A prospective trial to compare three anaesthetic techniques used for the reduction of fractures of the distal radius. A randomized trial of ultrasound-guided brachial plexus anaesthesia in upper limb surgery. Cubital nerve block vs haematoma block for the manipulation of Colles' fracture. Efficacy of vertical infraclavicular plexus block vs. modified axillary plexus block: a prospective, randomized, observer-blinded study. Ultrasound-guided infraclavicular versus supraclavicular block. Bier's block: a change of injection site. Anaesthesia for surgical correction of fractured femoral neck. A comparison of three techniques. Prospective, multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. [Postoperative course and endocrine stress reaction of geriatric patients with para-articular hip fractures. Prospective randomized study comparing spinal anesthesia and halothane intubation narcosis]. Comparison of topical anaesthesia methods for venous cannulation in adults. Brachial plexus anaesthesia in children: lateral infraclavicular vs axillary approach. A comparison of the vertical infraclavicular and axillary approaches for brachial plexus anaesthesia. Haematoma block or Bier's block for Colles' fracture reduction in the accident and emergency department--which is best? Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade. Comparison of local anaesthetic techniques in the reduction of Colles' fracture. Infraclavicular brachial plexus block versus humeral approach: comparison of anesthetic time and efficacy.
The aim of this study was to compare prospectively haematoma blocks alone and haematoma blocks with sedation with general anaesthesia for the reduction of distal radius fractures in adult patients, with respect to pain perception before, during and after manipulation using a visual analogue scale, radiological position, waiting time, procedure time and cost. Fifty-eight adult patients with closed, displaced distal radius fractures were included in the study. Pain experienced during manipulation was greatest in patients who received haematoma blocks alone compared with the other two groups. Post-manipulation pain was significantly greater in patients who received a general anaesthetic. Radiological correction was as good in those patients receiving a haematoma block with or without sedation as a general anaesthetic. The waiting and manipulation times and resource costs were greater in those receiving a general anaesthetic. There were no complications related to any of these anaesthetic methods. Patient acceptance is greater with a correctly performed haematoma block and sedation technique compared to general anesthesia. It is also more efficient with regard to time and the resources required. This is particularly important for a progressively increasing ambulatory, elderly population who require prompt, safe, effective and painless management. Ultrasound guidance allows real-time identification of relevant anatomy and needle position when performing brachial plexus regional anaesthesia. The aim of this investigation was to determine whether the use of surface ultrasound could improve the quality of brachial plexus anaesthesia for upper limb surgery. Forty patients were randomized to either conventional "landmark-based" plexus anaesthesia, or to an ultrasound-guided approach using a 13 mHz linear array transducer Both interscalene and axillary techniques were used. The use of ultrasound significantly improved the onset and completeness of sensory (P=0.011) and motor (P=0.002) block. Ultrasound guidance also significantly reduced (P=0.012) the incidence of paraesthesia during the performance of the blocks. Ultrasound guidance increases the quality of sensory and motor blockade in brachial plexus regional anaesthesia, and by reducing the incidence of paraesthesia during performance of the blocks, may confer greater safety. Blocking efficacy and acute toxicity of prilocaine (15 ml of 10 mg/ml prilocaine) was examined in 35 (16 + 19) patients by using blocks of the radial, ulnar and median nerves in the elbow region (Group 1), or the haematoma block method (Group 2) for the manipulation of Colles' fracture. In Group 1 vs Group 2, the reposition was painless in 44% (7/16) vs 68% (13/19), moderate pain occurred in 38% (6/16) vs 21% (4/19), and severe pain in 19% (3/16) vs 11% (2/19). At 15 minutes there was a higher degree of block, on average, at the median and ulnar nerve innervation areas in Group 1. Complete motor block at peripheral innervation regions of all three nerves was achieved in only one patient in Group 1 and in no case in Group 2. Despite this, the surgeons assessed the relaxation at the wrist satisfactory for reposition of the fracture in all but one patient (Group 2). The highest individual prilocaine plasma concentration in Group 1 was 0.68 microgram/ml at ten minutes, whereas the highest individual value in Group 2 was 0.77 microgram/ml at ten minutes. Systemic toxicity from the local anaesthetic did not occur. Despite containing severe risks, infraclavicular approaches to the brachial plexus gained increasing popularity. Likewise, the vertical infraclavicular plexus block improved anesthesia compared to the standard axillary approach but contains the risk of pneumothorax. Therefore we modified the standard axillary technique by inserting a proximal directed catheter, referred to as a high axillary plexus block. We prospectively compared quality and onset of neural blockade after vertical infraclavicular plexus block (VIP) and high axillary plexus block (HAP) in two randomized groups (30 patients in each).
