ORIGINAL ARTICLE
Bier Block Regional Anesthesia and Casting for Forearm Fractures: Safety in the Pediatric Emergency Department Setting Chad E. Aarons, MD, MPT,* Meagan D. Fernandez, DO,w Matt Willsey, DO,z Bret Peterson, MD,y Charles Key, MD,8 and Jorge Fabregas, MDz
Background: Bier block regional anesthesia was first described in 1908; however, it is uncommonly used for fears of cardiac and neurological complications. Although recent studies have documented safe usage in an adult population, no study to date has investigated its use in a pediatric setting. In addition, most emergency departments feel that splint placement is safer than casting after acute forearm fracture reduction in the pediatric population. However, to our knowledge there is no such study that documents the complication rates associated with immediate casting. The goal of this study was to assess the safety and efficacy of Bier block regional anesthesia and immediate cast application after closed reduction of pediatric forearm fractures. Methods: A retrospective review was conducted of patients treated for forearm fractures in a 2-year period at a major metropolitan pediatric hospital. Rates of complications and length and costs of the 2 procedures were analyzed. Results: A total of 600 patients were treated with Bier block regional anesthesia and 645 were treated with conscious sedation for displaced fractures of the forearm in the 2-year study period. No complications requiring admission were seen in either group. No patient experienced compartment syndrome or a need for readmission secondary to cast application. 2.2% and 4.3% (P = 0.0382) of patients in the Bier block and sedation groups, respectively, needed their cast bivalved secondary to swelling. The average time from initiation of procedural sedation to discharge was 1 hour and 42 minutes, whereas the time to discharge from initiation of Bier block regional anesthesia was 47 minutes (P < 0.0001). The average cost for a patient treated with procedural sedation was $6313, whereas the average cost for the Bier block regional anesthesia group was $4956.
From the *Tuckahoe Orthopaedic Associates, Richmond, VA; wDepartment of Orthopaedics, Geisinger Medical Center, Danville, PA; zDepartment of Orthopaedic Surgery, SUNY Upstate Medical University, Syracuse, NY; yDepartment of Orthopaedic Surgery, Duke University Medical Center, Durham, NC; 8Department of Orthopaedics, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA; and zChildren’s Orthopaedics of Atlanta, Atlanta, GA. None of the authors received financial support for this study. The authors declare no conflict of interest. Reprints: Chad E. Aarons, MD, MPT, Tuckahoe Orthopaedic Associates, 1501 Maple Ave., Suite 200, Richmond, VA 23226. E-mail: [email protected]. Copyright r 2013 by Lippincott Williams & Wilkins
J Pediatr Orthop
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Conclusions: Bier block regional anesthesia is a safe, efficient, and cost-effective method of reducing pediatric forearm fractures. Immediate cast application can be used without fear of major complications. Levels of Evidence: Level III—retrospective review. Key Words: Bier block regional anesthesia, pediatric forearm fractures, emergency department, safety, casting (J Pediatr Orthop 2014;34:45–49)
F
orearm fractures in children account for 45% of all fractures and 62% of all childhood upper limb fractures. The incidence of these fractures peaks during early adolescence around the time of the pubertal growth spurt.1–3 Parfitt has suggested that forearm fractures in adolescence are “an inescapable consequence of an appropriate level of physical activity, and [are] the price that has to be paid in order to maximize bone accumulation during growth and minimize fracture risk in old age.”4 This scenario means that pediatric forearm fractures are very common. Emergency departments and orthopaedic surgeons both desire to make the experience safe, comfortable, and efficient. This often entails procedural sedation and closed reduction followed by splint application. In some settings, this splint is changed in the coming weeks to more stable cast immobilization. This current regimen carries with it risks of sedation, significant cost, and possible loss of fracture reduction. The use of intravenous regional anesthesia is another option for pain control. First introduced in 1908 by Gustav Bier, the block provides a safe and efficient way to obtain a closed reduction.5 A Bier block is performed by starting an intravenous (IV) line in the hand of the affected forearm and infusing diluted lidocaine after a tourniquet on the upper arm is inflated. The entire arm below the tourniquet then becomes anesthetized. It is given below the systemic toxic levels of 5 mg/kg. This technique has a quick onset of action (10 min) and short duration that allows time efficiency and proper neurovascular assessment after reduction.5 It also avoids concern of when the child last ate. Up to this point, the most frequent use of Bier blocks for regional anesthesia has been in operating www.pedorthopaedics.com |
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rooms as an alternative to general anesthesia. However, it may also be successfully used for emergency room reduction of fractures and dislocations of the forearm, wrist, and hand. The block has been questioned in the past due to safety concerns. Common opposition is primarily due to unfamiliarity and fear of systemic reaction of lidocaine. The current body of literature demonstrates the Bier block to be effective and safe, with the most common adverse reactions being tourniquet pain.6–11 Prior studies have shown favorable comparison between Bier block regional anesthesia, nitrous oxide, and hematoma block. To our knowledge there have been no comparisons of Bier block regional anesthesia to the use of procedural sedation for reduction of upper extremity pediatric fractures with regard to safety, time efficiency, and total cost of care.12,13 Another common unnecessary fear is the application of a cast in the emergency room. It is a common practice to place a forearm fracture in a splint for fear of a compartment syndrome or tight cast issues due to edema. Although Mubarak et al14 reported on 9 cases of compartment syndrome related to spica casting we are unaware of any such series related to forearm fractures. Furthermore, while casting complications have been described in the literature, few reports entail specific outcomes of a large series of casted upper extremity fractures after Bier block regional anesthesia.15 The purpose of this study is to present an overview of pediatric patients who underwent either sedation or Bier block regional anesthesia for the treatment of forearm fracture reduction with cast application. Our hypotheses are that Bier block regional anesthesia is at least as safe and is more cost-effective than sedation, and that cast application can be utilized after acute closed reduction with low risk of serious complications.
