Skip to content
mskultrasound banner 2

Hematoma Block

Table of Contents show

Authors

Dustin Harris, MD, CAQSM
Assistant Professor of Emergency Medicine
UT Southwestern Medical Center

Summary

  • The hematoma block can provide faster and more timely analgesia in the ED for fractures when compared to procedural sedation.
  • The use of ultrasound can guide needle placement and offer more directed medication administration.
Illustration of a hematoma block.[1]Maleitzke T, Plachel F, Fleckenstein FN, Wichlas F, Tsitsilonis S. Haematoma block: a safe method for pre-surgical reduction of distal radius fractures. J Orthop Surg Res. 2020;15(1):351.
Hematoma block performed for a colles fracture. Note this is palpation guided, ultrasound was not used.
Description of an ultrasound-guided hematoma block. Note the procedure is not performed in this video.

Introduction

  • Fractures encountered in the emergency department (ED) can cause patients a great deal of pain and ED physicians have several modalities of pain relief at their disposal.
  • One option is the hematoma block which can provide analgesia without a significantly high rate of adverse events when compared to intravenous medication administration or procedural sedation.
  • The hematoma block can offer pain control with or without the need for fracture reduction by anesthetizing the periosteum nerve fibers and surrounding tissue.[2]Ross A, Catanzariti AR, Mendicino RW. The hematoma block: A simple, effective technique for closed reduction of ankle fracture dislocations. J Foot Ankle Surg. 2011;50(4):507-509.[3]McGee DL. Local and Topical Anesthesia. In: Clinical Procedures in Emergency Medicine. Elsevier; 2010:481-499.
  • By using ultrasound during the procedure, vital structures can be visualized, and the patient’s body habitus creates less of an obstacle.[4]Gottlieb M, Cosby K. Ultrasound-guided hematoma block for distal radial and ulnar fractures. J Emerg Med. 2015;48(3):310-312.
  • Multiple studies have shown that a hematoma block offers the near same amount of pain control as procedural sedation during fracture reduction.[5]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.[6]Myderrizi N, Mema B. The Hematoma Block an Effective Alternative for Fracture Reduction in Distal Radius Fractures. Med Arch. 2011;65(4):239.

Materials

  • Needle
    • 18g for drawing up medications
    • 23 – 25g for injection
  • Syringe
    • 5-10mL
  • Sterile materials
    • Chlorhexidine or Povidone-iodine
    • Sterile drape or Sterile Towels
    • Sterile gloves
    • Sterile Ultrasound Probe Cover
    • Sterile gauze bandage
  • Medications
    • Lidocaine without epinephrine 1% 5-10mL
    • Lidocaine without epinephrine 2% 5-10mL
    • Bupivacaine 0.5% 5-8mL
  • Ultrasound
    • Linear transducer (typically 5 -15 MHz)

Procedure

  • Pre-procedure
    • Obtain consent discussing risks and benefits
    • Perform time out with patient and staff. Confirm procedure, patient, and site location
    • Position the patient in a comfortable position with the affected at a position of comfort for the patient and the proceduralist
    • We recommend a pre-procedural sonographic evaluation to identify landmarks and best approach
  • Sterile Technique
    • Skin prep with antiseptic solution
    • Put on sterile gloves
    • Apply sterile draping and create a sterile field
    • Place sterile materials on sterile field or have assistant help you
    • Draw up anesthetic medication
    • Have assistant help place the ultrasound probe into the sterile cover
  • Procedure
    • Place sterile ultrasound gel onto site, locate fractured bone (interruption in cortex)[7]Gottlieb M, Cosby K. Ultrasound-guided hematoma block for distal radial and ulnar fractures. J Emerg Med. 2015;48(3):310-312.[8]Kiely PD, O’Farrell D, Riordan J, Harmon D. The use of ultrasound-guided hematoma blocks in wrist fractures. J Clin Anesth. 2009;21(7):540-542.[9]Wilson SR, Price DD, Penner E. Pain control for sternal fracture using an ultrasound-guided hematoma block. J Emerg Med. 2010;38(3):359-361.
    • Proximal to distal, insert needle, attached to anesthetic syringe, in-plane with ultrasound probe to watch needle approach fracture in real time.[10]Gottlieb M, Cosby K. Ultrasound-guided hematoma block for distal radial and ulnar fractures. J Emerg Med. 2015;48(3):310-312.
    • Aspirate small amount of hematoma to confirm location once at fracture site
    • Inject anesthetic into hematoma to provide pain relief and remove needle
On the left, sonogram of a distal radius fracture is marked ‘R’. The right image shows the needle in plane entering the fracture site.[11] Gottlieb M, Cosby K. Ultrasound-guided hematoma block for distal radial and ulnar fractures. J Emerg Med. 2015;48(3):310-312
  • Post-procedure
    • Apply sterile gauze bandage
    • Wait 5-10 minutes to perform reduction
Wrist US distal radius fracture before hematoma block
Ultrasound of distal radius fracture.[12]Kiely PD, O’Farrell D, Riordan J, Harmon D. The use of ultrasound-guided hematoma blocks in wrist fractures. J Clin Anesth. 2009;21(7):540-542.
The same distal radius fracture with needle in plane at the fracture.[13]Kiely PD, O’Farrell D, Riordan J, Harmon D. The use of ultrasound-guided hematoma blocks in wrist fractures. J Clin Anesth. 2009;21(7):540-542.

Additional Considerations

  • Troubleshooting
    • If no hematoma is aspirated, but the needle appears to be in the correct position and the anesthetic flows without difficulty, administer medication and check for pain relief in several minutes.
    • The hematoma may have organized and may not be able to be aspirated at the time of presentation.[14]McGee DL. Local and Topical Anesthesia. In: Clinical Procedures in Emergency Medicine. Elsevier; 2010:481-499.
  • Post-Procedure Care
    • Place sterile gauze or adhesive bandage on needle insertion site.
  • Risk Factors
    • Introduction of infection
    • Inadequate analgesia
    • Lidocaine toxicity
    • Transient paresthesias[15]Tseng P-T, Leu T-H, Chen Y-W, Chen Y-P. Hematoma block or procedural sedation and analgesia, which is the most effective method of anesthesia in reduction of displaced distal radius fracture? J … Continue reading
    • Lidocaine chondrotoxicity
  • Contraindications
    • Open fracture[16]McGee D. Anesthetic and Analgesic Techniques. ” Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, by James R. Roberts et al. Published online 2019:492–493.
    • Overlying cellulitis
  • Relative Contraindications
    • Bleeding disorder
    • Under 3 years of age
    • Fracture patterns in which serial exams to exclude acute compartment syndrome are required
      • Note this is not a regional nerve block but inadvertent administration of anesthetic around a nerve is possible.

Pearls & Pitfalls

  • Carefully make note of surrounding nerves and vessels when using the ultrasound to avoid regional anesthesia. 
  • You must weigh the risks and benefits of your chosen medication. For instance, lidocaine may have the fastest onset but bupivacaine last longer. 
  • Ropivacaine also was found to be the least chondrotoxic anesthetic. You could also  mix different anesthesias to decrease the risks of one alone.

References

References[+]