                In group VIP the insulated needle was inserted midway between the ventral process of the acromion and the jugular notch. In group HAP, first an axillary needle was placed. Through this a stimulating catheter was inserted in a proximal direction (10-15 cm); correct placement was confirmed by nerve stimulation. All patients received 40 ml ropivacaine 0.75% (300 mg). Discriminating between analgesia and anesthesia, a blinded observer assessed progression of neural blockade every 5 min for 60 min by pin prick. Incomplete blocks were supplemented 60 min after initial injection.
                All patients in both groups demonstrated sufficient surgical anesthesia. No patient needed systemic supplementation or general anesthesia. However, vertical infraclavicular plexus block indicated superior anesthesia compared to high axillary plexus block, regarding musculocutaneous, axillary and radial nerve, which were completely blocked with a higher success rate and in a shorter time interval (P < 0.05).
                While both techniques provide sufficient surgical anesthesia, vertical infraclavicular plexus block demonstrated a partially higher success rate and a faster onset than high axillary plexus block. In this prospective study we compared ultrasound-guided (USG) infraclavicular and supraclavicular blocks for performance time and quality of block. We hypothesized that the infraclavicular approach would result in shorter performance times with a quality of block similar to that of the supraclavicular approach. Eighty patients were randomized into two equal groups: Group I (infraclavicular) and Group S (supraclavicular). All blocks were performed using ultrasound visualization with a 7.5-MHz linear probe and neurostimulation. The anesthetic mixture consisted of 0.5 mL/kg of bupivacaine 0.5% and lidocaine hydrocarbonate 2% (1:3 vol.) with epinephrine 1:200,000. Sensory block, motor block, and supplementation rates were evaluated for the musculocutaneous, median, radial, and ulnar nerves. Surgical anesthesia without supplementation was achieved in 80% of patients in group I compared with 87% in Group S (P = 0.39). Supplementation rates were significantly different only for the radial territory: 18% in Group I versus 0% in group S (P = 0.006). Block performance times were not different between groups (4.0 min in Group I versus 4.65 min in Group S; P = 0.43). Technique-related pain scores were not different between groups (I: 2.0; S: 2.0; P = 1.00). We conclude that USG infraclavicular block is at least as rapidly executed as USG supraclavicular block and produces a similar degree of surgical anesthesia without supplementation. Bier's block or intravenous regional anesthesia is a well-proven technique that is useful in the traumatic setting to provide upper limb anesthesia in the manipulation of distal radial fractures. In this situation, the traditional injection site in the dorsum of the hand can present difficulties with subsequent plaster application and with venous access caused by swelling or pain. One hundred patients were randomly allocated into two groups of 50. The first group was injected into the dorsum of the hand and the second into the antecubital fossa, in each case on the injured side. Effectiveness of anesthesia at both the fractures site and the cuff was assessed using a visual analog scale. Results analyzed using Student's t test, showed no difference in anesthesia between the two groups. In addition, there were fewer technical problems associated with venous access and subsequent plaster application in the antecubital fossa group. Sixty patients with fractured neck of femur and scheduled for surgical correction were randomly allocated to receive one of three anaesthetic techniques: general anaesthesia; spinal analgesia; psoas compartment block. The patients in the local anaesthetic groups also received a light general anaesthetic. There was little difference in the pre-, intra- and postoperative events, and no difference in postoperative mortality. In a prospective randomized multi-centre study, the mortality following internal fixation surgery for fracture of the upper femur was investigated in 538 elderly patients allocated to receive subarachnoid blockade or general (narcotic-relaxant) anaesthesia. The 28-day mortality was 6.6% with subarachnoid, and 5.9% with general, anaesthesia. The difference was not significant (95% confidence limits: -3.5 to +4.8). At 1 year following surgery, the mortality was 20.4%. Increasing age, ischaemic heart disease, cardiac failure, preoperative arrhythmias and poor ASA status were all associated with increases in early and long term mortality. A delay to surgery of more than 24 h from admission was also associated with an increased 28-day mortality. Senile dementia and admission other than from the patient's own home, were factors associated with a poorer long term outcome. From the point of view of mortality, subarachnoid anaesthesia did not appear to confer any advantages over general anaesthesia in non-prosthetic surgery for hip fracture in the elderly. During a period of one year, all patients above the age of 60 with surgical repair of fractured neck of femur were investigated in a prospectively randomized design. A follow-up study included a total number of 56 patients, 32 were allocated to halothane anaesthesia with intubation, 24 received spinal anaesthesia. In addition, 15 patients of the halothane group and 17 patients with spinal anaesthesia were investigated with regard to endocrine stress response. Total mortality was 12.5%, and different anaesthetic management had no influence on the postoperative