Interesting. But I agree with Ray that Bier's block is very definitely a 
one-doctor procedure, can't see any reason why you would need two. And from 
what you say Bier's might even be faster than haematoma as you can usually 
start your Bier's manipulation 10-12 minutes after injection (and 
cannulating and applying the tourniquet take only a few minutes). You can 
generally deflate the cuff 15 minutes after injection (as I never do check 
x-rays with the cuff inflated, can't see the point).

I'm probably one of the guilty ones who doesn't do haematoma block very well 
(probably as I rarely do them) so would welcome any technical advice to the 
List that you wish to share, Mark.

AF

----- Original Message ----- 
From: "Prescott Mark (RLZ)" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Monday, December 21, 2009 10:28 AM
Subject: Re: Haematoma blocks

Always useful to consider why there is a difference between 2 methods -
as in this case

There is no doubt that in most EDs Biers blocks are less painful than
haematoma blocks (HB) - and it is likely that because of patient pain
with HB, the reduction is rushed & poor.

The problem - I believe, is that the majority of ED doctors do not
undertake HB correctly.

When done properly the patient should have no pain whatsoever, and there
would still be time for check Xrays before the block wears off

Unfortunately I have rarely seen an ED doctor put in a haematoma block
properly!

The pressure on departments to clear patients contributes to the problem
and there remains a view that Biers is time-consuming and Haematoma
blocks are fast for the doctor

Also Sedation and Biers blocks (BB) are 2 doctor procedures, HB is a
single doc process

Haematoma infiltration is a learned skill and simply flooding the
haematoma does not deal with all nerves supplying the joints involved,
the fracture site and the periosteum - eg I have seen few docs deal with
the Ulna haematoma when there is an associated fracture of the ulna
styloid

Most docs do not wait before manipulation - when I used to use the HB I
would wait at least 15 mins if not longer before embarking on the
reduction.

Another difference between an HB and a BB is that loss of sensation can
be tested with the BB, but there is no reliable indicator with the HB
before starting!

So in my view there are plenty of reasons why the best bet review
confirmed BB as superior

For interest in my neck of the woods we rarely pull wrists now as out
bone docs fix most to get the best result, and in the osteoporotic
elderly we adopt a conservative approach - based of the longer term
collapse that occurs at the fracture site in this group



Mark P





________________________________

From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Ray McGlone
Sent: 21 December 2009 09:33
To: [log in to unmask]
Subject: Haematoma blocks



I was called into work yesterday. There was an influx of fractures and
dislocations due to falls. Working using a combination of sedation and
Bier's blocks we got through the day.



At the same time my sister-in-law (49yrs) fractured her left wrist
following a fall in the ice and was at St.Elsewhere's.



She had a haematoma block which was really painful, so much so that her
husband almost fainted and was sent out.



I'm not a fan of haematoma blocks though I did use them during my
training in the last century (smile). They are quick for the doctor but
not good for the patient. The jury decided this in the 1990's! See Best
Bet below.



Who are still using haematoma blocks.... and why?



Ray



IVRA (Biers block) is better than haematoma block for manipulating
Colles' fractures

*                                 Report By: Simon Carley - Consultantin
Emergency Medicine

*                                 Search checked by Lesley Bethune - SpR
in Emergency Medicine

*                                 Institution: Manchester Royal
Infirmary

*                                 Date Submitted: 1st March 1999

*                                 Date Completed: 21st June 2000

*                                 Last Modified: 28th October 2005

*                                 Status:  Green (complete)

Three Part Question

In [elderly patients with uncomplicated Colles fractures] is [Biers
block or haematoma block better] at [reducing pain during manipulation,
reducing the need for multiple manipulations and improving long term
function]?

Clinical Scenario

A 71 year old lady presents to the A+E department following a fall on
the outstretched hand. X-rays reveal a Colles fracture with shortening
and dorsal angulation requiring manipulation. Having worked in several
different departments you have experience of reducing these fractures
with either Biers block or a Haematoma block. The department is better
and you think that it will be quicker to manipulate the fracture using a
haematoma block but you wonder which is best for your patient.

