A prospective trial to compare three anaesthetic techniques used for the reduction of fractures of the distal radius. Hyaluronidase (Hyalase): a useful addition in haematoma block? Reduction of Colles' fractures without anaesthesia using a new dynamic bone alignment system. Bier's block--an improved technique. Haematoma block or Bier's block for Colles' fracture reduction in the accident and emergency department--which is best? Anaesthesia for surgical correction of fractured femoral neck. A comparison of three techniques. Two procedures for Kirschner wire osteosynthesis of distal radial fractures. A randomized trial. Postoperative analgesia after triple nerve block for fractured neck of femur. [Analgesia after hip fracture repair in elderly patients: the effect of a continuous femoral nerve block: a prospective and randomised study]. A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radial fractures. Regional anaesthesia for cataract surgery: comparison of three techniques. [Acute pain management in proximal femoral fractures: femoral nerve block (catheter technique) vs. systemic pain therapy using a clinic internal organisation model]. The use of muscle relaxant to supplement local anaesthetics for Bier's blocks. Cubital nerve block vs haematoma block for the manipulation of Colles' fracture. Bier's block: a change of injection site. A randomised clinical trial of activity-focussed physiotherapy on patients with distal radius fractures.
The aim of this study was to compare prospectively haematoma blocks alone and haematoma blocks with sedation with general anaesthesia for the reduction of distal radius fractures in adult patients, with respect to pain perception before, during and after manipulation using a visual analogue scale, radiological position, waiting time, procedure time and cost. Fifty-eight adult patients with closed, displaced distal radius fractures were included in the study. Pain experienced during manipulation was greatest in patients who received haematoma blocks alone compared with the other two groups. Post-manipulation pain was significantly greater in patients who received a general anaesthetic. Radiological correction was as good in those patients receiving a haematoma block with or without sedation as a general anaesthetic. The waiting and manipulation times and resource costs were greater in those receiving a general anaesthetic. There were no complications related to any of these anaesthetic methods. Patient acceptance is greater with a correctly performed haematoma block and sedation technique compared to general anesthesia. It is also more efficient with regard to time and the resources required. This is particularly important for a progressively increasing ambulatory, elderly population who require prompt, safe, effective and painless management. To investigate whether hyaluronidase (Hyalase) is a useful and justified addition to haematoma block for pain relief.
                The study was a randomised double blind trial of 33 consecutive patients attending the accident and emergency department for manipulation of distal radius fracture under haematoma block. Control patients received 1% lignocaine; the treatment group received 1% lignocaine plus 1500 IU hyaluronidase. Manipulation occurred 10 minutes after instituting the block.
                16 patients received hyaluronidase, 17 received lignocaine only. One patient with unsuccessful manipulation was excluded. There was no significant difference between the two groups for any of three methods of pain assessment (P > 0.05, Mann Whitney).
                The addition of hyaluronidase does not increase the efficacy of the haematoma block when 10 minutes are allowed to elapse before manipulation, and the increased cost of adding (and risk of allergy) is not justified by any theoretical increased speed of analgesia. Two techniques for reduction of Colles' fractures were compared in a prospective, randomized study. With use of a newly designed dynamic bone alignment device, reduction manoeuvres were performed on 62 patients with Colles' fractures (group A) without any form of anaesthesia. In a control group of 54 patients (group B) Colles' fractures were reduced manually in the traditional way using local infiltration anaesthesia. In each group the pain experienced by the patients was recorded. Severe pain during the reduction was reported by 8 per cent of the patients in group A and by 35 per cent of those in group B. No complications occurred during or after dynamic reduction without anaesthesia. This method of treatment seems to be a very gentle one for the patients, with the advantage of causing less pain than treatment under local anaesthesia. A simple modification to the method of regional anaesthesia known as Bier's block is presented. This was applied to patients with Colles' fractures. In a controlled trial the technique produced anaesthesia more quickly than the other method. To offer clear guidance on the anaesthetic management of Colles' fractures in the accident and emergency (A&E) department in the light of the conflict between existing reports and current trends, and to address the issue of alkalinisation of haematoma blocks.
                This was a two centre, prospective, randomised clinical trial with consecutive recruitment of adult patients with Colles' fractures requiring manipulation to receive either Bier's block or haematoma block. There was subsequent blinded randomisation to alkalinised or non-alkalinised haematoma block.