course. During the operation, adrenaline and ADH increased in both groups. This increase was attenuated by spinal anaesthesia. Noradrenaline was markedly increased even before the operation, and concentrations increased in the halothane group in the course of the operation. There was a linear correlation to time between accident and the beginning of the operation. With regard to endocrine parameters, prompt surgical treatment is beneficial. A prospective, randomized clinical trial was performed in order to assess the efficacy and side-effects of commonly used topical anaesthesia methods in adults receiving peripheral venous cannulation. The study was double-blinded to the degree that the methodologies allowed. One hundred and fifty healthy adults undergoing elective surgery were allocated at random to five groups: EMLA cream, ethyl chloride spray, intracutaneous infiltration with 2% lidocaine, placebo cream and no treatment. Venipuncture was performed with a 18G cannula on the dorsal side of the hand. Puncture pain and pain caused by the topical treatment itself were measured using a visual analogue scale (VAS, range: 0-100 mm). Haemodynamic response, difficulties in performing the puncture and side-effects were recorded. All analgesic techniques were well tolerated. Haemodynamic response and degree of puncture difficulty showed no differences among the groups. Puncture pain (median mrnVAS) following infiltration (1.0) and EMLA (10.0) was significantly lower than no treatment (30.0) or placebo (30.0). The benefit of local infiltration was altered by injection pain (11.5). Spray did not significantly lower puncture pain (26.5) and, in addition, was associated with discomfort (10.5). In adults, EMLA cream significantly reduces puncture pain and represents an acceptable alternate method for topical anaesthesia in venous cannulation. Local lidocaine infiltration is impaired by applicational pain, whereas spraying the puncture site with ethyl chloride has no analgesic benefit. Brachial plexus blockade is a well-established technique in upper-limb surgery. In paediatric patients, the axillary route is usually preferred to infraclavicular approaches because of safety considerations. Recent reports on a lateral infraclavicular approach offering greater safety in adults prompted us to perform a prospective randomized study to assess the analgesic efficacy of axillary vs lateral vertical infraclavicular brachial plexus (LVIBP) blocks in paediatric trauma surgery.
                Forty paediatric trauma patients (ASA physical status I and II, age range 1-10 years) scheduled for forearm or hand surgery were randomly assigned to either axillary brachial plexus (ABP group) or LVIBP group blocks using 0.5 ml.kg(-1) ropivacaine 0.5%. Sensory blockade was evaluated by a visual analogue score and Vester-Andersen's criteria, the distribution of sensory and motor blockade was evaluated by a simplified pinprick test and motor tests.
                In the LVIBP group, Vester-Andersen's criteria were met by 100% of children, compared with 80% in the ABP group (P=0.035). Based on all assessable children, sensory blockade in the primary sensory regions of various nerves was significantly more effective in the LVIBP group (axillary: P < 0.0001; musculocutaneous: P=0.002; medial brachial cutaneous; P=0.008). Motor blockade was also significantly more effective (axillary: P < 0.0001; musculocutaneous: P=0.003). No major complications were observed in either group.
                We conclude that LVIBP blocks can be safely performed in children and that they add to the spectrum of sensory and motor blockade seen with the axillary approach. This prospective, randomized study compared the efficacy of the vertical infraclavicular and axillary approaches using a single injection blockade of the brachial plexus. The primary endpoint was complete blockade in dermatomes C5-Th1, while secondary endpoints included onset time, motor block, block performance time, surgical success rate, patient satisfaction, and side-effects/complications.
                Sixty patients, American Society of Anesthesiologists physical status I or II, scheduled for surgery of the forearm or hand received either a vertical infraclavicular (n = 30) or an axillary block (n = 30). A single injection of 0.5 ml/kg ropivacaine 7.5 mg/ml was made after electrolocalization of nerve fibres corresponding to the median nerve at maximum 0.5 mA (2 Hz, 0.1 ms). Onset and distribution of analgesia and motor block were assessed at 5, 10, 15, 20, 30 and 60 min after the local anaesthetic injection. A complete block was defined as analgesia in all dermatomes (C5-Th1) at 60 min post-injection.
                The vertical infraclavicular approach provided complete blockade in 29 patients (97%) and the axillary approach in 23 patients (77%). Analgesia in C5-C6 dermatomes and corresponding motor block occurred significantly more frequently in the vertical infraclavicular approach, which also had the shortest onset time. Block procedure was quicker in the axillary approach. Side-effects were similar in both groups, and there were no permanent sequelae. Patient satisfaction was equally high in both groups.
                The vertical infraclavicular approach provides a more complete block than the axillary approach when using a single injection technique and equal volumes/doses of local anaesthetic. To offer clear guidance on the anaesthetic management of Colles' fractures in the accident and emergency (A&E) department in the light of the conflict between existing reports and current trends, and to address the issue of alkalinisation of haematoma blocks.
