Pelvic Fractures in Kuwait: A multicenter analysis

Abstract

Abstract

Purpose:

To assess the safety and analgesic efficacy of the circumferential periosteal block (CPB) and compare it with the conventional fracture hematoma block (HB).

Methods

This study was a prospective single center randomized controlled trial performed in a national orthopedic hospital. Fifty patients with displaced distal radius (with or without concomitant ulna) fractures requiring reduction were randomized to receive either CPB or HB prior to the reduction. Pain was sequentially measured using the visual analogue scale (VAS 0-10) across three stages; before administration of local anesthesia (baseline), during administration (injection) and during manipulation and immobilization (manipulation). Further, the effect of demographic factors on severity of pain were analysed in a multivariate regression. Finally complications and end-outcomes were compared across both techniques.

Results:

Patients receiving CPB experienced significantly less pain scores during manipulation (VAS = 0.64) compared with HB (VAS = 2.44) (p = < 0.0001). There were no significant differences between groups at baseline (p = 0.55) and injection (p = 0.40) stages.

Conclusion:

The CPB provides a safe and superior analgesic effect over the conventional HB.

Key words:

Distal radius fracture, hematoma block, periosteal block, analgesia, reduction, nonoperative management

Level of evidence:

Therapeutic Level II

Introduction

Introduction

Fractures of the distal radius and ulna are among the most common in orthopedic trauma [1]. They are linked with a bimodal distribution of high and low energy trauma in the younger and older population respectively [1]. Geographic and provider-dependent variability in operative versus non-operative trends exist, reflecting a lack of a clear consensus or superiority of particular treatment modalities [2, 3]. 

Initial management often entails closed reduction and manipulation followed by immobilization, which if successful, may deter further operative management. Adequate analgesia is essential during reduction, as painful manipulation may hinder patient cooperation and preclude successful reduction [4]. Thus, various anesthetic techniques have been implemented. These notably include hematoma blocks (HB), intravenous regional anesthesia (Bier’s block), brachial plexus blocks and procedural sedation (opioids and sedatives). Hematoma blocks are widely utilized due to their simplicity. However, they require the presence of a hematoma and data has demonstrated variable analgesic efficacy [5, 6, 7]. The potential for systemic complications and the resultant need for hospital admission and monitoring limits the use of procedural sedation and Bier’s blocks in accordance with capacity and resources [7].

An ideal analgesic technique should result in safe, easy, and painless fracture manipulation. In 2015, Tageldin et al described a novel circumferential periosteal block (CPB) technique for the reduction of radius and ulna fractures [8]. The study reported painless reductions with no documented complications. In this randomized controlled trial, we assess the safety and efficacy of the CPB technique compared to the conventional hematoma block. Our hypothesis is that the CPB technique provides superior pain relief with no complications.

Author details

Author details

ali.esmaeel@gmail.com

Mohammad Alherz - MB BCh BAO, MSc - Alherzm@tcd.ie

Abdullah Nouri - MB BCh BAO- Abdullahfanouri@gmail.com

Mousa Behbehani – MB BCh BAO - Dr.mousabehbehani@gmail.com

Naser Alnusif - MD FRCS.C -Naser.alnusif@mail.mcgill.com

Journal 2

Minimally-invasive

Dega

Osteotomy in ambulatory pediatric patients with resistant developmental dysplasia of the hips

– A

Technique and

Prospective Case Series

Abstract

Purpose:

This study describes a

minimally-invasive

Dega o

steotomy (

MI

D

O) for treating resistant acetabular dysplasia in ambulatory pediatri

c as well as patients with cerebral palsy

. The focus is on assessing the safety, feasibility, and

early

outcomes of this minimally invasive technique.

Methods:

A prospective series was conducted in a single tertiary orthopedic center.

The procedure involved an initial examination of hip joint stability using intraoperative arthrography. The surgical procedure involved a small transverse incision distal and lateral to the anterior superior iliac spine, followed by a Dega osteotomy and bone

allo

-

grafting. Variables

such as operative time, blood loss, incision length and acetabular index were measured.

Results:

In

healthy

ambulatory patients, 1

6

osteotomies

were performed on

1

2

patients

with an average age of

32

months. The mean incision length was 2.

3

cm, average blood loss was

17

ml, and mean operative time was

2

1

minutes

per side

. Preoperative and postoperative acetabular indices averaged

40.3

and

18.6

respectively. No complications were seen in this series

.

Conclusions:

The

MIDO

technique

is

a safe and effective method for treating resistant acetabular dysplasia in ambulatory patients. It offers advantages of minimal invasiveness, reduced operative time, and less blood loss, with outcomes comparable to conventional methods. However, further studies with larger cohorts and longer follow-up are necessary to fully establish its efficacy and safety profile.

