Chapter 55. Regional Nerve Blocks for Bone Fractures

Digital Block

• • Provides analgesia in the fingers and toes for treatment of fractures, dislocations, and lacerations.

Hematoma Block

• • Analgesia for fracture reduction.

  • Most commonly used to reduce distal radius fractures or fractures of the fifth metacarpal (boxer’s fractures).

Absolute

• • Skin or soft tissue infection at or near the area to be injected.

  • Allergy to lidocaine or other agents used for regional anesthesia.

• • 5- or 10-mL syringe.

  • 18-gauge needle to draw medicine; 25–27-gauge needle to inject medicine.

  • Alcohol swabs to clean skin.

  • 1% or 2% plain lidocaine (no epinephrine) or 0.25% bupivacaine (can be combined 1:1).

• • Inadequate pain relief.

  • Allergic reaction.

• • Complete and document a neurologic examination before injecting the anesthetic.

  • Do not use epinephrine in the digits because it can result in ischemia, necrosis, and potential loss of the digit.

  • The maximum lidocaine dose is 5 mg/kg (1% lidocaine has 10 mg/mL; 2% has 20 mg/mL).

  • The maximum bupivacaine dose is 2 mg/kg.

  • A lidocaine injection provides approximately 2 hours of pain control, while a lidocaine/bupivacaine mixture (1:1) provides approximately 5–7 hours of pain relief.

• • For a digital block, pronate the patient’s hand and place it on a flat surface.

  • For the hematoma block, place the patient’s affected extremity on a flat surface.

• • There are 2 dorsal nerves and 2 palmar/plantar nerves that innervate each digit; these are the proper digital nerves and they run with the proper digital arteries on the medial/lateral aspect of the digits.

Digital Block

• • The needle is inserted 1–2 cm proximal to the webspace on 1 side of the digit (Figure 55–1).

• • It is advanced palmar/plantar to anesthetize those digital nerves.

  • Aspirate to be sure the needle is not intravascular.

  • Inject the lidocaine as the needle is slowly pulled out dorsally.

  • Repeat the procedure on the other side of the digit.

  • This is not a large area; commonly 3–5 mL total of anesthetic is sufficient.

  • Massage the area to help spread the agent.

Hematoma Block

• • Identify the fracture site and place the needle into the fracture site (dorsal approach for both distal radius and boxer’s fractures) (Figure 55–2).

• • Continue to aspirate until a flash of blood appears, redirecting the needle as necessary.

  • After the flash of blood, slowly inject the lidocaine.

• • Watch for vascular changes; vasospasm can occur but should resolve spontaneously.

  • The digit ...