Hematoma block

Hematoma block also called haematoma block, is defined as a procedural analgesia where a local anesthetic is injected directly into the fracture site and it is a safe and effective alternative technique for pain control in assistance with manual reduction for distal radius fracture ¹. Hematoma block is a simple alternative method to general anesthetic or Bier’s block (intravenous regional anesthesia) of providing rapid pain relief during reduction of distal radius fracture. Hematoma block potential benefits include avoidance of procedural sedation and analgesia-associated risks, high cost-effectiveness, and time-sparing procedure ². In recent years, evidence from well-conducted randomized controlled trials ³, ⁴ have confirmed the effectiveness of hematoma block in assistance with manual reduction of distal radius in both the adult and pediatric patients.

A recent meta-analysis ² comparing the most common two methods of anesthesia, hematoma block or procedural sedation and analgesia, used in emergency departments and clinics for reduction of distal radius fracture to compare level of pain relief, the risk of treatment failure as well as the frequency of complications. This meta-analysis showed that hematoma block is a safe and effective alternative to procedural sedation and analgesia for facilitating pain relief during distal radius fracture reduction in adult and pediatric patients. Specifically, hematoma block obtained a significantly larger reduction in pain severity compared to procedural sedation and analgesia in adult patients after reduction of fracture and for pediatric population during reduction of fracture  ².

In addition to hematoma block and procedural sedation and analgesia, several methods of anesthesia have also been advocated for alleviating discomfort and facilitating reduction in patients with displaced distal radius fracture, including intravenous regional anesthesia (Bier block) and regional nerve blocks such as radial, median, and ulnar nerve blocks at the elbow or in the axilla (armpit) ⁵. Bier’s block (intravenous regional anesthesia) has proven effective for anesthesia during upper limb surgery ⁶. However, concerns still exist over the complications including pain at the tourniquet site, local anesthetic toxicity, and instant recurrence of pain at surgical site following tourniquet deflation and the serious dangers of leakage of anesthetic after accidental deflation of the tourniquet ⁷. Regional nerve block is another effective method of controlling pain during fracture reduction ⁸. Nevertheless, highly skill-dependent technique may prevent the clinicians from general application of regional nerve block when treating distal radius fracture.

The procedural sedation and analgesia is widely used in the emergency department as a part of daily practice in both university and community hospitals, but patients undergoing procedural sedation and analgesia may be under risks of respiratory distress and need different levels of monitoring. The hematoma block provides a simple and alternative technique for pain relief during reduction of distal radius fracture. This meta-analysis ² showed that, in adult patients, for relief of larger post-reduction pain in adult patients, hematoma block is superior to procedural sedation and analgesia. However, there was no difference on the pain severity during reduction between these two groups. This implies that anesthesia with hematoma block, instead of procedural sedation and analgesia, is beneficial for maintaining the effect of pain relief after fracture reduction. In the pediatric patients, treatment by hematoma block also revealed less pain severity compared with that by procedural sedation and analgesia ². Additionally, the adult patients treated by procedural sedation and analgesia suffered most side effects, including nausea, vomiting, and respiratory distress. The rates of reported side effects did not differ between pediatric patients receiving hematoma block and those receiving procedural sedation and analgesia, nor difference on the final outcomes of reduction failure between groups in adult and pediatric patients.

What if the patient has a metal rod or partial prosthesis?

Avoid hematoma block for this patient, and consult an orthopedic surgeon because the risk for infection or complication is high.​

​What is the risk for infection from the hematoma block injection?

Risk for infection is extremely low, and will not complicate hematoma block procedure.

What if the patient has a history of carpal tunnel syndrome?

No big deal; it doesn’t matter. Go ahead with the hematoma block.

What if the patient is a diabetic or immunocompromised? Does he need antibiotics?

Probably not.

What if the patient still has pain and is not anesthetized?

Give him an intravenous opioid like hydromorphone or morphine. Make sure you’ve waited a full 15 minutes or even 20. Don’t be impatient.

What if the patient is on anticoagulants?

It shouldn’t really matter for the wrist or a hematoma block. Give strict return precautions.

What if the patient has distal radius and ulnar fractures? Do I do two blocks?

Don’t do two blocks! Generally, only one hematoma formed, and one block is enough.

