Friday 15 September 2023

Intra-articular Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle Fractures

I must have missed this paper originally published in 2018 in Foot and Ankle International… perhaps my subscription has lapsed.

Either way, I’m intrigued.

These researchers sought to compare intra-articular hematoma blocks (IAHB) vs. procedural sedation to aid in the reduction of displaced ankle fractures (fracture subluxations or dislocations).

This was a retrospective chart review without great methods… but what the hell.

They identified 221 patients that underwent IAHB vs. 114 who got PS over 11 years in their single ED in Minnesota. The primary outcome was rate of successful reduction. But they also looked at reduction attempts, time to successful reduction, length of stay in the ED and some adverse events. However, they did not report on adequacy of pain reduction or patient satisfaction.

A hematoma block was performed using 10 to 12ml of 1% lignocaine without adrenalin that was injected into the tibiotalar joint. Ultrasound guidance was not used (but in my opinion can be helpful).


Patients were not randomised and as such, there were some substantial differences between the groups. As you can discern from the numbers, they liked their hematoma blocks twice as much as procedural sedation. However, more patients with complete dislocations got sedation.

The rate of successful reduction was about the same in both groups. About 70% were reduced with one attempt and 25% more by the second. Overall, there was a 90% success rate.

As for safety, one patient in the procedural sedation group got intubated… yikes!

This study has many limitations and is not high-quality evidence. Nevertheless, it is yet another paper demonstrating the utility and uptake of hematoma blocks for displaced ankle fractures. Even the New England Journal of Medicine has jumped on board with these blocks for ankles.

The beauty of a haematoma block is no need for a resuscitation room and lots of resources. It can quickly be performed by a single provider. In addition, a further reduction attempts can easily take place as the block will last for a while.



MacCormick LM, Baynard T, Williams B, et al. Intra-articular Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle Fractures. Foot & Ankle Int. 2018;39:1162-8. [Link to article]

Thursday 14 September 2023

Have you heard about the HEAR score?

We’ve all heart about the HEART score for risk stratification of patients with chest pain in the ED. Take away the troponin and you’ve got the HEAR score!

Yes, the HEAR score tries to identify patients at very low risk of ACS that don’t even need a troponin. The thought is this will decrease resource utilisation and improve patient flow.

The original “derivation” of the HEAR score was in 2020 by Smith LM, et al. These subsequent researchers from Calgary (go stampede!) sought to externally validate this strategy.

They conducted a secondary analysis of a prospective cohort study of patients with chest pain that got a troponin to exclude MI in their single ED.

They enrolled 1150 patients. Of those, 8% had index MI and 11% with MACE by 30 days. HEAR score <1 identified 202 (17.6%) of patients at very low risk of adverse events with a 99% sensitivity (95% CI 95.6-99.9%). Only one patient out of 202 was missed. 

As with most screening tools that are highly sensitive, it often means they are terribly non-specific. The HEAR score is no exception. As such, it should only be used as a one-way decision instrument

The authors of this study appropriately conclude that this very low risk cohort of HEAR <1 is unlikely to benefit from troponin testing and will lead to significant resource savings.

This is not exactly ground-breaking. A young patient with a low-risk story, a normal ECG, and no risk factors is very unlikely to have a problem.

Sure, it’s probably fine to skip the troponin. I think a lot of us have been doing this over the years via gestalt. But at least this study quantifies the risk and provides support for those clinicians who want to avoid troponin testing in very low risk patients.

Perhaps the greatest use of HEAR score is to allow you sleep at night… perhaps a bit of medico-legal defense when you document the score and send that low risk patient home without blood tests.


O'Rielly CM, Andruchow JE, McRae AD. External validation of a low HEAR score to identify emergency department patients at very low risk of major adverse cardiac events without troponin testing. CJEM. 2022;24:68-74. [link to article]