METHODS Data Collection After approval from the hospital’s Institutional Review Board, our electronic medical record database was queried and narrowed down to include only patients with a both bone forearm fracture, Monteggia, Galeazzi, nightstick (ulna alone), or a distal radius fracture in the 2-year period from 2008 to 2010. Next these patients were filtered to include only those who had reductions done with either procedural sedation or Bier block regional anesthesia. Each chart was retrospectively reviewed and the diagnosis, triage time and date, procedure start time, discharge time and date, discharge versus admission status, subsequent returns to the emergency department, and chief complaint at the time of return were recorded. From the chart we were able to calculate the length of time that elapsed from initiation of the procedure to discharge and the time from discharge to return if any return occurred. In addition, it was noted if any patient required admission from adverse reaction to either procedural sedation or Bier block regional anesthesia.
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Bier Block Procedure Administration of the Bier block is given following a standardized protocol. The decision to perform a Bier block or use sedation was made by the orthopaedic resident after the initial encounter with the patient. The resident carefully evaluated the child’s predisposition and the parents comfort level. Once it was decided that a Bier block would be used, the patient’s guardian underwent informed consent. An IV line was established on the dorsum of the hand in the involved upper extremity and a brachial tourniquet was applied. We did not routinely place an IV in the contralateral limb. The tourniquet was inflated to 250 mm Hg. Exsanguination of the limb was not performed. Lidocaine (1%; 20 mL) and sterile saline (40 mL) were combined for a total possible anesthetic solution of 60 mL. This was then administered slowly at a weight-dependent dosing of 1 mL solution per kg body weight. This delivered a dose of 3.33 mg/kg of regional anesthesia. Lidocaine was chosen over prilocaine and bupivacaine as previous studies have shown it to be more efficacious and safer.16 In addition, the 3.33 mg/kg dose was chosen as it falls under the known toxic dose and has been shown to be more effective than a “mini-dose” of 1.5 mg/kg.17 This mixture was infused through the previously placed IV that was then removed after the physician determined that adequate anesthesia had been achieved. The reduction was performed by the orthopaedic resident with fluoroscopic assistance and a wellmolded long-arm fiberglass cast was applied. The cuff was then released no sooner than 20 minutes after injection of anesthetic. This allowed diffusion of the anesthetic into the surrounding tissues and did not require a slow release. Postreduction radiographs were routinely obtained with a mini-C-Arm fluoroscope before or after cuff deflation. During the entire procedure the patient’s vitals were monitored by a nurse.
Sedation Protocol As per the protocol at our hospital, sedation was performed by a dedicated pediatric emergency trained “sedation physician.” In the absence of contraindications, the general protocol included induction with 1 to 2 mg/kg of ketamine followed by propofol at 1 mg/kg with additional propofol boluses as required. All medications were administered by the sedation physician. During the entire procedure the patient was monitored by a nurse in the room.
Definition of Complications For both procedural sedation and Bier block regional anesthesia complications were defined as any life threatening cardiovascular event or seizure that required hospitalization or pharmacological intervention. Minor complications such as pruritis or minor rash were not included in our data collection. For cast application we defined a minor complication as return to the emergency room for univalving, bivalving, or need to change the cast. Major complication was defined as the development of compartment syndrome. r
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Cost Analysis The average cost of care for both treatment arms were obtained from the emergency department administration. These prices included the cost of radiographs and their interpretation, casting supplies, medications, reduction of the fracture by an orthopaedic team member, and general emergency evaluation costs.
Statistical Analysis After collection of all data the rate of complications were calculated for both groups. The average time to discharge from initiation of the procedure and the average time to return (if return occurred) were also calculated. In addition, the average cost per treatment for each group was calculated. These data were then analyzed using a Student t test and a w2 test to identify statistical significance (Microsoft Excel 2010, Redmond, WA).
RESULTS Following the inclusion and exclusion criteria described above, 1245 patients were included: 600 who were treated with Bier block and 645 that underwent procedural sedation. The average age of patients in Bier block group was 10.4 years (range, 3 to 18 y), whereas the average age in the procedural sedation group was 6.7 years (range, 6 mo to 16 y). This difference was statistically significant (P < 0.001). The average time from initiation of procedural sedation to discharge was 1 hour and 42 minutes, whereas the average time to discharge from initiation of Bier block regional anesthesia was 47 minutes. This represented a statistically significant difference (P < 0.0001). There were no episodes of cardiac, respiratory, or seizure events that necessitated either pharmacologic intervention or admission in either group. All patients were treated with cast immobilization immediately after reduction and no casts were prophylactically split in the study group. There were no episodes of compartment syndrome seen in either group. Thirtyone children in the sedation group returned to the emergency department within 2 weeks. However, only 28 of these needed some intervention to their cast because of tightness. Twenty-three patients from the Bier block regional anesthesia group returned to the emergency department within 2 weeks. Of these, 13 necessitated cast intervention for tightness. Therefore, 4.34% of those treated with procedural sedation and 2.16% of patients treated with Bier block regional anesthesia experienced a minor complication. This represented a statistically significant difference (P = 0.0382; Table 1). Other complaints in both groups that necessitated return to the emergency department included wet casts, minor swelling of fingers, prescription problems, falls, foreign objects in casts, pruritis, and 2 patients who missed follow-up appointment to check maintenance of reduction. For those patients who returned to the emergency department the average time from discharge to triage on return was 36 hours and 8 minutes in the sedation group and 32 hours and 35 minutes in the Bier r
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TABLE 1. Results
No. patients Average age (y) Average time from procedure start to discharge (h:min) Major complication from the procedure Minor complications from casting [n (%)] Major complications from casting Average time to return (h:min) Average cost ($)
Procedural Sedation
Bier Block Regional Anesthesia
P
645 6.7 1:42
600 10.4 0:47
< 0.001
None
None
28 (4.3)
13 (2.2)
None
None
36:08
32:35
6313
4956
0.0382
Not calculated
block group. Statistical analysis was not done between these 2 groups.
