Internet Book of Musculoskeletal Ultrasound » Hematoma Block

Hematoma Block
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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
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[+]
↑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. |
---|---|
↑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, ↑14 | McGee DL. Local and Topical Anesthesia. In: Clinical Procedures in Emergency Medicine. Elsevier; 2010:481-499. |
↑4, ↑7, ↑10 | Gottlieb M, Cosby K. Ultrasound-guided hematoma block for distal radial and ulnar fractures. J Emerg Med. 2015;48(3):310-312. |
↑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. |
↑8, ↑12, ↑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. |
↑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. |
↑11 | Gottlieb M, Cosby K. Ultrasound-guided hematoma block for distal radial and ulnar fractures. J Emerg Med. 2015;48(3):310-312 |
↑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 Orthop Surg Res. 2018;13(1). doi:10.1186/s13018-018-0772-7 |
↑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. |