Key Words

: Developmental Dysplasia; Pelvic osteotomy; Dega osteotomy; Hip dysplasia; Percutaneous osteotomy

Introduction

Developmental dysplasia of the hip (DDH) is a prevalent disorder, characterized by anomalies in hip joint anatomy. This encompasses a shallow acetabulum, diminished femoral coverage, and a lateralized hip center [1]. The disorder may span from inadequate acetabular coverage to complete dislocation of the femoral head. Therefore, therapeutic strategies typically align with the patient's age and the extent of anatomical abnormalities [2,3]. The overarching objective remains consistent: the attainment of a hip that is concentrically reduced within the acetabulum to prevent further dysplasia.

Various treatment algorithms have been suggested. For patients below the age of six months, interventions such as Pavlik harnesses or spica casts are preferred [4]. Conversely, for those beyond this age bracket, therapeutic strategies lean more towards surgical interventions, encompassing closed or open reductions, often accompanied by a concurrent pelvic osteotomy to correct the acetabular index [5].

The optimal timeframes for open versus closed reduction, choice of surgical techniques and the postoperative rehabilitation protocols remains controversial as they are often compounded by surgeon and institutional preferences. Nevertheless, the general outcomes in the early management of DDH are favorable. Hip arthrography is commonly utilized to evaluate the anatomic impediments to reduction. In closed reduction, it is used to ensure that concentric reduction is achieved by assessing medial dye pooling and for interposition of cartilaginous structures [6]. 

Open reduction is often performed through the anterior approach and many of its’ modifications, providing direct access to the hip capsule, and exposure to perform the pelvic osteotomy. However, it carries a risk of injury to the lateral femoral cutaneous nerve injuries [7]. In contrast, the medial approach, allows for direct access to reduction obstructions but carries a risk of damage to the obturator nerve and the medial femoral circumflex artery that may lead to femoral head avascular necrosis [8,9].

Within the broad scope of developmental dysplasia of the hip, there is variability in the severity of the dysplasia and the associated clinical manifestations. The treatment for the subset of ambulating patients who demonstrate a resistant dysplastic acetabulum yet maintain a relatively congruent hip, absent of any significant cartilaginous pathology is controversial. Recently, Canavese et al described a minimally-invasive approach to correcting acetabular dysplasia in non-ambulatory patients with severe cerebral palsy. In their series, they reported similar clinical results, less intraoperative bleeding along with a shorter operating time compared to the conventional technique [10,11]. In this study, the minimally-invasive Dega osteotomy (MIDO) technique performed in ambulatory patients with resistant acetabular dysplasia was reported. To our knowledge this is the first study present this technique in DDH patients.

Methodology

This study was designed as a prospective series performed in a single tertiary orthopedic center. Ethical approval was obtained from the institutional review board and registered in a research registry (UID: 10431). Given the pediatric nature of the patient population, informed consent was secured from parents or legal guardians prior to inclusion in the study.

Patients were consecutively recruited based on the presence of acetabular dysplasia, however, the final decision for operation was confirmed intraoperatively after arthrography. Participants were recruited if the following criteria were met; at least 2 years old, acetabular dysplasia with an index of at least 35 degrees, patients have been ambulating for a minimum of 1 year and no improvement seen on subsequent radiographs, patients have been followed up for at least 1 year with no evidence of improvement.

Patients with hip dislocation, medial pooling of the dye and cartilaginous pathology necessitating open reduction were excluded. Patients were evaluated according to their sex, age, side of dysplasia, preoperative and postoperative acetabular index, operative time, incision length and blood loss.

Surgical technique

The patient was placed supine on a translucent operative table with a gel pad under the ipsilateral flank. After draping, an arthrogram was performed through a sub-adductor approach using a spinal needle to inject approximately 2ml of a 50:50 solution consisting of radio-opaque dye diluted with normal saline. An examination was subsequently performed to assess the hip joint's stability. This was performed using fluoroscopy for the push, pull (telescoping test), abduction, adduction, salter and rotational views. (Figure 1). The medial dye pooling was assessed and should be less than 2 mm to represent hip stability and exclude capsular redundancy.

Landmarks included the groin skin crease (bikini line), the anterior superior iliac spine (ASIS), the bony iliac crest, and the medial inguinal lymph node. A 2 cm transverse skin incision was made, situated laterally from a point 1 cm distal to the ASIS and 1 cm lateral (Figure 2). After skin incision, deep dissection is continued until the muscle fascia. Metzenbaum scissors are utilized to create a small opening through the abductor muscle, dividing the muscle bluntly along its fibers until the acetabular edge is reached (Figure 3). This is followed by using a long-curved artery to dissect around the anterior aspect of the iliac crest down to the sciatic notch.

A periosteal elevator is used to prepare the planned osteotomy site. A Dega osteotomy is performed by using a straight 6 mm osteotome initiates the osteotomy on the lateral surface of the supra-acetabular roof (Figure 4). The osteotomy tracks anteriorly to the iliac crest and stops posteriorly, hinging just before reaching the sciatic notch. Curved osteotomes are then placed in sequentially increasing sizes to spread open the osteotomy.

