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Orthopedic injuries are commonly managed in the emergency department (ED) setting. Fractures and dislocations may require reduction for proper management. There are a variety of analgesic and sedative strategies to provide patient comfort during reduction. This narrative review evaluates hematoma block, intra-articular injection, intravenous regional analgesia (IVRA) (also known as the Bier block), and periosteal block for orthopedic analgesia in the ED setting. Analgesia is an essential component of management of orthopedic injuries, particularly when reduction is necessary. Options in the ED setting include hematoma blocks, intra-articular injections, IVRA, and periosteal blocks, which provide adequate analgesia without procedural sedation or opioid administration. When used in isolation, these analgesic techniques decrease complications from sedation and the need for other medications, such as opioids, while decreasing ED length of stay. Emergency clinicians can also use these techniques as analgesic adjuncts. However, training in these techniques is recommended prior to routine use, particularly with IVRA. Knowledge of analgesic techniques for orthopedic procedures can assist clinicians in optimizing patient care. [ABSTRACT FROM AUTHOR]

Purpose: To assess the analgesic efficacy of the circumferential periosteal block (CPB) and compare it with the conventional fracture hematoma block (HB). Methods: This study was a prospective single-center randomized controlled trial performed in a national orthopedic hospital. Fifty patients with displaced distal radius (with or without concomitant ulna) fractures requiring reduction were randomized to receive either CPB or HB prior to the reduction. Pain was sequentially measured using the visual analogue scale (VAS) across three stages; before administration of local anesthesia (baseline), during administration (injection) and during manipulation and immobilization (manipulation). Further, the effect of demographic factors on the severity of pain was analyzed in multivariate regression. Finally, complications and end outcomes were compared across both techniques. Results: Patients receiving CPB experienced significantly less pain scores during manipulation (VAS = 0.64) compared with HB (VAS = 2.44) (p = < 0.0001). There were no significant differences between groups at baseline (P = 0.55) and injection (P = 0.40) stages. Conclusion: The CPB provides a superior analgesic effect over the conventional HB with no documented complications in either technique. Level of evidence: Therapeutic Level II. [ABSTRACT FROM AUTHOR]

Isolated fractures of shaft of ulna are common. Plate fixation with anatomic reduction is thought to produce the best functional results in closed or open fractures. Surgery can be done under general and various types of regional anaesthesia. We report a case of fracture shaft of ulna treated by plating under a combination of WALANT (wide awake, local anaesthesia, no tourniquet) using tumescent anaesthesia and periosteal nerve block as a day care procedure.

Background: The peripheral nerve endings carrying pain contains opiod receptors. Blocking these receptors during haematoma block or periosteal block may provide better analgesia. Aim: Evaluation of effectiveness and safety of butorphanol as an adjuvant to lidocaine for haematoma block. Settings and Design: This is a two centre, prospective, individually randomised, two group, parallel, double-blind clinical trial. Methods: In this study, 115 American society of anaesthesiologist grade I and II adult patients scheduled for closed reduction of fractures were randomly allocated into two groups; Group A received 1% lidocaine (2 mg/kg) where as Group B received 1% lidocaine (2 mg/kg) with butorphanol (0.02 mg/kg) during haematoma block. Pain was assessed before, during and after manipulation of fracture by using visual analogue scale (VAS 0-10). Onset time of block, time for first rescue analgesic, 24 hour analgesic requirement and sedation levels were noted. Statistical Analysis: Data analysed with the unpaired t-test with Welch correction assuming unequal variances and Fisher′s exact test using Graph pad Prism 5.02 version. Results: Onset time of haematoma block was significantly less in the butorphanol group compared to the lidocaine group ( P=0.0003). The mean time for first rescue analgesic was significantly higher and total analgesic requirement was significantly lower in the butorphanol group ( P

