Manipulating Colles’ fractures under Bier’s blocks or haematoma block – which is better? - Pierre Pechon December 2007

Introduction:

The distal radius fracture is one of the most common fractures and frequently requires manipulation prior to casting. Manipulation can be done under general anaesthesia (GA), intra-venous regional anaesthesia (Bier's block or IVRA), haematoma block or sedation. This literature review focuses on comparisons of IVRA and haematoma blocks and aims to show which method provides best outcome in terms of pain, quality of reduction of the fracture and remanipulation rates.

Each method has pros and cons. IVRA is safe and well tolerated but requires several members of staff often including an anesthetist. Haematoma blocks breach the skin and are a potential risk of infection. Their efficacy is thought to be dependent on accurate injection of local anaesthetic into the fracture haematoma, though no trials were found that investigated this. The preferred choice of IVRA or haematoma block often varies from one hospital to another, and is a frequent topic of debate.

Methods:

Forty-six papers were identified by MEDLINE literature search, many were retrospective non-direct comparisons of the two methods however four were prospective clinical trials comparing biers block with haematoma block.

Results of the studies:

Popularity of each method

A survey of 54 UK hospitals covered by CEPOD who perform distal radius fracture manipulation showed the following preferences ¹ .

Safety

IVRA with Prilocaine used on 7410 patients showed no documented incidences of anaphylaxis, arrhythmia, convulsions or collapse ¹ .

Pain during manipulation

Pain during manipulation has been showed to be significantly lower with IVRA than haematoma block by all four studies ^2-5 .

Remanipulation rates

Remanipulation rates, either immediate or delayed, were shown to be lower for IVRA than haematoma blocks by three of the four studies ^2,4,5 .

Post manipulation position

When examining post-manipulation radial length, radial angulation and dorsal angulation all four studies found that IVRA was significantly superior to haematoma block in one or more of these variables ^2-5 .

Conclusion

In conclusion IVRA provides a better anatomical reduction of colles fracture, has a lower remanipulation rate and is associated with less pain than haematoma blocks. There are differences in duration of patient time in hospital, staff and equipment requirements between methods. IVRA typically is slower and requires a member of the anaesthetic team and it is presumed that cost analysis, though not formally investigated here, would show haematoma block to be cheaper.

References

1. S.A.W. Pickering J.B. Hunter. Bier’s block using prilocaine: safe, cheap and well tolerated. Surg J R Coll Surg Edinb Irel., 1 October 2003, 283-285
2. Kendall JM. Allen P. Younge P. Meek SM. McCabe SE. Haematoma block or Bier's block for Colles ' fracture reduction in the accident and emergency department--which is best? J Accid Emerg Med 1997; 14(6): 352-6
3. Cobb AG. Houghton GR. Local anaesthetic infiltration versus Bier's block for Colles ' fracture s. Br Med J (Clin Res Ed) 1985; 291(6510): 1683-4.
4. Wardrope J. Flowers M. Wilson DH. Comparison of local anaesthetic techniques in the reduction of Colles' fracture. Arch Emerg Med 1985; 2(2): 67-72.
5. Abbaszadegan H. Jonsson U. Regional anesthesia preferable for Colles' fracture. Controlled comparison with local anesthesia. Acta Orthop Scand 1990; 61(4):348-9

Mr Pierre Pechon, SHO Orthopaedics, RNOH Stanmore, London