Procedure: Haematoma Block

Procedure, instructions and discussion

Haematoma Block

This week we cover a practical alternative to sedation for fracture reduction — the haematoma block. Simple, effective, and resource-sparing, it has become a core ED skill.

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Instructions

• Reduction after a haematoma block can still be very painful
• It is not recommended as a sole modality of pain relief for fracture reduction
• It may be considered as an adjunct where procedural sedation is contraindicated

Indications

• Forearm or distal radius fracture requiring reduction

Contraindications (absolute in bold)

• Open fracture
• Allergy to local anaesthetic agents

Alternatives

• Bier block
• Procedural sedation (parenteral or inhalational)
• General anaesthesia with reduction in operating theatre

Consent

VERBAL – IF HAS CAPACITY

• This is a simple procedure with low risks of complications

NOT REQUIRED – IF LACKS CAPACITY

• Emergency procedure to prevent pain and distress
• Brief verbal explanation of the procedure is still recommended for the patient who lacks capacity.

Potential complications

• Failure (ineffective analgesia)
• Neurovascular injury
• Infection (cellulitis, osteomyelitis)
• Compartment syndrome

Infection control

• Standard precautions
• Aseptic non-touch technique
• PPE: sterile gloves

Area

• Any clinical area suitable for fracture reduction and cast application

Staff

• Procedural clinician
• Assistant required for fracture reduction

Equipment

• 10ml syringe
• Drawing up needle
• 23g needle for the injection
• High-frequency linear transducer and ultrasound (optional)

Positioning (patient)

• Supine with forearm and palm down on a supportive surface

Medication

• 10-15ml lignocaine 1% (without adrenaline) up to maximum of 3mg/kg

Sequence (without ultrasound)

• Review fracture X-ray noting dorsal pattern and location of fractured periosteum
• Palpate the fracture (‘bony step off’) on the dorsum of the wrist
• Insert the needle at the fracture site aspirating the needle as it advances
• Confirm placement in the fracture haematoma with flashback of blood
• Inject 10-15ml lignocaine (and aspirated blood) into the fracture site

Sequence (with ultrasound)

• Review fracture X-ray noting dorsal pattern and location of fractured periosteum
• Trace the radius longitudinally with the US, noting the break in the cortex
• Insert the needle using ultrasound in plane technique through the break in cortex into the fracture space
• Confirm placement in the fracture haematoma with flashback of blood and inject 10ml of lignocaine
• Consider tracing the ulnar laterally (associated styloid fracture) injecting 5ml lignocaine if fracture present

Post procedure care

• Remove needle and dress with adherent waterproof dressing
• Proceed with reduction after 10 minutes when the block is fully in effect

Tips

• A common error is to perform this procedure too soon after injection (5-10 minutes is required)
• Ultrasound use is recommended for impacted multi-fragment fractures with loss of palpable landmark
• If the injury is several hours old, the haematoma may not provide flashback on aspiration
• Analgesia with lignocaine alone may last for several hours

Discussion

The haematoma block is a technique to inject a local anaesthetic solution into the haematoma between the fractured bone fragments. The dorsal aspects of arm contain fewer neurovascular structures and is preferred.

Haematoma blocks of the distal forearm are considered safe in children and adults, and with systemic analgesia, can often provide the conditions needed to reduce a fracture without procedural sedation. Generally, intravenous regional anaesthesia (Bier’s block) provides better analgesia during fracture manipulation, enabling better reduction of the fracture, but with additional risks from IV anaesthetic injection.

References

• Petron DJ. Distal radius fractures in adults. In: UpToDate. Waltham (MA): UpToDate. 2018 Sept 17.
• Handoll HH, Madhok R, Dodds C. Anaesthesia for treating distal radial fracture in adults. Cochrane Database Syst Rev. 2002;2002(3):CD003320
• 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 Mar 27;13(1):62.
• Orbach H, Rozen N, Rinat B, Rubin G. Hematoma block for distal radius fractures – prospective, randomized comparison of two different volumes of lidocaine. J Int Med Res. 2018 Nov;46(11):4535-4538.
• 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 Jan;40(1):57-61.
• 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 Jun;32(6):474-7.
• Gottlieb M, Cosby K. Ultrasound-guided hematoma block for distal radial and ulnar fractures. J Emerg Med. 2015 Mar;48(3):310-2.
• Case RD. Haematoma block–a safe method of reducing Colles’ fractures. Injury. 1985 Jul;16(7):469-70.
• Younge D. Haematoma block for fractures of the wrist: a cause of compartment syndrome. J Hand Surg Br. 1989 May;14(2):194-5.

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