Colles' fracture reduction

1. Colles’ fracture
reduction techniques
ROSALIND OAKES
1/12/16

2. 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%

3. 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

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

5. 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

6. 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

7. Haematoma Block
Pros 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

8. Procedural Sedation

9. Procedural Sedation
Pros Cons
Effective Aspiration
‘An unfasted GA with no airway in place…’
SE from sedation: hypoxia, hypotension,
bradycardia
Higher risk in some patients: OSA, difficult airway
Resource heavy: Resus Bay, monitoring, personnel,
time to recover
Proceduralist needs anaesthetic experience

10. Theatre GA
Pros 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 time
Potentially most pleasant option for patient

11. 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

12. 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

13. Peripheral NB in non-operative settings
Tran 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

14. 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

15. Applications ED

16. 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

17. Review of evidence of efficacy for PNB
Kessler (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.

18. Regional Blocks
Pros 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

19. SCGH experience
Fracture LA Site Outcome Further
analgesia
65 F Radial # 1%
lignocaine
Radial 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,Ro
piviciane
Axillary
approach
Motor block No

20. Patient leaflet post block

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

22. 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.