                72 patients were recruited into the Bier's block group, and 70 into the haematoma block group. Bier's block was less painful to give than the haematoma block (median pain score 2.8 v 5.3; P < 0.001), and fracture manipulation was also less painful in the Bier's block group (median pain score 1.5 v 3.0; P < 0.01). There was no significant difference in overall A&E transit time between the two groups. There was better initial radiological outcome in terms of dorsal angulation in the Bier's block group (-3.6 degrees v 2.1 degrees; P = 0.003). More remanipulations were required in the haematoma block group (17/70 v 4/72; P = 0.003). There was a trend towards decreased pain on administration of the alkalinised haematoma block when compared with non-alkalinised haematoma block, but this did not reach significance. There was no difference in pain score on fracture manipulation. There were no complications in either group.
                Bier's block is superior to haematoma block in terms of efficacy, radiological result, and remanipulation rate; transit times are equal, both procedures are practical in the A&E environment, and there were no complications. Bier's block is the anaesthetic management of choice for Colles' fractures requiring manipulation within the A&E department. Sixty patients with fractured neck of femur and scheduled for surgical correction were randomly allocated to receive one of three anaesthetic techniques: general anaesthesia; spinal analgesia; psoas compartment block. The patients in the local anaesthetic groups also received a light general anaesthetic. There was little difference in the pre-, intra- and postoperative events, and no difference in postoperative mortality. The treatment of displaced Colles-type fractures of the distal part of the radius remains a challenge. Two procedures for closed reduction and Kirschner wire osteosynthesis of these fractures were compared in a prospective randomized study.
                One hundred consecutive patients with a Colles fracture of the distal part of the radius (AO classification 23-A2, 23-A3, or 23-C1) were treated over an eighteen-month period. One group was managed with the conventional method, described by Willenegger and Guggenbuhl in 1959, in which two Kirschner wires are introduced into the styloid process of the radius. The other group was treated with the Kapandji method, as modified by Fritz et al., in which two Kirschner wires are inserted into the fracture gap and a third is placed through the styloid process. Postoperative care was standardized for both groups and carried out according to a strict procedure. Forty patients who had been operated on according to the modified Kapandji method and forty-one treated with the Willenegger technique were available for follow-up, for a follow-up rate of 81%. The follow-up assessment was performed with a modified version of the Martini score.
                The median time to follow-up was ten months (range, six to twenty months). The results as assessed with the Martini score were, on the average, good to very good for the patients treated with the Kapandji method and satisfactory to good for the patients treated with the conventional Kirschner wire fixation. The duration of radiographic exposure was significantly shorter with the Kapandji method than with the Willenegger technique.
                Conventional Kirschner wire fixation remains a good method of osteosynthesis for the treatment of displaced fractures of the distal part of the radius. We found both the functional and radiographic outcomes of the Kapandji method to be significantly better than those of the Willenegger technique.
                Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence. Fifty patients with fractured neck of femur that required surgical correction with either a compression screw or pin and plate device were randomly allocated to receive one of two anaesthetic techniques, general anaesthesia combined with either opioid supplementation or triple nerve block (three in one block) with subcostal nerve block. The nerve blocks significantly reduced the quantity of opioid administered after operation; 48% of these patients required no additional analgesia in the first 24 hours. Plasma prilocaine levels in these patients were well below the toxic threshold, and peak absorption occurred 20 minutes after the injection. No untoward sequelae were associated with the nerve blocks. The usefulness of peripheral femoral nerve block for pain management after hip fracture has been established. This prospective and randomised study compared the analgesia effect of a continuous femoral nerve block (CF) versus two conventional analgesia procedures after hip fracture.
                Patients. (n=62) scheduled for surgery under spinal anaesthesia were prospectively included. After surgery, analgesia (48 hours) was randomised: group FC (femoral catheter, anterior paravascular approach, initial bolus followed by continuous infusion of ropivacaine 0.2%), group P (iv 2 g propacetamol/6 hours), group M (sc morphine, 0.05 mg/kg per 4 hour). Intravenous morphine titration was performed, followed by subcutaneous (sc) morphine every 4 hours according to the VAS score. The primary end-point was the morphine requirements. Secondary end-points were VAS score, side effects, and mortality.
                Demographic data and surgical procedures were similar between groups. After morphine titration, the VAS pain score did not differ between groups. All patients in-group M received additional morphine. Morphine mean consumption was increased in CF group: 26 mg (5-42) versus P: 8 mg (3-12) (p=0.0001) or M: 19 mg (8-33) (p<0.006) while constipation was decreased in P group vs CF. Percentage of patients requiring no morphine was similar between P (n=6; 28%) and CF (n=6; 28%) and greater than M (n=0; 0%). Hospital discharge, cardiovascular or pulmonary complications and mortality after 6 months showed no statistical difference.
