Hematoma Block

Published on 16/03/2015 by admin

Filed under Orthopaedics

Last modified 22/04/2025

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Chapter 2 Hematoma Block

Overview

1. A hematoma block may be performed anywhere an acute fracture is present.
2. Typically, hematoma blocks are performed in regions where selective nerve blocks or regional blocks are impractical to perform.
3. Hematoma blocks function on the principle that a fracture hematoma surrounds a fracture site.

a. The fracture hematoma acts as a fluid medium; thus injection of anesthetic into the hematoma results in diffusion of the anesthetic around the fracture site.
b. Diffusion of the anesthetic around the fracture site results in effective regional anesthesia.

Indications for use

1. Hematoma blocks are most commonly used for closed reduction of a distal radius fracture.
2. Any diaphyseal or metaphyseal fracture is amenable to a hematoma block.

Precautions

1. Hematoma blocks should not be used in patients with broken or tenuous skin overlying the fracture site.
2. Hematoma blocks typically are ineffective in open fractures.

Pearls

1. A combination of lidocaine and bupivacaine is used to provide both immediate and lasting analgesia. Use of bupivacaine is not mandatory, but fracture reductions are painful, and the use of a long-acting analgesic facilitates recovery in the postreduction period.
2. The injection site can be reasonably approximated with use of palpation and radiographs. Because the periosteum is extremely sensitive, the practice of “walking” the needle down the bone until the fracture site is reached should be avoided.
3. Most patients present for treatment several hours after the initial injury occurred and the fracture hematoma has started to organize. Thus most fracture hematomas cannot be aspirated, and typically no flashback of hematoma is seen in the syringe.
4. A hematoma block typically requires 5 to 10 minutes to become fully effective.

Equipment

1. Antiseptic: Chlorhexidine prep stick or alcohol-soaked gauze
2. Syringe: 10-mL syringe
3. Needle:

a. Large-bore, blunt-tipped, drawing-up needle
b. 1-inch, 22-gauge needle

4. Anesthetic (for a typical adult):

a. Lidocaine: 5 mL of 2%
b. Bupivacaine: 5 mL of 0.5%

5. Sterile gloves
6. 4 × 4 inch gauze

Basic technique

1. Patient positioning:

a. The extremity should be positioned on a hard surface.
b. If a distal radius fracture hematoma is being injected, the hematoma block can be performed before or after setting traction.

2. Landmarks:

a. Fracture site on radiograph
b. Area of swelling and/or deformity

3. Steps:

a. Prepare anesthetic
b. Palpate landmarks
c. Prepare skin with antiseptic solution
d. Numb skin with ethyl chloride
e. Inject anesthetic
f. Place sterile bandage over injection site (if desired)

Detailed technique

1. Prepare the anesthetic by drawing up 5 mL of lidocaine and 5 mL of bupivacaine (or age-appropriate lower dose).
2. Palpate landmarks (Figure 2-1):

a. Use the radiograph to predetermine a soft tissue landmark that can be used as a guide for the precise fracture location.
b. The deformity or a step-off may be palpable.
3. Prepare the skin with an antiseptic solution. This step may need to be performed several times if the patient’s skin is particularly soiled.
4. Numb the skin with ethyl chloride (if desired).
5. Inject the anesthetic (Figure 2-2):

a. Enter the skin directly over the fracture.
b. Aspirate the needle while advancing it to avoid intravascular placement of anesthetic. Return of very dark blood suggests that the hematoma has been reached.
c. Inject the anesthetic while being vigilant for any warning signs of intravascular injection.
6. Remove the needle and apply pressure with a gauze bandage.
7. Place a sterile bandage over the injection site if desired.
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Figure 2-1

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Figure 2-2

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