Curved osteotomes follow, guiding the osteotomy to the triradiate cartilage. Upon osteotomy completion, two large curved osteotomes gradually spread the osteotomy site, followed by a laminar spreader to hold it open (Figure 4). Next, a synthetic allograft is measured, cut into a wedge, then slid into the incision and finally impacted into the osteotomy site. Fluoroscopy is used to confirm correction of the dysplasia and sizing of the graft. The wound is then irrigated, and closure is performed in layers.

Postoperatively, a fiberglass hip spica cast was applied for approximately 6 weeks, to allow time for bone healing. Afterwards, all patients were allowed full weight bearing and unlimited range of motion after removal of the spica cast. Follow up radiographs are obtained (Figure 5.)

Results

The patient characteristics and patient outcomes are summarized in Table 1

. A total of

1

6

osteotomies were performed on 1

2

patients with an average age of

32

months. The mean incision length was 2.

3

cm, average blood loss was

17

ml, and mean operative time was 2

1

minutes

per hip

. Preoperative and postoperative acetabular indices averaged

40.3

and 18.

6

degrees respectively.

There were no documented complications in any of the included cases.

Three

patient

s

required

an adductor release

in the non-CP group

.

All patients mobilized

subsequently

without difficulty

after the period of immobilization.

The minimum

follow-

up for the included patients was

6 months.

Discussion

Developmental dysplasia of the hip remains a challenging condition with diverse therapeutic

approaches

tailored to

the patient and the extent of dysplasia

.

V

arious surgical techniques have been

used

to address the anatomical

abnormalities

associated with DDH.

Recently, there has been a rise in the utility of minimally invasive techniques, however, these techniques are still uncommonly used

.

Further, t

he

minimally invasive

osteotomy

initially described by Canavese et al

has

only been performed

in

non-ambulatory

patients with cerebral palsy

. Translating this technique for utilization in ambulatory patients with dysplastic hips

is a potential

direction for select patients.

Especially when reasonable conservative attempts with monitoring shows progression of the dysplasia.

Nevertheless,

it

is important to stress that a concentrically reduced hip is

required

for this technique to yield favorable results

, this is confirmed by an intraoperative arthrogram.

There is ongoing controversy regarding the optimal approach to managing these patients, with potential geographic variation in treatment strategies across different institutions. While some advocate for long-term observation, increasing evidence suggests that residual dysplasia carries a significant risk of early degenerative joint disease

. Therefore, addressing dysplasia may play a crucial role in long-term hip preservation. Predicting which cases of dysplasia will resolve spontaneously is challenging and often unpredictable

. Additionally, correcting dysplasia at a younger age is typically a simpler procedure compared to interventions performed in older children.

Further

, early correction of dysplasia with pelvic osteotomies potentially limits or reverses dysplastic changes in the acetabulum

.

In their multi-center study, Li et al. emphasized the importance of the acetabular index in predicting outcomes. In their multicenter study, they identified an acetabular index of 28 degrees at one-year post-closed reduction and 25 degrees at two years as critical thresholds for surgical intervention, citing poor outcomes beyond these values. They concluded that the acetabular index is the most reliable predictor of late residual dysplasia

.

The inherent advantages of this

minimally invasive

technique include a less invasive approach, reduced tissue dissection, and a smaller incision, which may reduce surgical morbidity and expedite patient recovery. Additionally, the

utilized approach is

distant from high-risk anatomical

structures such as the lateral femoral cutaneous nerve,

potentially reducing

complications related to nerve injuries.

Although

conventional techniques are currently the gold standard and are warranted when open reduction is required

,

w

e

believe

that open reduction may not be necessary in patients with a dysplastic hip alone and a simple

pelvic

osteotomy

should

suffice

in addressing the abnormality

. As such, the technique serves to reduce the trauma and potential complications of open approaches.

The adequacy of the acetabular index correction was consistent with conventional approaches

, suggesting that the percutaneous technique does not jeopardize the accuracy of the osteotomy

.

Further, incisions were small and may be cosmetically more appealing to both surgeon and patients

This study is limited by the relatively small sample size of patients included that reflect selective recruitment. In addition to a short follow-up period that focuses on early outcomes and feasibility of the technique. However, o

ur initial observations in a short series of ambulatory patients with dysplastic hips

show the

potential utility for this technique in this specific population. Nevertheless, it is essential to approach these preliminary findings with caution. While promising, these results require validation from larger cohorts and extended follow-up periods to more robustly

investigate

the long-term

effects

and safety profile of this procedure.

Conclusion

The

modified

minimally-invasive

Dega

osteotomy is an effective procedure for select

ambulatory

patients with

resistant acetabular

dysplas

ia

. The technique has a short learning curve

and yields

favourable

outcomes in ambulatory patients.

The technique is safe and is associated with a small incision and short operative times.