                Continuous femoral nerve block provided limited pain relief after hip fracture did not reduced side effects and induced an expensive cost. Distal radial fractures are common, and many methods of treatment have been reported but there are no studies that compare the different treatment methods. This randomized prospective study demonstrated no advantage in using an external fixator to immobilize reduced distal radial fractures over closed reduction and plaster cast immobilization in patients less than 60 years of age. The external fixator group had a significant complication rate. Two methods of periocular anaesthesia (PI and PII) were compared with the traditional retrobulbar block in a prospective study of 450 patients undergoing elective cataract extraction and intraocular lens implantation. A solution of local anaesthetic containing equal amounts of 2% lignocaine and 0.5% bupivacaine was used in all the groups. Hyaluronidase (75 IU/10 ml of local anaesthetic solution) was added. Three groups of patients were studied, with 150 patients in each group. The retrobulbar injection (group R) was performed with 4 ml of the anaesthetic solution through the lower eyelid inferotemporally and a further 6 ml was injected for seventh cranial nerve block. In the first periocular technique (group PI) the local anaesthetic was injected inferotemporally (5 ml) through the lower lid and superonasally (5 ml) through the upper lid. In the second periocular technique (PII) the injections were performed inferotemporally (5 ml) and into the medial compartment (2 ml) of the orbit at the medial canthus. Satisfactory anaesthesia could be achieved with all of these methods. Additional block because of insufficient akinesia of the muscles was required in 12% (18/150) in group R, in 19% (28/150) in group PI, and in 11% (16/150) in PII. The medial compartment technique (PII) was associated with the highest percentage of total akinesia of the muscles and lowest reblock rate. All three methods produced sufficient analgesia during surgery and there were no differences in the requirements for additional analgesic drugs during surgery. It is concluded that the medial compartment technique represents a good alternative to retrobulbar block. The aim of this study was to compare safety and efficacy of catheter-mediated femoral nerve block analgesia with systemic pain therapy in patients with proximal femoral fractures in the pre-operative and post-operative setting using a protocol for coordinating pain management.
                In a prospective randomised trial of patients attending the emergency department, 100 individuals were selected with a clinically diagnosed proximal femoral fracture. Patients were divided into two equal groups A and B. Group A (n=50) received a catheter-mediated femoral nerve block with 1% prilocaine (40 ml) and post-operatively 0.2% ropivacaine (30 ml) 6 hourly. Group B (n=50) initially received intravenous metamizol (1 g) and a fixed combination of oral tilidine (100 mg) + naloxone (8 mg). Patients aged 90 years or more received a reduced dose (tilidine 75 mg + naloxone 6 mg). In the post-operative period regular oral ibuprofen (400 mg, 8 hourly) in addition to oral tilidine (50 mg) + naloxone (4 mg) was given as required for break through pain. Pain intensity was measured using a verbal rating scale (VRS) from 1 to 5: pain free (=1), mild pain (=2), moderate pain (=3), severe pain (=4), excruciating pain (=5). Pain scores were recorded at rest (R), during passive anteflection (30 degrees) of the hip (PA) on arrival and at 15 and 30 min after initial administration of analgesia. Thereafter, recordings were made 4 times a day up to the third post-operative day.
                Pain scores were comparable for both groups on admission (VRS in R 2.50 vs. 2.46; VRS during PA 4.30 vs. 4.34). Significant pain relief was achieved in both groups following initial administration of analgesia, but the total pain scores in group A were significantly lower than in group B (VRS in R 1.22 vs. 1.58, p<0.01 and VRS during PA 2.66 vs. 3.26; p<0.001). No difference was noted between the two groups during the first 3 post-operative days. No severe complications occurred as a result of analgesia, however, the catheter was dislodged in 20% of patients in group A resulting in the need for systemically administered analgesia.
