Anaesthetic management of forearm fractures using a combination of haematoma block and intravenous regional anaesthesia

Intravenous regional anaesthesia (IVRA) has been successfully used as a sole technique for forearm fractures and has high success rates. However, it is uncomfortable for the patient when the fresh fracture is manipulated for conduct of IVRA. Haematoma block (HB) has also been demonstrated as an effective anaesthetic technique for treatment of radial fractures in the ER. Unfortunately, HB does not provide muscular relaxation and may not be sufficient for operative intervention. An observational case series was designed with the hypothesis that a combination of HB and IVRA would overcome the aforementioned drawbacks. A standardized protocol was followed for HB with 0.1ml/kg of 0.5% bupivacaine preceding the conduct of IVRA, which permitted adequate exsanguination of the extremity (using compression bandage). For IVRA, 0.5% lignocaine at 3mg/kg was used with an electro-pneumatic tourniquet. Pain scores were noted after the HB, at exsanguination and during surgery. 100 cases were studied. Average time of onset of block after HB was 2min 18s. By the time the IVRA procedure was performed, 99% of patients had a pain score of zero. The quality of surgical anaesthesia revealed that 94% of the patients did not have any pain of incision, tourniquet or positioning at any time during surgery. The use of dual technique of HB and IVRA improved patient acceptance and compliance, and the safety and efficacy of the IVRA. The combination anaesthesia was found to be easy to administer, effective and safe with no complications.