Declarations

Consent

Written informed consent was obtained from the patient’s family for publication of this case series and accompanying images A copy of the written consent is available for review by the Editor-in-Chief of this journal on request

Funding

No funding was received.

Conflicts of interest

The authors declare no conflict of interests in any regard.

Table Legend

Table 1 – Demographics, characteristics and operative details of the included cases.

VDRO; Varus

derotation

osteotomy, SEMLS; Single event multilevel surgery.

Figure Legend:

Figure 1. – Intraoperative hip arthrogram assessing hip stability. A) Injection of dye, B) Salter view, C) Push view, D) Pull view, E) Abduction view and F) Adduction view.

Figure 2. – Photographs of the initial approach. A) Skin marking with iliac crest proximally, anterior thigh fold distally, anterior superior iliac spine (ASIS) marked by a circle. The incision is marked 1cm distal and lateral to the ASIS. B) Blunt dissection through superficial layers.

Figure 3. – Intraoperative photographs. A) two osteotomes being used to keep the osteotomy open, B) A laminar spreader holding the osteotomy open while a wedge-shaped graft is inserted.

Figure 4. – Intraoperative fluoroscopy. A) Identification of the level of the incision and osteotomy site. B) After blunt dissection, the osteotomy site is confirmed by image. C) A curved osteotome is used to create the osteotomy hinging just before the sciatic notch. D) Another osteotome is introduced to correct the coverage. E) A laminar spreader is used to maintain the position of the osteotomy. F) Image taken after the wedge-shaped bone graft is inserted.

Figure 5. –Radiograph showing preoperative right-sided acetabular dysplasia of 33 degrees (Image on left). Radiograph showing right postoperative acetabular index of 18 degrees (Image on right side).

References

1. Harsanyi S, Zamborsky R, Krajciova L, Kokavec M, Danisovic L. Developmental Dysplasia of the Hip: A Review of Etiopathogenesis, Risk Factors, and Genetic Aspects. Medicina (B Aires). 2020;56:153.
2. Lucchesi G, Sacco R, Zhou W, Li Y, Li L, Canavese F. DDH in the Walking Age: Review of Patients with Long-Term Follow-Up. Indian J Orthop. 2021;55:1503–14.
3. Ashoor M, Abdulla N, Elgabaly EA, Aldlyami E, Alshryda S. Evidence based treatment for developmental dysplasia of the hip in children under 6 months of age. Systematic review and exploratory analysis. The Surgeon. 2021;19:77–86.
4. Sankar WN, Gornitzky AL, Clarke NMP, Herrera-Soto JA, Kelley SP, Matheney T, et al. Closed Reduction for Developmental Dysplasia of the Hip: Early-term Results From a Prospective, Multicenter Cohort. Journal of Pediatric Orthopaedics. 2019;39:111–8.
5. Cummings JL, Oladeji AK, Rosenfeld S, Johnson M, Goldstein R, Georgopoulos G, et al. Outcomes of Open Reduction in Children With Developmental Hip Dislocation: A Multicenter Experience Over a Decade. Journal of Pediatric Orthopaedics. 2023;43:e405–10.
6. Zhang Z, Fu Z, Yang J, Wang K, Xie L, Deng S, et al. Intraoperative Arthrogram Predicts Residual Dysplasia after Successful Closed Reduction of DDH. Orthop Surg. 2016;8:338–44.
7. Murphy RF, Kim Y-J. Surgical Management of Pediatric Developmental Dysplasia of the Hip. Journal of the American Academy of Orthopaedic Surgeons. 2016;24:615–24.
8. Pollet V, Van Dijk L, Reijman M, Castelein RMC, Sakkers RJB. Long-term outcomes following the medial approach for open reduction of the hip in children with developmental dysplasia. Bone Joint J. 2018;100-B:822–7.
9. Konigsberg DE, Karol LA, Colby S, O’Brien S. Results of medial open reduction of the hip in infants with developmental dislocation of the hip. J Pediatr Orthop. 2003;23:1–9.
10. Canavese F, Marengo L, de Coulon G. Results and complications of percutaneous pelvic osteotomy and intertrochanteric varus shortening osteotomy in 54 consecutively operated GMFCS level IV and V cerebral palsy patients. European Journal of Orthopaedic Surgery & Traumatology. 2017;27:513–9.
11. Canavese F. Percutaneous pelvic osteotomy in cerebral palsy patients: Surgical technique and indications. World J Orthop. 2013;4:279.
12. Jia G, Wang E, Lian P, Liu T, Zhao S, Zhao Q. Anterior approach with mini-bikini incision in open reduction in infants with developmental dysplasia of the hip. J Orthop Surg Res. 2020;15:180.
13. Hu X, Tan Q, Mei H, Mo S, Liu K. Research on anterior minimally invasive approach in the treatment of children with developmental dysplasia of the hip. BMC Musculoskelet Disord. 2023;24:482.
14. Wyatt MC, Beck M. The management of the painful borderline dysplastic hip. J Hip Preserv Surg. 2018;5:105–12.
15. Garcia S, Demetri L, Starcevich A, Gatto A, Swarup I. Developmental Dysplasia of the Hip: Controversies in Management. Curr Rev Musculoskelet Med. 2022;15:272–82.
16. Ashoor M, Abdulla N, Elgabaly EA, Aldlyami E, Alshryda S. Evidence based treatment for developmental dysplasia of the hip in children under 6 months of age. Systematic review and exploratory analysis. The Surgeon. 2021;19:77–86.
17. Lucchesi G, Sacco R, Zhou W, Li Y, Li L, Canavese F. DDH in the Walking Age: Review of Patients with Long-Term Follow-Up. Indian J Orthop. 2021;55:1503–14.
18. Hosny G, Fattah H. Salter’s innominate osteotomy: the biologic stimulating effect. J Pediatr Orthop B . 1998;7:150–3.
19. Li Y, Guo Y, Li M, Zhou Q, Liu Y, Chen W, et al. Acetabular index is the best predictor of late residual acetabular dysplasia after closed reduction in developmental dysplasia of the hip. Int Orthop. 2018;42:631–40.
20. Zein A, Khalifa AA, Elsherif ME, Elbarbary H, Badaway MY. Are the outcomes of single-stage open reduction and Dega osteotomy the same when treating DDH in patients younger than 8 years old? A prospective cohort study. Journal of Orthopaedics and Traumatology. 2023;24:43.
21. Lari A, Alherz M, Hussain S, Burhamah W, Alabbad F, Jarragh A, et al. The Importance of Scar Cosmesis across the Surgical Specialties: Factors, Perceptions, and Predispositions. Plast Reconstr Surg Glob Open [Internet]. 2022;10:e4219. Available from: https://journals.lww.com/10.1097/GOX.0000000000004219