                This was a two centre, prospective, randomised clinical trial with consecutive recruitment of adult patients with Colles' fractures requiring manipulation to receive either Bier's block or haematoma block. There was subsequent blinded randomisation to alkalinised or non-alkalinised haematoma block.
                72 patients were recruited into the Bier's block group, and 70 into the haematoma block group. Bier's block was less painful to give than the haematoma block (median pain score 2.8 v 5.3; P < 0.001), and fracture manipulation was also less painful in the Bier's block group (median pain score 1.5 v 3.0; P < 0.01). There was no significant difference in overall A&E transit time between the two groups. There was better initial radiological outcome in terms of dorsal angulation in the Bier's block group (-3.6 degrees v 2.1 degrees; P = 0.003). More remanipulations were required in the haematoma block group (17/70 v 4/72; P = 0.003). There was a trend towards decreased pain on administration of the alkalinised haematoma block when compared with non-alkalinised haematoma block, but this did not reach significance. There was no difference in pain score on fracture manipulation. There were no complications in either group.
                Bier's block is superior to haematoma block in terms of efficacy, radiological result, and remanipulation rate; transit times are equal, both procedures are practical in the A&E environment, and there were no complications. Bier's block is the anaesthetic management of choice for Colles' fractures requiring manipulation within the A&E department. The use of ultrasonography in regional anesthetic blocks has rapidly evolved over the past few years. It has been speculated that ultrasound guidance might increase success rates and reduce complications. The aim of our study is to compare the success rate and quality of interscalene brachial plexus blocks performed either with direct ultrasound visualization or with the aid of nerve stimulation to guide needle placement.
                A total of 160 patients (American Society of Anesthesiologists physical status classification I-III) scheduled for trauma-related upper arm surgery were included in this randomized study and grouped according to the guidance method used to deliver 20 mL of ropivacaine 0.75% for interscalene brachial plexus blockade. In the ultrasound group (n = 80), the brachial plexus was visualized with a linear 5 to 10 MHz probe and the spread of the local anesthetic was assessed. In the nerve stimulation group (n = 80), the roots of the brachial plexus were located using a nerve stimulator (0.5 mA, 2 Hz, and 0.1 millisecond bandwidth). The postblock neurologic assessment was performed by a blinded investigator.
                Sensory and motor blockade parameters were recorded at different points of time. Surgical anesthesia was achieved in 99% of patients in the ultrasound vs 91% of patients in the nerve stimulation group (P < .01). Sensory, motor, and extent of blockade was significantly better in the ultrasound group when compared with the nerve stimulation group.
                The use of ultrasound to guide needle placement and monitor the spread of local anesthetic improves the success rate of interscalene brachial plexus block. A trial comparing the use of Bier's block and the direct infiltration of the fracture site with local anaesthetic was carried out to assess their effectiveness in the reduction of Colles' fracture. This showed Bier's block to be superior in terms of patient acceptability and in ease of reduction. The results of the reduction were also significantly better using the Bier's block, as judged by the measurement of the residual displacement on the X-ray. Most upper arm regional anesthesia techniques are successful and differences in efficacy should not dictate the choice of technique. In the present study, we compared humeral block (HB) and infraclavicular brachial plexus block (ICB) using anesthetic time (i.e., duration of the procedure + onset time) as the primary outcome measure. The block was successful when a complete sensory block was obtained in the four major nerves of the arm, and the time to complete block was recorded. Patients undergoing orthopedic surgery of the upper limb were included in a prospective randomized study and received ICB (group I, n = 60 patients) or HB (group H, n = 60 patients). Total anesthetic time was 19.5 min (95% confidence interval [CI], 17.4-21.6 min) for ICB and 20.8 min (95% CI, 18.7--22.9 min) for HB (not significant). Time to perform the block was 4.5 min (95% CI, 4-5 min) for ICB and 9.8 min (95% CI, 8.9--10.7 min) for HB (P < 0.05). The onset time was 15 min (95% CI, 13-17 min) for ICB and 11 min (95% CI, 9--13 min) for HB (P < 0.05). The success rate was 92% for ICB and 95% for HB (not significant). One self-limited vascular puncture was made in each group. HB had a faster onset time but ICB using a double-stimulation technique was faster to perform. Anesthetic time was similar with the two techniques.
                We have compared infraclavicular brachial plexus block (ICB) with humeral block. Efficacy and anesthetic time were not significantly different, although time to perform the block was shorter with the ICB.
There was insufficient robust evidence from randomised trials to establish the relative effectiveness of different methods of anaesthesia, different associated physical techniques or the use of drug adjuncts in the treatment of distal radial fractures. There is, however, some indication that haematoma block provides poorer analgesia than IVRA, and can compromise reduction.
Given the many unresolved questions over the management of these fractures, we suggest an integrated programme of research, which includes consideration of anaesthesia options, is the way forward.