Cost Analysis The average cost for a patient treated with procedural sedation was $6313, whereas the average cost for the Bier block regional anesthesia group was $4956. These figures reflect the common costs of radiographs prereduction and postreduction ($460), radiology interpretation ($72), emergency department level 5 facility fee ($2779), emergency department physician fee ($443), fracture reduction procedure fee ($874), and casting supplies ($400). In addition the sedation group included an IV medication fee ($144), a sedation procedure fee ($213), and an anesthesia provider fee ($500 to $1000; Table 2).
DISCUSSION Bier block regional anesthesia was first introduced in 1908 but quickly faded due to complications from systemic effects. It was reintroduced in the United States by Holmes18 in 1963 but yet continues to be infrequently used. Bier blocks have been proven safe in multiple small studies. Guay reviewed the literature from 1950 to 2007 and identified 24 seizures and 13 cardiac-related deaths due to Bier block. All of these were associated with either high doses above the systemic toxic levels or unreliable tourniquets. Given this he concluded that Bier blocks were safe.19 Mohr reviewed 1816 Bier blocks performed at a single institution and had only 9 adverse events, 5 of which were inadequate anesthesia. None of the adverse events resulted in failure to complete the procedure or in morbidity or mortaility.11 Despite this a survey conducted in 2007 showed that only 20% of orthopaedic surgeons and pediatric emergency medicine physicians utilize Bier blocks for forearm fracture reduction.20 Interestingly, at our institution we have been utilizing Bier block regional anesthesia for over 25 years with no known serious complications. Our current study confirms the excellent safety profile of Bier block regional anesthesia that has been www.pedorthopaedics.com |
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TABLE 2. Cost Analysis Reduction With Bier Block Radiology films Radiology reading ED facility level: level 5, extensive resources ED procedure: fracture reduction ED supplies: splint/cast ED E & M level
Total
$230 prereduction and postreduction; $460 total $72 total for prereduction and postreduction $2779 $874 $300-400 $235-443
Reduction With Sedation Radiology films
$230 prereduction and postreduction: $460 total Radiology reading $72 total for prereduction and postreduction ED facility level: level 5, extensive $2779 resources ED procedure: fracture reduction $874 ED supplies: splint/cast ED E & M level ED procedure: sedation (if ED performs) Sedation: by sedation services: anesthesia codes ED procedure: IV push
$4956
$300-400 $235-443 $213 $500-1000 $144 $6313
ED indicates emergency department.
documented in the literature previously. There were no major events, as described earlier, that required hospital admission or pharmacological intervention. The nontoxic dose allowed for safe administration even in one case when the tourniquet was inadvertently deflated at 10 minutes. In addition, Bier block regional anesthesia allowed for a patient to be discharged from the emergency department nearly an hour sooner than patients treated with procedural sedation (47 min as compared with 1 h and 42 min). This difference proved to be statistically significant and could help to alleviate the burden of overcrowded emergency departments. Casting is a well accepted method for maintaining fracture reduction and the current study demonstrates that it is also a safe method when used in the acute setting. Although Mohler et al21 found that pressures measured on the forearms of healthy volunteers averaged 22 mm Hg beneath fiberglass casts, we did not find that this added pressure created any problems. We failed to identify any cases of compartment syndrome after fracture reduction with Bier block regional anesthesia or procedural sedation. As stated in the results, only 28 (4.34%) procedural sedation patients and 13 (2.16%) Bier block patients returned to the emergency department for cast alteration. Thus, altogether, 41 (3.3%) of those immediately casted after reduction returned to have pressure relieved from their casts. The significant difference in casting complication rate could reflect selection bias. The initial decision to perform procedural sedation rather than Bier block may have been based on the anticipated difficulty of reduction. Finally, if reductions were more complicated, more swelling would be expected leading to a higher need for intervention of the initially placed cast. The difference that existed in the age of the patients between the 2 groups is not unexpected. Bier blocks require some degree of patient cooperation, both for IV placement in the affected limb and during reduction.