References

1. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 2001;26(5):908–15
2. Lichtman DM, Bindra RR, Boyer MI, Putnam MD, Ring D, Slutsky DJ, Taras JS, Watters WC 3rd, Goldberg MJ, Keith M, Turkelson CM, Wies JL, Haralson RH 3rd, Boyer KM, Hitchcock K, Raymond L. Treatment of distal radius fractures. J Am Acad Orthop Surg. 2010 Mar;18(3):180-9. doi: 10.5435/00124635-201003000-00007. PMID: 20190108.
3. Chung KC, Shauver MJ, Yin H, Kim HM, Baser O, Birkmeyer JD. Variations in the use of internal fixation for distal radial fracture in the United States medicare population. J Bone Joint Surg Am. 2011 Dec 7;93(23):2154-62. doi: 10.2106/JBJS.J.012802. PMID: 22159850; PMCID: PMC3226419.
4. Kendall JM, Allen P, Younge P, Meek SM, McCabe SE. Haematoma block or Bier&#039;s block for Colles&#039; fracture reduction in the accident and emergency department–which is best? J Accid Emerg Med. 1997;14(6):352–356.
5. Handoll HH, Madhok R, Dodds C. Anaesthesia for treating distal radial fracture in adults. Cochrane Database Syst Rev 2002; 3: CD003320
6. Tageldin, M.E., Alrashid, M., Khoriati, AA. et al. Periosteal nerve blocks for distal radius and ulna fracture manipulation—the technique and early results. J Orthop Surg Res 10, 134 (2015). https://doi.org/10.1186/s13018-015-0277-6
7. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection. Plast Reconstr Surg. 2013 Sep;132(3):675-684. doi: 10.1097/PRS.0b013e31829ad1e2. PMID: 23985640.
8. Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin. 2012;28(2):113-125. doi:10.1016/j.hcl.2012.02.001
9. Fathi M, Moezzi M, Abbasi S, Farsi D, Zare MA, Hafezimoghadam P. Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial. Emerg Med J. 2015 Jun;32(6):474-7. doi: 10.1136/emermed-2013-202485. Epub 2014 Jul 12. PMID: 25016389.
10. Godwin SA, Caro DA, Wolf SJ, et al. American College of Emergency Physicians. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med 2005;45:177–96

Patients and Methods

Patients and Methods

Study design

This was a single-center, prospective randomized controlled trial. Informed consent was obtained from eligible patients prior to their inclusion in the study. Plain radiographs were reviewed and the Frykman classification was utilized to classify their fractures. The study was conducted in accordance with the 1964 Helsinki Declaration, approved by our local ethical committee board (UID 1733/2021) and registered on the Research Registry (UIN: 6639). This study adheres to the appropriate CONSORT guidelines.

