Colles’ fracture reduction techniquesROSALIND OAKES1/12/16

Epidemiology Common

A 50 year old white woman in N Europe and USA has a 15 % lifetime risk of distal radius fracture

2% for men in the same group

Osteoporosis and increased falls in older women

Admission rate is about 20%

Options Aim: To allow the patient to tolerate a painful procedure

Haematoma Blocks

Intravenous Regional Anaesthesia (IVRA) Biers Block

Procedural Sedational

Regional blocks: peripheral nerve blocks (radial median ulnar) & Brachial plexus

GA in theatre

What are the pros and cons of IV regional anaesthesia (Biers block)? 4 marks (2 each)

What are the pros and cons of IV regional anaesthesia (Biers block)? 4 marks (2 each)Pros Cons

Effective May fail

Often well tolerated Risk of local anaesthetic toxicity

No risk of sedation Poor tolerance of pressure cuff

Could use for foot and ankle surgery Staff heavy

Monitored area required

Haematoma Block Prepare skin with Antiseptic solution

5-15mls 1% Lignocaine into fracture cavity and around the adjacent periosteum

Confirm site by aspirating blood

Do not use for open fractures

Roberts & Hedges (2014) p 519

Haematoma BlockPros Cons

Simple, 1 doctor, does not require cardiac monitoring or IV access

Not suitable for fractures with marked displacement

Lower LA dose than Bier’s Less effective than Bier’s in terms of analgesia and usually needs supplemental analgesia E.g. Entonox

Procedural Sedation

Procedural SedationPros Cons

Effective Aspiration‘An unfasted GA with no airway in place…’SE from sedation: hypoxia, hypotension, bradycardiaHigher risk in some patients: OSA, difficult airway

Resource heavy: Resus Bay, monitoring, personnel, time to recoverProceduralist needs anaesthetic experience

Theatre GAPros Cons

Anaesthetic: Less risks than procedural sedation due to airway protection

Logistically unlikely to be able to achieve in a timely manner

Fractures that need an operation anyway.. Preventing double procedure and timePotentially most pleasant option for patient

Anaesthesia for treating distal radial fracture in adults Cochrane (2002)

Attempted to compare all the above methods for outcome in terms of failed/inadequate anaesthesia, anatomical restoration, resource use

1a. Intravenous regional anaesthesia (IVRA) versus haematoma block (5 studies)

IVRA patients experienced significantly less pain during fracture manipulation

Fewer remanipulations

statistically better anatomical post-reduction measurements

No difference between the two groups in the overall time in the accident and emergency department

Regional Blocks Many options for forearm blocks

Peripheral nerve blocks - radial, median ulnar at elbow or supraclavicular, infraclavicular, axillary approach which all target the brachial plexus at different points

Most evidence for regional blocks comes from anaesthesia literature

Different level of training, different patient group

Peripheral NB in non-operative settingsTran et al (2014)

RCTs n=14

Kriwanek et al (2006) Children with forearm fractures AXB v deep sedation (Midaz/ketamine) but transarterial approach not US guided

Blaivas et al (2011) compared interscalene brachial plexus blocks versus procedural sedation for shoulder reduction are found shorter length of stay but similar post reduction pain

Other blocks from this paper relate to femoral nerve blocks in ED or on a ward

GA v US guided brachial plexus block O’Donnell et al (2009)

US guided axillary block v GA evaluating anesthetic and perioperative analgesic outcomes.

Patients were randomized

OOP approach, equal parts 2% lidocaine with 1:200,000 epinephrine and 0.5% bupivacaine with 7.5 mg/mL clonidine was injected after identifying the median, ulnar, radial, and musculocutaneous nerves.

General anesthesia was induction with fentanyl and propofol, maintenance with sevoflurane

All blocks were successful

The block group had lower visual analog scale pain scores in the recovery room in 2 and 6 hours and were discharged earlier

Applications ED

Regional Anaesthesia for Trauma Fleming et al (2013) [a review]

Distal radius fractures undergoing closed reductions in the emergency department are amenable to supracondylar radial nerve block to minimize sedation requirements.

Acute compartment syndrome. A difficult diagnosis and RA could eliminate pain as the presenting symptom. Discuss with Orthopaedics in high risk patients prior to blocking

Trauma induced coagulopathy – ROTEM, neuroaxial blocks

‘Double crush injury’ patients with pre- existing nerve lesions are more susceptible to further injury when exposed to a secondary insult

Unrelieved acute pain is a risk factor for chronic pain 1-4% non operatively managed Colles’ CRPS

Review of evidence of efficacy for PNBKessler (2015)

Nerve Damage

Neuropathy post Axillary NB was 1.48:100 (95% CI: 0.52-4.11:100) with no cases of permanent nerve damage Brull (2007)

For comparison femoral NB post op neuropathy is 0.34:100 (95% CI: 0.04-2.81:100)

However, on postoperative days 1, 7, and 14 there were no differences in pain, opioid consumption, adverse effects, Pain-Disability Index, or patient satisfaction.51

Training

High success rates of 93 – 98 in different retrospective studies with more than 6500 patients can only be achieved after intensive training.

Regional BlocksPros Cons

Small volume of LA compared to IVRA (less risk of toxicity)

Nerve damage & ‘Double crush syndrome’

Less resource used – single operator, no need for a resus bay, no recovery time

Probably the most difficult to learn, high training time required

Patient alert ‘Patchy’ or ineffective blocks leading to supplementary analgesia

Potentially reduces risk of chronic pain Concern about ability to diagnose Compartment Syndrome

Does not expose patient to risk of GA Not well studied in the ED setting

SCGH experience Fracture LA Site Outcome Further

analgesia65 F Radial # 1%

lignocaineRadial below elbow

Analgesia with some motor block in hand

Converted to sedation

68F Radial and Ulnar #

1% Lignocaine

Ulnar, radial Motor block No

85F Radial and Ulnar #

1% lignocaine, 0.2% Ropivicaine

Ulnar, Radial and Median at elbow

Analgesia Converted to sedation

72F Radial # 1% lignocaine,Ropiviciane

Axillary approach

Motor block No

Patient leaflet post block

http://scghed.com/wp-content/uploads/2014/05/Colles-Austin.pdf

References Fleming, I. and Egeler, C., 2013. Regional anaesthesia for trauma: an update. Continuing Education in Anaesthesia, Critical Care & Pain, p.mkt048.

Imasogie, N., Ganapathy, S., Singh, S., Armstrong, K. and Armstrong, P., 2010. A prospective, randomized, double-blind comparison of ultrasound-guided axillary brachial plexus blocks using 2 versus 4 injections. Anesthesia & Analgesia, 110(4), pp.1222-1226.

O’Donnell, B.D., Ryan, H., O’Sullivan, O. and Iohom, G., 2009. Ultrasound-guided axillary brachial plexus block with 20 milliliters local anesthetic mixture versus general anesthesia for upper limb trauma surgery: an observer-blinded, prospective, randomized, controlled trial. Anesthesia & Analgesia, 109(1), pp.279-283.

Mannion, S., 2013. Regional anaesthesia for upper limb trauma: a review. Rom J Anaest Intens Care, 20(1), pp.49-59.

Tran, D.Q., Bernucci, F., Iyaprasertkul, W. and Finlayson, R.J., 2014. Peripheral Nerve Blocks in Non-Operative Settings: A Review of the Evidence and Technical Commentary. Journal of Anesthesia & Clinical Research, 2014.