Hematoma block indications

• Clean, closed fracture site
• Fracture sites where hematoma block can be used:
  • Distal Radius Fracture
  • Phalanx Fracture
  • Ankle Fracture (by orthopedic surgeon)

Hematoma block contraindications

• DO NOT do a hematoma block for open fractures. These usually go to the operating room and need a washout.
• DO NOT inject more than 10-15 mL of lidocaine into the fracture site. If you have used 15 mL of 2% lidocaine, that is 300 mg of lidocaine! You must consider toxicity, and don’t forget about compartment syndrome with large amounts of fluid in this small space.
• DO NOT repeat injections into the joint space.
• DO NOT inject into the volar surface of the wrist.

Hematoma block procedure

Equipment

• Sterile gloves
• Sterile gauze
• Antiseptic solution (e.g. iodine, chlorhexidine or alcohol)
• Syringe (12 cc syringe)
• Needles (large bore for drawing up local (18 gauge), small gauge for injection [smaller gauge for injection (22-27g)])
• Anesthetic (e.g. 2% lidocaine or 0.5% bupivicaine)

Hematoma block procedure

• Position extremity on hard surface
• Find landmarks – the injection site is identified through palpation of the dorsal aspect of the deformity and then cleansed with a cleansing solution (e.g. iodine, chlorhexidine or alcohol). Care must be taken to not contaminate this site after cleansing
  • Fracture site based on imaging
  • Area of swelling or deformity
• Draw up anesthetic
• Prep skin
• Enter skin directly over fracture – the needle is then inserted into the fracture site. This may be accomplished blindly through readjustments until the needle “falls” into the fracture with loss of resistance or with the help of bedside imaging techniques such as ultrasound or bedside fluoroscopy
  • Advance needle until bone encountered
  • Aspirate until blood is seen to confirm placement within hematoma
  • Inject anesthetic (5 to 15 mL of plain 1% lidocaine or 5 to 10 mL of plain 2% lidocaine) ⁹
    • Goal is to anesthetize bone and periosteum
• Remove needle, apply pressure with gauze
• Dress site, proceed with reduction(s) only after 5-10 minutes when block is fully in effect.
• After immobilization with a splint, post-reduction radiographs is obtained to show improved alignment of fracture.

References

1. Ogunlade SO, Omololu AB, Alonge TO, Salawu SA, Bamgboye EA. Haematoma block in reduction of distal radial fractures. West Afr J Med. 2002;21(4):282-285. doi:10.4314/wajm.v21i4.27998
2. Tseng PT, Leu TH, Chen YW, Chen YP. Hematoma block or procedural sedation and analgesia, which is the most effective method of anesthesia in reduction of displaced distal radius fracture?. J Orthop Surg Res. 2018;13(1):62. Published 2018 Mar 27. doi:10.1186/s13018-018-0772-7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5869786
3. Fathi M, Moezzi M, Abbasi S, Farsi D, Zare MA, Hafezimoghadam P. Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial. Emerg Med J. 2015;32(6):474–477. doi: 10.1136/emermed-2013-202485
4. Bear DM, Friel NA, Lupo CL, Pitetti R, Ward WT. Hematoma block versus sedation for the reduction of distal radius fractures in children. J Hand Surg Am. 2015;40(1):57–61. doi: 10.1016/j.jhsa.2014.08.039
5. Handoll HH, Madhok R, Dodds C. Anaesthesia for treating distal radial fracture in adults. Cochrane Database Syst Rev. 2002;(3):CD003320. doi:10.1002/14651858.CD003320 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003320/full
6. Jafarian A, Hassani V, Jesmi F, Ramezani K, Javaheri F, Shariatzadeh H. Efficacy of a modified Bier’s block in patients undergoing upper limb bone surgery. Anesth Pain Med. 2015;5(1):e22007. doi: 10.5812/aapm.22007
7. Jakeman N, Kaye P, Hayward J, Watson DP, Turner S. Is lidocaine Bier’s block safe? Emerg Med J. 2013;30(3):214–217. doi: 10.1136/emermed-2011-200999
8. Unluer EE, Karagoz A, Unluer S, Kosargelir M, Kizilkaya M, Alimoglu O, et al. Ultrasound-guided supracondylar radial nerve block for Colles Fractures in the ED. Am J Emerg Med. 2016;34(8):1718–1720. doi: 10.1016/j.ajem.2016.06.007
9. McGee D. Local and Topical Anesthesia. In: Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014.