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Although some institutions use strict age parameters for inclusion criteria, we have not found this necessary and continue to evaluate each child individually. We feel that Bier blocks can be done in younger children as no increased risk has been identified. Our youngest patient in this series was 3 years old. Several authors have studied the amount of pressure relieved with cutting and spreading casts.22–25 On the basis of the findings from our current study we feel that, given the low rate of intervention, routine cast splitting at the time of application is not necessary. On the contrary, children may be casted in the emergency department. Every study has strengths and weaknesses and ours is no exception. Although the study was conducted on patients who presented to one hospital’s emergency department a common computer record exists between the 2 largest pediatric hospitals in the region. This helped to ensure accurate follow-up; however, we cannot completely eliminate the fact that a patient may have gone outside of the region for a complication. Selection bias is an inherent weakness of the study that a future randomized controlled study could address, assigning patients to sedation or regional anesthesia and casting versus splinting groups. Such a study would not only further elucidate the efficacy of regional anesthesia but may also allow direct comparison between casting and splinting for forearm fractures in children. Despite the aforementioned weaknesses we feel that we have shown that both the Bier block regional anesthesia and immediate casting can be used in the emergency department for acute forearm fractures in children.
REFERENCES 1. Landin LA. Fracture patterns in children. Acta Orthop Scand. 1983;54(suppl 202):1–109. 2. Kramhøft M, Bødtker S. Epidemiology of distal forearm fractures in Danish children. Acta Orthop Scand. 1988;59:557–559. r
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3. Bailey DA, Wedge JH, McCulloch RG, et al. Epidemiology of fractures of the distal end of the radius in children as associated with growth. J Bone Joint Surg Am. 1989;71:1225–1231. 4. Parfitt AM. The two faces of growth: benefits and risks to bone integrity. Osteoporos Int. 1994;4:382–398. 5. Farrell RG, Swanson SL, Walter JR. Safe and effective IV regional anesthesia for use in the emergency department. Ann Emerg Med. 1985;14:288–292. 6. Olney BW, Lugg PC, Turner PL, et al. Outpatient treatment of upper extremity injuries in childhood using intravenous regional anaesthesia. J Pediatr Orthop. 1988;8:576–579. 7. Barnes CL, Blasier RD, Dodge BM. Intravenous regional anesthesia: a safe and cost-effective outpatient anesthetic for upper extremity fracture treatment in children. J Pediatr Orthop. 1991;11:717–720. 8. Juliano PJ, Mazur JM, Cummings RJ, et al. Low-dose lidocaine intravenous regional anesthesia for forearm fractures in children. J Pediatr Orthop. 1992;12:633–635. 9. Bolte RG, Stevens PM, Scott SM, et al. Mini-dose Bier block intravenous regional anesthesia in the emergency department treatment of pediatric upper-extremity injuries. J Pediatr Orthop. 1994;14:534–537. 10. Blasier RD, White R. Intravenous regional anesthesia for management of children’s extremity fractures in the emergency department. Pediatr Emerg Care. 1996;12:404–406. 11. Mohr B. Safety and effectiveness of intravenous regional anesthesia (Bier block) for outpatient management of forearm trauma. CJEM. 2006;8:247–250. 12. Kendall JM, Allen P, Younge P, et al. Haematoma block or Bier’s block for Colles’ fracture reduction in the accident and emergency department–which is best? J Accid Emerg Med. 1997;14:352–356. 13. Gregory PR, Sullivan JA. Nitrous oxide compared with intravenous regional anesthesia in pediatric forearm fracture manipulation. J Pediatr Orthop. 1996;16:187–191.
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14. Mubarak SJ, Frick S, Sink E, et al. Volkmann contracture and compartment syndromes after femur fractures in children treated with 90/90 spica casts. J Pediatr Orthop. 2006;26:567–572. 15. Halanski M, Noonan KJ. Cast and splint immobilization: complications. J Am Acad Orthop Surg. 2008;16:30 –40. 16. Davidson AJ, Eyres RL, Cole WG. A comparison of prilocaine and lidocaine for intravenous regional anesthesia for forearm fracture reduction in children. Pediatr Anesth. 2002;12:146–150. 17. Bratt HD, Eyres RL, Cole WG. Randomized double-blind trial of low- and moderate-dose lidocaine regional anesthesia for forearm fractures in childhood. J Pediatr Orthop. 1996;16:660–663. 18. Holmes CM. Intravenous regional analgesia. A useful method of producing analgesia of the limbs. Lancet. 1963;1:245–247. 19. Guay J. Adverse events associated with intravenous regional anesthesia (Bier block): a systematic review of complications. J Clin Anesth. 2009;21:585–594. 20. Constantine E, Steele DW, Eberson C, et al. The use of local anesthetic techniques for closed forearm fracture reduction in children: a survey of academic pediatric emergency departments. Pediatr Emerg Care. 2007;23:209–211. 21. Mohler LR, Pedowitz RA, Byrne TP, et al. Pressure generation beneath a new thermoplastic cast. Clin Orthop Relat Res. 1996;322: 262–267. 22. Davids JR, Frick SL, Skewes E, et al. Skin surface pressure beneath an above-the-knee cast: plaster casts compared with fiberglass casts. J Bone Joint Surg Am. 1997;79:565–569. 23. Marson BM, Keenan MA. Skin surface pressures under short leg casts. J Orthop Trauma. 1993;7:275–278. 24. Bingold AC. On splitting plasters: a useful analogy. J Bone Joint Surg Br. 1979;61:294–295. 25. Garfin SR, Mubarak SJ, Evans KL, et al. Quantification of intracompartmental pressure and volume under plaster casts. J Bone Joint Surg Am. 1981;63:449–453.