Search Strategy

MEDLINE using OVID interface on the world wide web 1966-December 1997.
[exp Colles fracture OR exp wrist injuries OR colles.ti,ab,sh] AND
[biers.ti,ab,sh OR haematoma.ti,ab,sh OR exp nerve block OR exp
anaesthesia, intravenous OR regional-anaesthesia.ti,ab,sh OR exp local
anaesthesia OR local-anaesthesia.ti,ab,sh]

Search Outcome

46 papers identified of which 4 were clinical trials comparing biers
block vs haematoma block. The remaining papers are shown in the table.

Relevant Paper(s)

Author, date and country

Patient group

Study type (level of evidence)

Outcomes

Key results

Study Weaknesses

Cobb AG and Houghton GR,
1985,
England

100 consecutive patients with uncomplicated Colles fractures

PRCT

Pain during manipulation

Less pain during manipulation with Biers block. No difference in pain in
first few hours following manipulation

Outcome assessment not blinded Inadequate basic data reporting
Randomisation procedures are not explicit

Wardrope J et al,
1985,
England

79 (possibly 81 as some data missing) patients presenting with Colles'
fractures. Aged over 45. Patients with previous fractures excluded.

PRCT

Need for remanipulation

Fewer remanipulations in Biers' block group

Outcome assessment not blind Questionable randomisation procedures No
long term follow up Some data missing on study subjects

Radiographic changes

No difference in radiographic appearances*

Pain during manipulation

Less pain during manipulation with Biers block

Abbaszadegan H and Jonsson U,
1990,
Sweden

99 consecutive patients with Colles fractures requiring manipulation.
Randomly assigned into treatment groups.

PRCT

Pain during manipulation & at 2,3, and 6 months

Pain during manipulation greater with haematoma block (no difference at
subsequent follow up)

Outcome assessment not blinded Inadequate basic data reporting No
account of Ahandedness made in assessment of grip strength Randomisation
procedures are not explicit

Grip strength and Range of wrist motion at 2,3 & 6 months

No difference in grip strength or range of motion

Radiographic changes

Radiographic appearances better in Biers block group

Kendall JM et al,
1997,
England

150 patients with colles fractures. More than 15 degrees dorsal
angulation and 2mm shortening. 72 patients received Biers block, 70
haematoma block

PRCT

Radiological outcome

Better with IVRA in terms of initial angulation. -3.6 degrees vs. 2.1
degrees. 0=0.003

Data missing in 8 patients Differences in position probably not
clinically relevant. No long term follow up of functional disability

Time spent within department

No significant difference found

Remanipulation rate

Less with IVRA. 17/70 vs. 4/72 p=0.003

Median pain score during block

Better for Biers block. 2.8 vs.5.3 p<0.001

Median pain scores during manipulation

Better for Biers. 1.5 vs. 3.0 p<0.01

Comment(s)

Pain and the need for remanipulation are very relevant patient outcomes
but long term function is only addressed in one paper. The use of grip
strength as an indicator of wrist function is only a crude assessment
and further work is needed. Clearly there are other methods of reducing
Colles fractures, (sedation, general anaesthesia, nerve blockade etc.)
which have not been addressed here. However, Biers block and Haematoma
block are the two most common methods of reducing this fracture in the
UK with an increase in the proportion of departments using Haematoma
block between 1989 and 1994 (see Cobb and Houghton).

Clinical Bottom Line

On the best evidence available at the present time Intravenous regional
anaesthesia (Biers block) is preferable to local anaesthesia (haematoma
block) for the reduction of uncomplicated Colles fractures in the
elderly.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1.      Cobb AG, Houghton GR. Local anaesthetic infiltration versus
Bier's block for Colles' fractures. BMJ 1985;291(6510):1683-4.

2.      Wardrope J, Flowers M, Wilson DH. Comparison of local
anaesthetic techniques in the reduction of Colles' fracture. Archives of
Emergency Medicine 1985;2(2):67-72.

3.      Abbaszadegan H, Jonsson U. Regional anesthesia preferable for
Colles' fracture. Controlled comparison with local anesthesia. Acta
Orthop Scand 1990;61(4):348-9.

4.      Kendall JM, Allen P, Younge P, et al. Haematoma block or Bier's
block for Colles' fracture reduction in the accident and emergency
department -- which is best? Emergency Medicine Journal
1997;14(6):352-6.