                All patients presenting with proximal femoral fractures should receive adequate analgesia within the emergency department even prior to radiographic imaging. Femoral nerve block should be considered as the method of choice. The insertion of a femoral nerve block catheter has the dual advantage of early analgesia permitting repeated clinical examination in addition to continued post-operative pain management. The cumbersome logistics inherent in this technique within the clinical setting limits its practical application. An initial single-shot regional nerve block followed by a systemic post-operative analgesia protocol was considered an appropriate alternative. The execution of safe, consistent and appropriate regional nerve block anaesthesia is reliant on formal guidelines and protocols as agreed by the multidisciplinary teams involved with patient-directed pain management and good clinical practice. In searching for the 'ideal' muscle relaxant for use with intravenous regional anaesthesia, muscle relaxation was assessed with and without the addition of Atracurium to Bier's Block in four volunteers. This was followed by a clinical study of 36 patients with wrist fractures to confirm the drug's safety and examine the possible clinical advantages of using a muscle relaxant. The addition of 2 mg of Atracurium to the Bier's Block improved the ease of reduction (P less than 0.025) and the quality of analgesia (P less than 0.05) (Mann-Whitney U test). The authors conclude that the addition of Atracurium to a Bier's Block is useful in selected patients with a wrist fracture. Blocking efficacy and acute toxicity of prilocaine (15 ml of 10 mg/ml prilocaine) was examined in 35 (16 + 19) patients by using blocks of the radial, ulnar and median nerves in the elbow region (Group 1), or the haematoma block method (Group 2) for the manipulation of Colles' fracture. In Group 1 vs Group 2, the reposition was painless in 44% (7/16) vs 68% (13/19), moderate pain occurred in 38% (6/16) vs 21% (4/19), and severe pain in 19% (3/16) vs 11% (2/19). At 15 minutes there was a higher degree of block, on average, at the median and ulnar nerve innervation areas in Group 1. Complete motor block at peripheral innervation regions of all three nerves was achieved in only one patient in Group 1 and in no case in Group 2. Despite this, the surgeons assessed the relaxation at the wrist satisfactory for reposition of the fracture in all but one patient (Group 2). The highest individual prilocaine plasma concentration in Group 1 was 0.68 microgram/ml at ten minutes, whereas the highest individual value in Group 2 was 0.77 microgram/ml at ten minutes. Systemic toxicity from the local anaesthetic did not occur. Bier's block or intravenous regional anesthesia is a well-proven technique that is useful in the traumatic setting to provide upper limb anesthesia in the manipulation of distal radial fractures. In this situation, the traditional injection site in the dorsum of the hand can present difficulties with subsequent plaster application and with venous access caused by swelling or pain. One hundred patients were randomly allocated into two groups of 50. The first group was injected into the dorsum of the hand and the second into the antecubital fossa, in each case on the injured side. Effectiveness of anesthesia at both the fractures site and the cuff was assessed using a visual analog scale. Results analyzed using Student's t test, showed no difference in anesthesia between the two groups. In addition, there were fewer technical problems associated with venous access and subsequent plaster application in the antecubital fossa group. Physiotherapy is considered by some authorities to be an important aspect of management in patients following distal radius fractures. There is evidence of improvement in impairment with physiotherapy; however, there is no evidence to support early return of functional activity. Traditional physiotherapy management has focussed on improving impairment; however, there are no trials with emphasis on skill acquisition via motor re-learning principles.
                Forty-one participants with conservatively managed distal radius fractures were studied in a randomised, single-blinded, prospective trial. Two treatment options were compared: exercise and advice versus activity-focussed physiotherapy with measurement periods of 6 weeks after removal of cast and follow-up at 24 weeks.
                Participants allocated to the exercise and advice group consulted a physiotherapist an average of 0.9 (SD 0.4) times, while the participants allocated to the more intensive activity-focussed group consulted with physiotherapy a mean of 4.4 (SD 2.3) times. At both 6 and 24 weeks there were no significant differences between the groups for change in impairment (as measured by grip strength, range of motion of wrist flexion and extension and pain intensity), activity limitation and participation restriction, as measured by the Patient-Rated Wrist Evaluation (PRWE). Exercise and advice given by a physiotherapist were equally as effective as activity-focussed physiotherapy in recovery both at 6 and 24 weeks.
                The results suggest that after removal of cast from fracture of distal radius, patients may routinely require no more than a single session of advice and exercise provided by a physiotherapist.
There was insufficient robust evidence from randomised trials to establish the relative effectiveness of different methods of anaesthesia, different associated physical techniques or the use of drug adjuncts in the treatment of distal radial fractures. There is, however, some indication that haematoma block provides poorer analgesia than IVRA, and can compromise reduction.
Given the many unresolved questions over the management of these fractures, we suggest an integrated programme of research, which includes consideration of anaesthesia options, is the way forward.