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Bier Block Regional Anesthesia and Casting for Forearm Fractures: Safety in the Pediatric Emergency Department Setting Chad E. Aarons, MD, MPT,* Meagan D. Fernandez, DO,w Matt Willsey, DO,z Bret Peterson, MD,y Charles Key, MD,8 and Jorge Fabregas, MDz
Background: Bier block regional anesthesia was first described in 1908; however, it is uncommonly used for fears of cardiac and neurological complications. Although recent studies have documented safe usage in an adult population, no study to date has investigated its use in a pediatric setting. In addition, most emergency departments feel that splint placement is safer than casting after acute forearm fracture reduction in the pediatric population. However, to our knowledge there is no such study that documents the complication rates associated with immediate casting. The goal of this study was to assess the safety and efficacy of Bier block regional anesthesia and immediate cast application after closed reduction of pediatric forearm fractures. Methods: A retrospective review was conducted of patients treated for forearm fractures in a 2-year period at a major metropolitan pediatric hospital. Rates of complications and length and costs of the 2 procedures were analyzed. Results: A total of 600 patients were treated with Bier block regional anesthesia and 645 were treated with conscious sedation for displaced fractures of the forearm in the 2-year study period. No complications requiring admission were seen in either group. No patient experienced compartment syndrome or a need for readmission secondary to cast application. 2.2% and 4.3% (P = 0.0382) of patients in the Bier block and sedation groups, respectively, needed their cast bivalved secondary to swelling. The average time from initiation of procedural sedation to discharge was 1 hour and 42 minutes, whereas the time to discharge from initiation of Bier block regional anesthesia was 47 minutes (P < 0.0001). The average cost for a patient treated with procedural sedation was $6313, whereas the average cost for the Bier block regional anesthesia group was $4956.
From the *Tuckahoe Orthopaedic Associates, Richmond, VA; wDepartment of Orthopaedics, Geisinger Medical Center, Danville, PA; zDepartment of Orthopaedic Surgery, SUNY Upstate Medical University, Syracuse, NY; yDepartment of Orthopaedic Surgery, Duke University Medical Center, Durham, NC; 8Department of Orthopaedics, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA; and zChildren’s Orthopaedics of Atlanta, Atlanta, GA. None of the authors received financial support for this study. The authors declare no conflict of interest. Reprints: Chad E. Aarons, MD, MPT, Tuckahoe Orthopaedic Associates, 1501 Maple Ave., Suite 200, Richmond, VA 23226. E-mail: [email protected]. Copyright r 2013 by Lippincott Williams & Wilkins
J Pediatr Orthop
Volume 34, Number 1, January 2014
Conclusions: Bier block regional anesthesia is a safe, efficient, and cost-effective method of reducing pediatric forearm fractures. Immediate cast application can be used without fear of major complications. Levels of Evidence: Level III—retrospective review. Key Words: Bier block regional anesthesia, pediatric forearm fractures, emergency department, safety, casting (J Pediatr Orthop 2014;34:45–49)
F
orearm fractures in children account for 45% of all fractures and 62% of all childhood upper limb fractures. The incidence of these fractures peaks during early adolescence around the time of the pubertal growth spurt.1–3 Parfitt has suggested that forearm fractures in adolescence are “an inescapable consequence of an appropriate level of physical activity, and [are] the price that has to be paid in order to maximize bone accumulation during growth and minimize fracture risk in old age.”4 This scenario means that pediatric forearm fractures are very common. Emergency departments and orthopaedic surgeons both desire to make the experience safe, comfortable, and efficient. This often entails procedural sedation and closed reduction followed by splint application. In some settings, this splint is changed in the coming weeks to more stable cast immobilization. This current regimen carries with it risks of sedation, significant cost, and possible loss of fracture reduction. The use of intravenous regional anesthesia is another option for pain control. First introduced in 1908 by Gustav Bier, the block provides a safe and efficient way to obtain a closed reduction.5 A Bier block is performed by starting an intravenous (IV) line in the hand of the affected forearm and infusing diluted lidocaine after a tourniquet on the upper arm is inflated. The entire arm below the tourniquet then becomes anesthetized. It is given below the systemic toxic levels of 5 mg/kg. This technique has a quick onset of action (10 min) and short duration that allows time efficiency and proper neurovascular assessment after reduction.5 It also avoids concern of when the child last ate. Up to this point, the most frequent use of Bier blocks for regional anesthesia has been in operating www.pedorthopaedics.com |
45
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rooms as an alternative to general anesthesia. However, it may also be successfully used for emergency room reduction of fractures and dislocations of the forearm, wrist, and hand. The block has been questioned in the past due to safety concerns. Common opposition is primarily due to unfamiliarity and fear of systemic reaction of lidocaine. The current body of literature demonstrates the Bier block to be effective and safe, with the most common adverse reactions being tourniquet pain.6–11 Prior studies have shown favorable comparison between Bier block regional anesthesia, nitrous oxide, and hematoma block. To our knowledge there have been no comparisons of Bier block regional anesthesia to the use of procedural sedation for reduction of upper extremity pediatric fractures with regard to safety, time efficiency, and total cost of care.12,13 Another common unnecessary fear is the application of a cast in the emergency room. It is a common practice to place a forearm fracture in a splint for fear of a compartment syndrome or tight cast issues due to edema. Although Mubarak et al14 reported on 9 cases of compartment syndrome related to spica casting we are unaware of any such series related to forearm fractures. Furthermore, while casting complications have been described in the literature, few reports entail specific outcomes of a large series of casted upper extremity fractures after Bier block regional anesthesia.15 The purpose of this study is to present an overview of pediatric patients who underwent either sedation or Bier block regional anesthesia for the treatment of forearm fracture reduction with cast application. Our hypotheses are that Bier block regional anesthesia is at least as safe and is more cost-effective than sedation, and that cast application can be utilized after acute closed reduction with low risk of serious complications.