Study population

Study population

Eligible patients were over 12 years of age presenting acutely for the first time with a displaced distal radius fracture (in the presence or absence of a concomitant distal ulnar fracture) requiring reduction via manipulation. Exclusion criteria entailed known allergy to local anesthesia, multiple fractures, polytrauma, head trauma, unconsciousness, open fractures, neurovascular deficit, any evidence of compartment syndrome or ipsilateral upper limb fractures precluding effective reduction or analgesia. All included had presented to the emergency department within 6 hours of injury, to ensure the presence of a viable hematoma.

The sample size calculation for this study was based on the repeated-measures ANOVA design for two groups (HB vs CPB) measured at three observations (baseline, injection, and manipulation). A study with an effect size of 0.5 and a power of 95% required a total sample of 38 to test the association at a 5% alpha level. The power calculation was carried out using G*power 3.1.9. A total of 50 patients were included in the study.

Randomization

Techniques [8]

Outcome assessments

Demo Test

Results:

Patients receiving CPB experienced significantly less pain scores

during manipulation (VAS = 0.64) compared with HB (VAS = 2.44) (p = < 0.0001). There were no significant differences between groups at baseline (p = 0.55) and injection (p = 0.40) stages.

Conclusion:

The CPB

provides

a safe and superior analgesic effect over the conventional HB

.

Key words

:

Distal radius fracture, hematoma block, periosteal block, analgesia, reduction, nonoperative management

Level of evidence

:

Therapeutic Level II

Introduction

Fractures of the d

istal radius and ulna are among the most common in orthopedic trauma [1]. They are linked with a bimodal distribution of high and low energy trauma in the younger and older population respectively [1]. Geographic and provider-dependent variability in operative versus non-operative trends exist, reflecting a lack of a clear consensus or superiority of particular treatment modalities [2, 3]. 

Initial management often entails closed reduction and manipulation followed by immobilization, which

if successful,

may deter

further

operative management.

A

dequate analgesia is essential

during reduction

,

as painful manipulation may hinder patient cooperation and preclude successful reduction [4].

Thus,

various anesthetic techniques have been implemented

. These

notably

include

hematoma block

s

(HB), intravenous regional anesthesia

(Bier’s block)

,

brachial plexus block

s

and procedural sedation

(opioids and sedatives)

. Hematoma blocks are widely utilized due to their simplicity

.

H

owever, they require the presence of a hematoma and data has demonstrated variable analgesic efficacy [5, 6, 7].

T

he

potential for systemic complications and the resultant need for hospital admission and monitoring limits the

use of procedural sedation

and Bier’s block

s in accordance with capacity and resources

[7].

An ideal analgesic technique should result in

safe, easy, and

painless

fracture manipulation

. In 2015,

Tageldin

et al described a novel circumferential periosteal block (CPB) technique for the reduction of radius and ulna fractures [8]. The study

reported

painless reductions

with

no documented complications. In this rando

mized control

led

trial, we assess

the safety and efficacy of the

CPB

technique compared to the conventional hematoma block.

Our hypothesis is that the CPB technique provides superior pain relief with no complications.

Patients and

Methods

Study design

This was a single-center, prospective randomized controlled trial. Informed consent was obtained from eligible patients prior to their inclusion in the study. Plain radiographs were reviewed and

the

Frykman classification was utilized to classify their fractures. The study was conducted in accordance with the 1964 Helsinki Declaration

,

approved by our local ethical committee board (UID 1733/2021) and registered on the Research Registry

(

UIN: 6639).

This study adheres to the

appropriate

CONSORT guidelines.

Study population

Eligible patients were over 12 years of age

presenting acutely for the first time with a

displaced distal radius fracture (in the presence or absence of a

concomitant

distal ulnar fracture) requiring reduction via manipulation. Exclusion criteria

entailed

known allergy to local anesthesia, multiple fractures

,

polytrauma, head trauma

, unconsciousness

, open fractures, neurovascular deficit, any evidence of compartment syndrome

or

ipsilateral upper limb fracture

s

precluding effective reduction or analgesia.

All

included

had presented to the emergency department within 6 hours of injury, to ensure the presence of a viable hematoma.

The sample size calculation for this study was based on the repeated-measures ANOVA design for two groups (HB vs CPB) measured at three observations (baseline, injection, and manipulation). A study with an effect size of 0.5 and a power of 95% required a total sample of 38 to test the association at a 5% alpha level. The power calculation was carried out using G*power 3.1.9. A total of 50 patients were included in the study.

Randomization

Patients were selected consecutively in the emergency department of a tertiary

orthopedic

center

if they met the inclusion criteria

. Patients were

block-

randomized to receive either HB or CPB by computer generated list

s

equally distributed to

two

trained orthopedic

surgeons.

Technique

s

[8]

Patients were positioned supine with the

elbow

extended on a dressing table. Precautionary measures including

oxygen, intravenous access and intra-lipid emulsion

were

available. The affected arm

was

draped and sterilized.

For both techniques, lidocaine 1% without epinephrine was used.

