This may have changed with secondary prevention 
but I doubt it. Anecdotal stuff about good results in young patients with 
good initial reduction unless they have a die punch fracture in which case 
there's not a lot you can do anyway.

As an aside I used to reduce Colles fractures with slow gentle traction then 
push into place with thumb and finger once disimpacted. Now I don't use 
traction at all: just increase the angulation then push hard. This seems to 
give better results. Certainly it's more stable immediately post reduction.

Matt Dunn

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