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, |
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, |
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, |
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, |
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.