For the CPB,

a 10-ml syringe with a (25G) needle

was

used to infiltrate the subcutaneous tissue

under aseptic technique

on the

radial

aspect of the radius approximately 6cm proximal

to

the wrist joint (2-3cm from

the

fracture). Once the entire

radial

aspect

(subcutaneous and periosteal)

is infiltrated, the needle is changed

to

a (22G) needle. The next injection follow

ed

the parallel plane of the dorsal and volar surfaces of the radius, ensuring contact with bone whilst advancing to avoid any soft tissue

or

neurovascular structures.

Rolling of the skin

allowed

for a single injection to access both surfaces.

In the presence of

a

concomitant ulnar fracture, the process is repeated on the ulnar aspect. Lastly, manipulation

was

performed 15 minutes after the block, whilst recording the required data.  

The hematoma block was performed in the traditional way. A 22G needle

is

inserted on the dorsal aspect of the radial fracture, aspiration of the hematoma to confirm location, followed by subsequent injection of lidocaine within the hematoma.

Techniques to minimize pain on injection of local anesthesia were utilized in both blocks [9].

Outcome assessments

The p

rimary outcome was pain

measured using the

visual analogue scale (VAS

1-10)

.

Measurements

were

taken

a

cross

three

stages

;

before administration of local anesthesia

(baseline)

, during administration

(injection)

and during manipulation and immobilization

(manipulation)

. Post-reduction radiographs were obtained. Patients were subsequently monitored in the

emergency department

for 1 hour to assess for any complications; particularly sensory or vascular deficit. Further, patients were evaluated according to age, sex, definitive treatment (within 6 weeks),

Frykman classification, radiographic assessment,

need for re-manipulation and the presence of any intervention-related complication.

Statistical analysis

Data analysis was performed using Minitab 19 (Minitab LLC, PA USA) and

Graphpad

Prism 9. Descriptive statistics shown in Table 1 for the 25 participants in each group employ the median, interquartile range, frequency and percentage of patients as appropriate.

Differences between

HB

and

CPB

groups on demographic

s

, fracture

type/classification

and

outcome variables were tested using chi-squared tests (

χ

2

) for categorical variables and the Mann-Whitney test for age due to its non-parametric distribution (Table 1).

Mixed ordinal logistic regression (using logit link) was used to test for differences between the two techniques, between the three stages (baseline, injection, manipulation), as well as the interaction of the two main effects (Stage x Method) (Table 2). Mixed ordinal regression was used to take into account the ordinal nature of the VAS score and the correlation of VAS values obtained from each patient. Stage and method were included as main effects and patients were included as a random effect. Type II Wald test for Sum of Squares was used to test the statistical significance of the main effects and interaction.

Post-hoc analysis for differences between the two groups at each stage employed Bonferroni’s multiple comparisons test. Post-hoc pairwise comparisons were performed on the log odds-ratio scale.

Responses from the ordinal model (on the linear scale) were back transformed to estimates of the probability distribution of each rating and the average of these probability distributions

(mean class)

was plotted

along with the standard errors

(Figure 1).

In addition, a cumulative ordinal logistic regression analysis was carried out to assess the relationship of pain during manipulation as the dependent variable, with the independent variables of age, gender, and operator, baseline level of pain, fracture type and Frykman classification

.

.

The regression model (Table 3) yielded an R

2

of

46.4

% for the overall regression. Individual p-values for each of the predictors along with the

odds ratio

and 95% Confidence Intervals (95% CI) are reported in Table 3.

Diagnostics

confirmed

the

lack of multicollinearity

using the Variance Inflation Factor (VIF). A p-value of less than 0.05 was considered to be statistically significant. 

Results

Between January 2021 and June 2021, a total of 50 patients met the inclusion criteria and were consecutively recruited

and randomized

to receive

either a HB or CPB

(Figure 1.)

.

Twenty-five patients were included evenly in both groups. Six patients were excluded for not m

eeting the inclusion criteria; 4

were excluded for ipsilateral upper limb fractures

,

2 excluded due to the presence of significant head trauma.

• Insert Figure 1 here -

Figure 1 – CONSORT Flowchart displaying enrolment, allocation, follow up and analysis of participants.

The descriptive characteristics o

f

our study population are displayed in [

Table 1

].

Out of the

50 patients, the majority were males (66%)

who

sustained isolated

distal end radius (

DER

)

fractures

(84%)

. The age range was 13-67 years old. Frykman classification 1 and 3 were the most common patterns encountered. The vast majority of the fractures underwent non-operative treatment after successful reduction (88%) with no significant

difference

between block method and outcome. Nine patients (18%) underwent operative management; 5 with percutaneous pinning and 4 with ORIF. There were no documented complications

for either

technique. Two patients; one in each

group

, subsequently required re-manipulation. No statistical significance

s were observed

between the

distribution

s

a

nd end-outcomes

of

both groups, thereby ensuring comparability

.

• Insert Table 1. here –

• Insert Table 2. Here –

Mixed ordinal logistic regression

(Table 2.)

revealed significant main effects for both method and stage (P: 0

.