The aim of this study was to evaluate the efficacy of a biodegradable, lidocaine-embedded, nanofibrous membrane for the sustainable analgesic release onto fragments of a segmental femoral fracture site. Membranes of three different lidocaine concentrations (10%, 30%, and 50%) were produced via an electrospinning technique. In vitro lidocaine release was assessed by high-performance liquid chromatography. A femoral segmental fracture, with intramedullary Kirschner-wire fixation and polycaprolactone stent enveloping the fracture site, was set-up in a rabbit model for in vivo assessment of post-operative recovery of activity. Eighteen rabbits were randomly assigned to three groups (six rabbits per group): group A comprised of rabbits with femoral fractures and underwent fixation; group B comprised of a comparable fracture model to that of group A with the implantation of lidocaine-loaded nanofibers; and group C, the control group, received only anesthesia. The following variables were measured: change in body weight, food and water intake before and after surgery, and total activity count post-surgery. All membranes eluted effective levels of lidocaine for more than 3 weeks post-surgery. Rabbits in group B showed faster recovery of activity post-operatively, compared with those in group A, which confirmed the pain relief efficacy of the lidocaine-embedded nanofibers. Nanofibers with sustainable lidocaine release have adequate efficacy and durability for pain relief in rabbits with segmental long bone fractures. [ABSTRACT FROM AUTHOR]

Background: The peripheral nerve endings carrying pain contains opioid receptors. Blocking these receptors during haematoma block or periosteal block may provide better analgesia. Aim: Evaluation of effectiveness and safety of butorphanol as an adjuvant to lidocaine for haematoma block. Settings and Design: This is a two centre, prospective, individually randomised, two group, parallel, double-blind clinical trial. Methods: In this study, 115 American society of anaesthesiologist grade I and II adult patients scheduled for closed reduction of fractures were randomly allocated into two groups; Group A received 1% lidocaine (2 mg/kg) where as Group B received 1% lidocaine (2 mg/kg) with butorphanol (0.02 mg/kg) during haematoma block. Pain was assessed before, during and after manipulation of fracture by using visual analogue scale (VAS 0-10). Onset time of block, time for first rescue analgesic, 24 hour analgesic requirement and sedation levels were noted. Statistical Analysis: Data analysed with the unpaired t-test with Welch correction assuming unequal variances and Fisher's exact test using Graph pad Prism 5.02 version. Results: Onset time of haematoma block was significantly less in the butorphanol group compared to the lidocaine group (P=0.0003). The mean time for first rescue analgesic was significantly higher and total analgesic requirement was significantly lower in the butorphanol group (P<0.0001). Mean VAS scores were lower and sedation scores were higher in the butorphanol group. Conclusions: Addition of butorphanol to lidocaine quickens onset of haematoma block, provides excellent post manipulation analgesia and decreases 24 hour total analgesic requirement without excessive sedation. [ABSTRACT FROM AUTHOR]

Introduction Closed reduction is an effective method of treatment for distal end radius fractures. We present a case series of patients with distal end radius fractures who underwent closed manipulative reduction using the periosteal block. We describe the technique in detail and examine its efficacy in pain lowering effect during closed reduction. Methods Nineteen patients with distal end radial and ulnar fractures were included and grouped based on the Frykman classification. The reduction was performed using a periosteal block of 10 ml of 2% lignocaine injection. The severity of pain was recorded by utilizing the visual analog scale (VAS) in five phases: 1) before injection, 2) after 15 minutes of analgesia in a resting position, 3) during minimal motion, 4) during full manipulation and reduction, and 5) post-procedure. The VAS scoring was classified as painless (VAS score of 0), mild pain (VAS score between 1-3), and painful (VAS score of 4 and above). Results The study included 19 patients [median age of 53 years (range: 18-88 years)]; there were 11 (58%) males and eight (42%) females. The mechanism of injury was a fall (n=12, 63%) or a motor vehicle accident (n=7, 37%). There was a statistically significant reduction of pain between phase one and all the other phases. Between the different fracture configurations, there was no significant difference in pain reduction. The most painful phase was expected to be phase four, ie, during full manipulation, in which four (21%) patients had a VAS score of 0, 12 (63%) patients had a VAS score between 1-3, and three (16%) patients had a VAS score of 4. Thus, 16 out of 19 patients (84%) had no or minimal pain during the most painful phase. There were no complications from the periosteal blocks. Conclusions The periosteal nerve block is an effective procedure providing satisfactory analgesia during the reduction of distal radial and ulnar fractures. It has no side effects and is free from complications associated with conventional sedation., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Wan Ali et al.)