This study sought to compare the efficacy of ultrasound guided hematoma block vs. procedural sedation (midazolam/fentanyl) for reduction of distal radius fractures in the ED.
The “primary” outcome was pain on a numerical rating scale recorded at 5, 10 and 15 minutes after reduction. Secondary outcomes looked at satisfaction, early/late complications and time to discharge from the ED.
I liked this paper, but it is impossible to overlook some of their sloppy methods and statistical analysis. For example, “We don’t need no stinkin power calculation...”
They randomised 143 patients in to the two groups. In the end, the pain scores were quite similar. But time to discharge was significantly lower in the hematoma block group. And there were more adverse events in the procedural sedation group.
The limitations are several. Single site, only one type of procedural sedation, the outcome measures was perhaps dubious, and given small numbers we definitely can’t make conclusions about rare adverse events (i.e. infections.)
What do we take from this?
Effective hematoma blocks are probably just fine for the reduction of distal radius fractures. They are quicker, simpler, and avoid the nuisance of procedural sedation. (In my opinion, if you can do an “in-plane” ultrasound guided nerve block, then you should have no trouble using the same technique to do a hematoma block.)
Although not addressed in this paper, lots of ED’s in Australia are doing Bier’s blocks. There is no doubt they are highly effective in the reduction of pain. But they probably carry just as much, if not more hassle than a procedural sedation.
So the hematoma block? When done properly it is simple, quick & pretty darn effective. So break a leg (or arm) and give it a try...
Fathi M, Moezzi M, Abbasi S, et al. Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial. Emerg Med J. 2015;32:474-477.