02

,

<0.0001 respectively)

, the latter being an indicator of achieved analgesia regardless of method. In addition, the significant interaction effect (P<0.0001) indicates that the differences between block methods vary across the stages of analgesia. Post-hoc comparisons using a Bonferroni correction confirmed that a difference between block methods is only found during the manipulation stage (P<0.0001).

• Insert Figure 2. Here –

Figure 2 -

Bonferroni's multiple comparison's test for differences in pain scores between the block methods

Post-hoc analysis revealed that the only significant difference between the two groups was found to be during the manipulation stage (p = <0.0001). The lack of a difference at baseline confirms the comparability of both groups. There was no difference during the injection stage (p = 0.

213

).

The m

ean pain score

during manipulation

for HB was

2.44

and for CPB

0.64

(

Figure 2

)

.

Hematoma blocks had a

wider

VAS range of 0-5

(SD = 1.44)

, whereas CPB had a narrower VAS range of 0-3 (SD = 0.86).

• Insert Table 3. Here –

Predictors of pain during manipulation using multivariate regression analysis are displayed in Table 3. None of gender, fracture types and

F

rykman classification were found to be significant factors in affecting

severity of

pain during reduction. Notably, there was no significant operator variability in pain among block methods.

Significant predictors of pain during manipulation

include

;

increasing

age

(p =0.

05

)

, baseline pain score

(p = 0.

05

)

,

and block method

(p <0.0001)

.

Overall

,

the odds of having a higher pain grade at the manipulation stage were 21.24 times higher in the HB group than the CPB group (OR = 21.24, P < 0.001)

, whilst keeping all other variables constant.

Discussion

The management of distal radius and ulna fractures remain

s

largely non-operative, emphasizing the necessity of

adequate reduction

[10

].

Fracture reduction can be unpleasant for both patient and provider if pain is not

sufficiently

managed.

This study has

shown

a

significantly superior analgesic effect using the CPB compared to the HB, in which

all

reductions were described as

either

painless

(VAS = 0)

or minimally painful

(VAS = 1-3)

. Further, no operator variability existed

in both the CPB and HB

.

The variability in the analgesic effect of the HB may

necessitate

supplementary analgesia. In our study, the HB displayed a wider

, less predictable

range of analgesi

c

effect (

VAS 0-5) than the CPB (VAS 0-3).

The lack of predictability encountered in our study is in keeping with previous literature [5, 6, 12].

Similar to our data,

Myderrizi

et al, noted a mean VAS score of (2.25) [5].

Fathi

et al, also described wide-ranging pain scores during reduction of distal radius fractures after an ultrasound guided hematoma block

(numerical rating scale =

1-7) [13].

This is further reinforced in an article by Orbach et al, with a mean VAS range of (3-5.5) [6],

Yet

it is worth mentioning that the

degree of force in

manipulation techniques is normally tailored to the nature of the fracture itself and the subsequently predicted difficulty in reduction. The latter may influence variation among pain scores in different studies.

Further, our analysis has shown that a higher baseline pain score

predicts

greater

pain during manipulation. This may reflect a higher sensitivity to pain in the specific subset of patients.

Increasing age also exerted a

statistically

significant, yet inconsiderable effect on pain during manipulation.

Our results have reproduced

Tageldin

et

al’s

[8] findings. The

consistent

pain scores also suggest that the technique is reproducible and requires only an adequate understanding of the technique, anatomy and administration of local anesthesia.

The technique

may be of particular use in cases where; hematomas are not pr

esent or difficult to access and

in

re-manipulations of older fractures in either the emergency or outpatient setting.

In comparison

to

Bier’s block and procedural sedation, both techniques require fewer resources to perform

, and are less likely to result in systemic complications

[12, 14].

An

initial concern was the risk of neurovascular injury while entering the volar surface of the radius

.

H

owever, no complications of this nature arose during c

lose follow-up and examination.

Future direct

ion

should focus on operator experience-dependent reproducibility of the technique. Further, larger sample sizes should aim to uncover potential

complications.

This study

included a limited number of operators and did not take into account experience with the technique. There was no difference in

definitive

outcomes after reduction, which perhaps indicates effectiveness of analgesia may not affect end-outcomes. However, this may be an artefact of a relatively small sample size, and future research may benefit from matching fracture characteristics in order to assess outcomes accurately.

While participants were unaware of the allocated blocks during administration, there was no feasible method of blinding the operators from the interventions, which is a potential source of bias.

Conclusion

The c

ircumferential periosteal block offers a safe and superior analgesic effect over the traditional hematoma block during manipulation of distal radius and ulna fractures.

This study shows that the periosteal block is an effective

and safe

alternative to the hematoma block, with no observed

complications

and no

effect of operator

variability

on outcomes.

Competing interests

The authors have no competing interests to declare that are relevant to the content of this article

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