Displaced distal radius fractures


A 65yo woman comes into your Emergency Department (ED) presenting with right wrist pain, swelling and deformity following a fall onto an outstretched hand (FOOSH). An x-ray reveals a dorsally angulated and displaced distal radius fracture. It is suggested this type of fracture requires reduction and cast immobilisation, so how do you make the decision on when to perform closed reduction and which anaesthetic technique is most appropriate……

So What?

Distal radius fractures are the most common fractures treated in the UK ED’s. They comprise 16% of all fractures and are particularly prevalent in the young and elderly. It is widely believed that accurate reduction to restore anatomy produces superior radiographic outcome which is essential to maximise functional outcome (BMJ, 2016). NICE advise the consideration of closed reduction in adults with dorsally displaced distal radius fractures and recommend considering Intravenous Regional Anaesthesia (IVRA) aka Bier’s Block to achieve this (NICE Guideline 38, 2016). However, it has been observed that practice varies between clinicians and the evidence upon which these clinical decisions are based is not clear (Sprot et al., 2013).

In 2003 the Cochrane Collaboration concluded there was insufficient evidence to determine the most appropriate method of conservative treatment for distal radius fractures in adults, advising further research is necessary to determine whether moderately displaced fractures should be manipulated back into position (Handoll et al., 2003). They also concluded there was insufficient evidence to establish the effectiveness of methods of anaesthesia used in this treatment, but with some indication that haematoma block provides less analgesia than IVRA, which could therefore compromise reduction (Handoll et al., 2002).

Despite this guidance there is substantial variation in clinical practice around the UK. A 2013 survey of 105 ED’s in England and Wales shows the most frequently used anaesthetic types were haematoma block (50%), conscious sedation (20%) and IVRA (17%) (Sprot et al., 2013).

A systematic review of the evidence after the Cochrane review, from 2003 to 2017 carried out by this author demonstrated:

  • If radial displacement is less than 5mm and angulation less than 15° then closed reduction is not indicated and cast immobilisation alone is sufficient in the emergency department.
  • Initial complete displacement or radial shortening of greater than 5mm has a high risk of re-displacement after reduction and should be referred for a surgical opinion.
  • There is no benefit in closed reduction of severely displaced distal radius fractures in the emergency department, these should be simply immobilised and managed surgically.
  • Leaving a fracture unreduced before surgery is not associated with any adverse events.
  • Inadequate radiological outcome parameters are unrelated to functional outcomes in older patients.
  • Teaching of closed reduction and casting techniques needs to be improved in the emergency department.
  • Haematoma block should be the treatment of choice in emergency departments for closed reduction of displaced distal radius fractures based on cost, ease of technique and safety profile.

The table below shows the costs involved in the most commonly used anaesthetic approaches in emergency departments in the UK:




HCP Needed


Time Spent


HCP Time Costs


Anaesthetic / Equipment Costs


Total Cost


Conscious Sedation


2 x Clinician

1 x Nurse


240 minutes (120 minutes with patient)










2 x Clinician 1 x Nurse


45 mins


60 Mins Observation (Nurse Only)








Haematoma Block


1 x Clinician

1 x Nurse


45 Mins







(Adapted from Nice Guideline 38, 2016)

Now What?

In the 15 years since the Cochrane reviews there remains insufficient evidence on which to base clinical decisions to manage displaced distal radius fractures in the emergency department. NICE recommendations to consider IVRA is based on older literature with the more recent literature supporting haematoma block. However, recent evidence is of low to moderate quality, being mostly retrospective cohort studies with a high risk of bias due to a lack of blinding. Randomised controlled trials are necessary to directly compare anaesthetic techniques.


Nathan Humphries





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