Pain management in wrist fractures

How do you control pain when reducing wrist fractures?

For those of us in rural settings, we frequently have patients present with broken bones. When we do, the problem is not usually “how to reduce a fracture”, but “how do we manage pain while reducing the fracture”. If you are working in a metropolitan area, you give the patient a little pain medication and send them to the Orthopedist. Well guess what, in the rural setting you are probably going to be as close to an Orthopedic Surgeon as the patient gets.

Now some of the techniques Ralph and I are going to mention might not be within your scope of practice in the state you are working in, so just because you read about it here, DOES NOT give you permission to go try it. You have to remember that I work in frontier rural Alaska and the closest orthopedist is over 300 air miles away.   Also, some of the “details and statistics” I mention come from a variety of places. If you are looking for specific data and the most recent and factual information, you need to research it yourself so you can include specific citations.

Today we are going to talk about “wrist fractures”. These fractures usually occur in two specific populations. The first is youth and result from high energy falls, the second is the elderly and result from low energy falls and are an indirect result of osteoporotic bones. In both groups, the fractures are most commonly the result of a fall onto an outstretched hand.

With any fracture, we want to identify the mechanism of injury and complete assessment of neurovascular status including motor function. ANY FRACTURE WITH NEURO OR CIRCULATORY COMPROMISE IS A TRUE EMERGENCY! These are not the focus of this discussion.

After we have established adequate circulation, motor function (remember there is a BIG difference between “I don’t want to because it hurts” and “I am trying and nothing is happening”), and neuro status, we need an x-ray.  Things that increase the severity of the injury include, but are not limited to: severe comminution, fracture-dislocation, etc.

 

Indications for Orthopedic consultation include: open fractures, fractures that cause circulatory compromise, compartment syndrome, acute neuropathy, palmarly displaced fractures (Smith’s fractures), fracture dislocations, distal radial fractures associated with styloid and scaphoid fractures, or fractures with significant displacement.

Now that we have determined that it is appropriate for us to reduce and stabilize the fracture, how do we manage pain during the reduction? If the usual populations are the young and the old, do we really want to use moderate sedation? I am not sure about you, but I would rather not, despite what Ralph says.

The method of choice for reduction pain management is a “hematoma block”. It sounds complicated, but it really isn’t. The hematoma block can be used with or without systemic pain medication. I am going to summarize the technique from several sources.  Before attempting this, verify it is within your scope of practice and find a mentor that is willing to show you the proper technique on an actual patient.

This fracture was reduced using a small amount of IV Fentanyl prior to performing a hematoma block. The patient tolerated the procedure well without sedation.

Have a great day!