Dr Conor McDermott
Dr David McCreary
A 70-year-old, normally fit and well lady presents to the ED following a fall in her garden. It was a simple trip over uneven paving, she fully recalls the event and aside from a painful left wrist, you don’t find any other signs of injury. You prescribe her some simple analgesia and request an X-ray.
What does the X-ray show?
There are AP and lateral views of the left wrist. These show a displaced left distal radial fracture with dorsal and lateral displacement with associated dislocation of the ulnocarpal joint.
The most relevant question for an ED patient with a fracture of the distal radius is does it actually need a reduction?
Indications For Reduction
These are dependent on the patient: a 10-year-old is not the same as a 30-year-old is not the same as a 90-year-old.
- Indication for reduction changes with age
- Younger children will remodel more and can accept greater degrees of deformity without jumping in for a reduction
- Angulations over 20 degrees in the 0-5 group need reduced and this acceptable angulation decreases by 5 degrees in subsequent age groups
(Image courtesy of the RCH Clinical Guidelines)
Named for the position of the distal fracture segment relative to the bone looking like this nasty piece of equipment:
It looks as if it shouldn’t be allowed but in younger children it’s acceptable to leave the fracture in a bayonet position that will remodel and grow to length.
Acceptable if <6 years old with acceptable angulation and <1cm overlap
- Based off 3 measurements (remember 11, 11, 22)
- Radial inclination – normal 22°
- Radial height (shortening) – normal 11mm
- Volar angulation – normal 11°
(Images courtesy of the OrthoFlow App, with permission)
🤓 Editor’s Comment: while there are quoted acceptable deviations from normal, any deviation from 11, 11, 22 is probably worthy of a pull (if for no other reason than it’s easy to remember).
These quoted criteria (all the 5s: 5mm shortening, <5o change in inclination & <5o change in angulation) are really for the final resting position of the fracture. Taking into account that it is likely to slip a little post your reduction, you may as well give it the best numbers from the outset.
Next question is how are we going to do it?
Patients will need either local or systemic analgesia and/or anaesthetic.
The choice of which is again down to the patient, as well as your abilities and the department work-load.
Below is a quick overview of the different options with the pitfalls of each.
The choice of which sedation depends on the patient, the fracture and the resources however the details of each should be the subject of a blog themselves. The main choices are:
- Nitrous oxide +/- fentanyl
- Propofol & fentanyl
- Great overview here RCEM guidelines
- Or here RCH guidelines
- Useful for compliant children and adults and especially useful for those you can’t sedate.
- Not useful in patients who are severely anxious or unable to tolerate the cuff.
- Other contraindications include: SBP > 200mmhg, PVD, bilateral fractures, morbid obesity as well as in rarer conditions such as Raynaud’s, scleroderma, sickle cell, methhaemoglobinaemia.
- Prilocaine (preferred): 0.6mls/kg of 5% (3mg/kg)
- Lignocaine: 0.6mls/kg of 5% (3mg/kg)
🤓 Ed: The question I ask everyone when teaching Bier’s block is – why do we have two cuffs? No, it’s not just because we’re so scared that one of the cuffs will fail…have a think then click for the answer…
To have the option of cuff rotation! Tourniquets can be pretty painful, particularly after the 20-25 minute mark, and some patients will find it worse than others. An option is to:
- inflate the proximal (A) cuff first, leaving the distal (B) cuff deflated
- inject the LA
- once LA is working, inflate the distal (B) cuff
- if patient experiences a lot of pain from the inflated cuff, the proximal (A) cuff can be deflated – leaving the (B) cuff inflated over anaesthetised limb
- in the unlikely event of anaesthetic leak you still have the option of inflating the (A) cuff as a backup
(Image courtesy of RCEM Best Practice Guideline)
- An overview – WikiEM
- Good for patients you can’t sedate, with relatively fresh fractures and who you can’t use a bier’s and if there are limited staffing resources, however some old evidence here showing that better analgesia gained by Bier’s.
- If you’re an ultrasound whizz this can be used to ensure you’re going in the right spot (the right spot being below the periosteum and into the fracture haematoma)
- Make sure you leave enough time for the anaesthetic to work, 5-10mins
- Patient’s may have some residual pain – useful to add some fentanyl
- Doesn’t give as good a reduction as a bier’s
Ultrasound guided blocks
- The future for the Ultrasound buffs
- Different approaches are proposed, some which require single injection, others that require multiple
- The RAPTIR approach is a single injection with further explanation of the anatomy here by NYSORA
- While blocks of individual nerves further distal require 1 or more injections and are described here, here and again by NYSORA at this link
(Images courtesy of NYSORA.com)
Above: the RAPTIR approach and distribution of analgesia showing the needle entering the skin superiorly, passing posteriorly to the clavicle and then injecting local anasthetic into the axillary sheath. This method does not require identification of the nerves just identification of the artery.
You’ve decided it needs reduced, and chosen your mode of analgesia. Next question is how to effectively pull?
The fracture is likely impacted, with intact periosteum acting as a barrier to your reduction, but will also prevent over correction if you are apprehensive.
(Image courtesy of musculoskeletalkey.com)
The key to an easy reduction is focus on the dis-impaction.
- Perform prolonged traction on the distal fragment
- Then hyperextend the distal fragment
- Before flexing it back into position
- It will feel funny making the fracture worse, but this will make it easier to push back into the correct position
- When you think you’ve dis-impacted enough, keep going for an extra minute
- Make sure to manipulate the distal fracture fragment and not the carpals, the hand itself should be flopping around in a neutral position with gravity. A trick is to try identify the radial styloid and work proximal from that.
🤓 Ed: you can also feel for the ulnar styloid to get a feel for how your length and position is going by comparing relative position of the two styloids. You can also get a repeat X-Ray if you’re in doubt (and leaded-up), or use US.
- Don’t be afraid to put all your might into the flexion, the dorsal periosteum will stop you from going too far
Fitting the plaster
Now it’s time to plaster using what your department has (plaster of paris/dynacast or equivalent)
What type, again, depends on the patient:
- Minor fractures in children can be treated with a simple below-elbow backslabs
- Almost all others can be treated with a Charnley slab shown below
- If this plaster is going to be definitive management e.g. nursing home patient then reasonable to place a full POP
- These can be split along the ulnar edge once set if you are worried about swelling
- RCH also have this great resource for teaching casting
- Again, make sure to put pressure on the distal fracture fragment, and not the carpals
Check your work
Once you’re done, take a repeat X-ray in cast to check your position and celebrate when the report uses the words “near anatomical positioning”.
Hopefully with these tips you will be able to get the same result.
References / Want to read more?
- The Royal Children’s Hospital guideline for distal radial / ulna fractures
- Feeling like an ultrasound Jedi? Read about ultrasound guided supra-condylar blocks here
- The NYSORA regional anaesthesia guide for elbow blocks
- The Royal College of Emergency Medicine’s Best Practice Guideline for Bier’s Block
- RCH’s Bier’s Block guideline
- WikiEM on haematoma block
- US guided brachial plexus blocks from NYSORA
- The OrthoFlow App – iOS& Android
Emergency Registrar, Alfred Health
Conor, originally from Ireland, has been an Emergency Registrar at The Alfred since February 2021, having first started working in ED in 2015 in Brisbane as part of a planned 1 year working holiday that was extended long term. His medical interests include POCUS as well as reducing unnecessary resource waste in hospitals. Outside of work he can be found tasting wine, training for a triathlon and occasionally painting.