METHODS Data Collection After approval from the hospital’s Institutional Review Board, our electronic medical record database was queried and narrowed down to include only patients with a both bone forearm fracture, Monteggia, Galeazzi, nightstick (ulna alone), or a distal radius fracture in the 2-year period from 2008 to 2010. Next these patients were filtered to include only those who had reductions done with either procedural sedation or Bier block regional anesthesia. Each chart was retrospectively reviewed and the diagnosis, triage time and date, procedure start time, discharge time and date, discharge versus admission status, subsequent returns to the emergency department, and chief complaint at the time of return were recorded. From the chart we were able to calculate the length of time that elapsed from initiation of the procedure to discharge and the time from discharge to return if any return occurred. In addition, it was noted if any patient required admission from adverse reaction to either procedural sedation or Bier block regional anesthesia.
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Volume 34, Number 1, January 2014
Bier Block Procedure Administration of the Bier block is given following a standardized protocol. The decision to perform a Bier block or use sedation was made by the orthopaedic resident after the initial encounter with the patient. The resident carefully evaluated the child’s predisposition and the parents comfort level. Once it was decided that a Bier block would be used, the patient’s guardian underwent informed consent. An IV line was established on the dorsum of the hand in the involved upper extremity and a brachial tourniquet was applied. We did not routinely place an IV in the contralateral limb. The tourniquet was inflated to 250 mm Hg. Exsanguination of the limb was not performed. Lidocaine (1%; 20 mL) and sterile saline (40 mL) were combined for a total possible anesthetic solution of 60 mL. This was then administered slowly at a weight-dependent dosing of 1 mL solution per kg body weight. This delivered a dose of 3.33 mg/kg of regional anesthesia. Lidocaine was chosen over prilocaine and bupivacaine as previous studies have shown it to be more efficacious and safer.16 In addition, the 3.33 mg/kg dose was chosen as it falls under the known toxic dose and has been shown to be more effective than a “mini-dose” of 1.5 mg/kg.17 This mixture was infused through the previously placed IV that was then removed after the physician determined that adequate anesthesia had been achieved. The reduction was performed by the orthopaedic resident with fluoroscopic assistance and a wellmolded long-arm fiberglass cast was applied. The cuff was then released no sooner than 20 minutes after injection of anesthetic. This allowed diffusion of the anesthetic into the surrounding tissues and did not require a slow release. Postreduction radiographs were routinely obtained with a mini-C-Arm fluoroscope before or after cuff deflation. During the entire procedure the patient’s vitals were monitored by a nurse.
Sedation Protocol As per the protocol at our hospital, sedation was performed by a dedicated pediatric emergency trained “sedation physician.” In the absence of contraindications, the general protocol included induction with 1 to 2 mg/kg of ketamine followed by propofol at 1 mg/kg with additional propofol boluses as required. All medications were administered by the sedation physician. During the entire procedure the patient was monitored by a nurse in the room.
Definition of Complications For both procedural sedation and Bier block regional anesthesia complications were defined as any life threatening cardiovascular event or seizure that required hospitalization or pharmacological intervention. Minor complications such as pruritis or minor rash were not included in our data collection. For cast application we defined a minor complication as return to the emergency room for univalving, bivalving, or need to change the cast. Major complication was defined as the development of compartment syndrome. r
2013 Lippincott Williams & Wilkins
J Pediatr Orthop
Volume 34, Number 1, January 2014
Cost Analysis The average cost of care for both treatment arms were obtained from the emergency department administration. These prices included the cost of radiographs and their interpretation, casting supplies, medications, reduction of the fracture by an orthopaedic team member, and general emergency evaluation costs.
Statistical Analysis After collection of all data the rate of complications were calculated for both groups. The average time to discharge from initiation of the procedure and the average time to return (if return occurred) were also calculated. In addition, the average cost per treatment for each group was calculated. These data were then analyzed using a Student t test and a w2 test to identify statistical significance (Microsoft Excel 2010, Redmond, WA).
RESULTS Following the inclusion and exclusion criteria described above, 1245 patients were included: 600 who were treated with Bier block and 645 that underwent procedural sedation. The average age of patients in Bier block group was 10.4 years (range, 3 to 18 y), whereas the average age in the procedural sedation group was 6.7 years (range, 6 mo to 16 y). This difference was statistically significant (P < 0.001). The average time from initiation of procedural sedation to discharge was 1 hour and 42 minutes, whereas the average time to discharge from initiation of Bier block regional anesthesia was 47 minutes. This represented a statistically significant difference (P < 0.0001). There were no episodes of cardiac, respiratory, or seizure events that necessitated either pharmacologic intervention or admission in either group. All patients were treated with cast immobilization immediately after reduction and no casts were prophylactically split in the study group. There were no episodes of compartment syndrome seen in either group. Thirtyone children in the sedation group returned to the emergency department within 2 weeks. However, only 28 of these needed some intervention to their cast because of tightness. Twenty-three patients from the Bier block regional anesthesia group returned to the emergency department within 2 weeks. Of these, 13 necessitated cast intervention for tightness. Therefore, 4.34% of those treated with procedural sedation and 2.16% of patients treated with Bier block regional anesthesia experienced a minor complication. This represented a statistically significant difference (P = 0.0382; Table 1). Other complaints in both groups that necessitated return to the emergency department included wet casts, minor swelling of fingers, prescription problems, falls, foreign objects in casts, pruritis, and 2 patients who missed follow-up appointment to check maintenance of reduction. For those patients who returned to the emergency department the average time from discharge to triage on return was 36 hours and 8 minutes in the sedation group and 32 hours and 35 minutes in the Bier r
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TABLE 1. Results
No. patients Average age (y) Average time from procedure start to discharge (h:min) Major complication from the procedure Minor complications from casting [n (%)] Major complications from casting Average time to return (h:min) Average cost ($)
Procedural Sedation
Bier Block Regional Anesthesia
P
645 6.7 1:42
600 10.4 0:47
< 0.001
None
None
28 (4.3)
13 (2.2)
None
None
36:08
32:35
6313
4956
0.0382
Not calculated
block group. Statistical analysis was not done between these 2 groups.
Cost Analysis The average cost for a patient treated with procedural sedation was $6313, whereas the average cost for the Bier block regional anesthesia group was $4956. These figures reflect the common costs of radiographs prereduction and postreduction ($460), radiology interpretation ($72), emergency department level 5 facility fee ($2779), emergency department physician fee ($443), fracture reduction procedure fee ($874), and casting supplies ($400). In addition the sedation group included an IV medication fee ($144), a sedation procedure fee ($213), and an anesthesia provider fee ($500 to $1000; Table 2).
DISCUSSION Bier block regional anesthesia was first introduced in 1908 but quickly faded due to complications from systemic effects. It was reintroduced in the United States by Holmes18 in 1963 but yet continues to be infrequently used. Bier blocks have been proven safe in multiple small studies. Guay reviewed the literature from 1950 to 2007 and identified 24 seizures and 13 cardiac-related deaths due to Bier block. All of these were associated with either high doses above the systemic toxic levels or unreliable tourniquets. Given this he concluded that Bier blocks were safe.19 Mohr reviewed 1816 Bier blocks performed at a single institution and had only 9 adverse events, 5 of which were inadequate anesthesia. None of the adverse events resulted in failure to complete the procedure or in morbidity or mortaility.11 Despite this a survey conducted in 2007 showed that only 20% of orthopaedic surgeons and pediatric emergency medicine physicians utilize Bier blocks for forearm fracture reduction.20 Interestingly, at our institution we have been utilizing Bier block regional anesthesia for over 25 years with no known serious complications. Our current study confirms the excellent safety profile of Bier block regional anesthesia that has been www.pedorthopaedics.com |
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TABLE 2. Cost Analysis Reduction With Bier Block Radiology films Radiology reading ED facility level: level 5, extensive resources ED procedure: fracture reduction ED supplies: splint/cast ED E & M level
Total
$230 prereduction and postreduction; $460 total $72 total for prereduction and postreduction $2779 $874 $300-400 $235-443
Reduction With Sedation Radiology films
$230 prereduction and postreduction: $460 total Radiology reading $72 total for prereduction and postreduction ED facility level: level 5, extensive $2779 resources ED procedure: fracture reduction $874 ED supplies: splint/cast ED E & M level ED procedure: sedation (if ED performs) Sedation: by sedation services: anesthesia codes ED procedure: IV push
$4956
$300-400 $235-443 $213 $500-1000 $144 $6313
ED indicates emergency department.
documented in the literature previously. There were no major events, as described earlier, that required hospital admission or pharmacological intervention. The nontoxic dose allowed for safe administration even in one case when the tourniquet was inadvertently deflated at 10 minutes. In addition, Bier block regional anesthesia allowed for a patient to be discharged from the emergency department nearly an hour sooner than patients treated with procedural sedation (47 min as compared with 1 h and 42 min). This difference proved to be statistically significant and could help to alleviate the burden of overcrowded emergency departments. Casting is a well accepted method for maintaining fracture reduction and the current study demonstrates that it is also a safe method when used in the acute setting. Although Mohler et al21 found that pressures measured on the forearms of healthy volunteers averaged 22 mm Hg beneath fiberglass casts, we did not find that this added pressure created any problems. We failed to identify any cases of compartment syndrome after fracture reduction with Bier block regional anesthesia or procedural sedation. As stated in the results, only 28 (4.34%) procedural sedation patients and 13 (2.16%) Bier block patients returned to the emergency department for cast alteration. Thus, altogether, 41 (3.3%) of those immediately casted after reduction returned to have pressure relieved from their casts. The significant difference in casting complication rate could reflect selection bias. The initial decision to perform procedural sedation rather than Bier block may have been based on the anticipated difficulty of reduction. Finally, if reductions were more complicated, more swelling would be expected leading to a higher need for intervention of the initially placed cast. The difference that existed in the age of the patients between the 2 groups is not unexpected. Bier blocks require some degree of patient cooperation, both for IV placement in the affected limb and during reduction.
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Although some institutions use strict age parameters for inclusion criteria, we have not found this necessary and continue to evaluate each child individually. We feel that Bier blocks can be done in younger children as no increased risk has been identified. Our youngest patient in this series was 3 years old. Several authors have studied the amount of pressure relieved with cutting and spreading casts.22–25 On the basis of the findings from our current study we feel that, given the low rate of intervention, routine cast splitting at the time of application is not necessary. On the contrary, children may be casted in the emergency department. Every study has strengths and weaknesses and ours is no exception. Although the study was conducted on patients who presented to one hospital’s emergency department a common computer record exists between the 2 largest pediatric hospitals in the region. This helped to ensure accurate follow-up; however, we cannot completely eliminate the fact that a patient may have gone outside of the region for a complication. Selection bias is an inherent weakness of the study that a future randomized controlled study could address, assigning patients to sedation or regional anesthesia and casting versus splinting groups. Such a study would not only further elucidate the efficacy of regional anesthesia but may also allow direct comparison between casting and splinting for forearm fractures in children. Despite the aforementioned weaknesses we feel that we have shown that both the Bier block regional anesthesia and immediate casting can be used in the emergency department for acute forearm fractures in children.
REFERENCES 1. Landin LA. Fracture patterns in children. Acta Orthop Scand. 1983;54(suppl 202):1–109. 2. Kramhøft M, Bødtker S. Epidemiology of distal forearm fractures in Danish children. Acta Orthop Scand. 1988;59:557–559. r
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3. Bailey DA, Wedge JH, McCulloch RG, et al. Epidemiology of fractures of the distal end of the radius in children as associated with growth. J Bone Joint Surg Am. 1989;71:1225–1231. 4. Parfitt AM. The two faces of growth: benefits and risks to bone integrity. Osteoporos Int. 1994;4:382–398. 5. Farrell RG, Swanson SL, Walter JR. Safe and effective IV regional anesthesia for use in the emergency department. Ann Emerg Med. 1985;14:288–292. 6. Olney BW, Lugg PC, Turner PL, et al. Outpatient treatment of upper extremity injuries in childhood using intravenous regional anaesthesia. J Pediatr Orthop. 1988;8:576–579. 7. Barnes CL, Blasier RD, Dodge BM. Intravenous regional anesthesia: a safe and cost-effective outpatient anesthetic for upper extremity fracture treatment in children. J Pediatr Orthop. 1991;11:717–720. 8. Juliano PJ, Mazur JM, Cummings RJ, et al. Low-dose lidocaine intravenous regional anesthesia for forearm fractures in children. J Pediatr Orthop. 1992;12:633–635. 9. Bolte RG, Stevens PM, Scott SM, et al. Mini-dose Bier block intravenous regional anesthesia in the emergency department treatment of pediatric upper-extremity injuries. J Pediatr Orthop. 1994;14:534–537. 10. Blasier RD, White R. Intravenous regional anesthesia for management of children’s extremity fractures in the emergency department. Pediatr Emerg Care. 1996;12:404–406. 11. Mohr B. Safety and effectiveness of intravenous regional anesthesia (Bier block) for outpatient management of forearm trauma. CJEM. 2006;8:247–250. 12. Kendall JM, Allen P, Younge P, et al. Haematoma block or Bier’s block for Colles’ fracture reduction in the accident and emergency department–which is best? J Accid Emerg Med. 1997;14:352–356. 13. Gregory PR, Sullivan JA. Nitrous oxide compared with intravenous regional anesthesia in pediatric forearm fracture manipulation. J Pediatr Orthop. 1996;16:187–191.
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14. Mubarak SJ, Frick S, Sink E, et al. Volkmann contracture and compartment syndromes after femur fractures in children treated with 90/90 spica casts. J Pediatr Orthop. 2006;26:567–572. 15. Halanski M, Noonan KJ. Cast and splint immobilization: complications. J Am Acad Orthop Surg. 2008;16:30 –40. 16. Davidson AJ, Eyres RL, Cole WG. A comparison of prilocaine and lidocaine for intravenous regional anesthesia for forearm fracture reduction in children. Pediatr Anesth. 2002;12:146–150. 17. Bratt HD, Eyres RL, Cole WG. Randomized double-blind trial of low- and moderate-dose lidocaine regional anesthesia for forearm fractures in childhood. J Pediatr Orthop. 1996;16:660–663. 18. Holmes CM. Intravenous regional analgesia. A useful method of producing analgesia of the limbs. Lancet. 1963;1:245–247. 19. Guay J. Adverse events associated with intravenous regional anesthesia (Bier block): a systematic review of complications. J Clin Anesth. 2009;21:585–594. 20. Constantine E, Steele DW, Eberson C, et al. The use of local anesthetic techniques for closed forearm fracture reduction in children: a survey of academic pediatric emergency departments. Pediatr Emerg Care. 2007;23:209–211. 21. Mohler LR, Pedowitz RA, Byrne TP, et al. Pressure generation beneath a new thermoplastic cast. Clin Orthop Relat Res. 1996;322: 262–267. 22. Davids JR, Frick SL, Skewes E, et al. Skin surface pressure beneath an above-the-knee cast: plaster casts compared with fiberglass casts. J Bone Joint Surg Am. 1997;79:565–569. 23. Marson BM, Keenan MA. Skin surface pressures under short leg casts. J Orthop Trauma. 1993;7:275–278. 24. Bingold AC. On splitting plasters: a useful analogy. J Bone Joint Surg Br. 1979;61:294–295. 25. Garfin SR, Mubarak SJ, Evans KL, et al. Quantification of intracompartmental pressure and volume under plaster casts. J Bone Joint Surg Am. 1981;63:449–453.
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