Bilateral distal radius fractures

[Intubate]

This is a 40 yo, generally healthy for ORIF bilateral distal radius fractures as an outpatient (ASC). Concerned about blocking both arms and sending her home, unable to protect herself from a fall. Do you block both sides and send her home, or, block the "worst" side, let the surgeon put local in the other side, and hope for the best?

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[Mman]

just give her some narcs

 

[Hoya11]

This is a 40 yo, generally healthy for ORIF bilateral distal radius fractures as an outpatient (ASC). Concerned about blocking both arms and sending her home, unable to protect herself from a fall. Do you block both sides and send her home, or, block the "worst" side, let the surgeon put local in the other side, and hope for the best?

Block one side surgeon local one side

 

[GaseousClay]

Bilateral infraclavs make sure husband truly loves her

 

[ranvier]

Bilateral infraclavs make sure husband truly loves her

D/c home with ambu bag to husband?

 

[DocVapor]

I'm assuming she's going to get two casts so she isn't going to be wiping her own butt anyway. So I think bilateral axillary blocks (make sure you get the musculocutaneous) would be reasonable.

 

[GaseousClay]

D/c home with ambu bag to husband?

funny but low risk of phrenic nerve palsy with target block. Agree with above can do bilateral Ax

 

[jwk]

funny but low risk of phrenic nerve palsy with target block. Agree with above can do bilateral Ax

I had phrenic involvement with both of my U/S guided ISBs for my shoulder scopes.

We would probably not do bilateral blocks in our shop, due to the risk of LAST but to each his own. I'm sure volume and/or concentration of LA can be adjusted with the bilateral blocks to decrease the risk but still not something we would do.

 

[Lecithin5]

Either bilateral ax blocks (wouldn’t risk even bilateral infraclav as you can still get phrenic); or block one of them; or just local/narcs! Many options- discuss with surgeon and patient…

 

[GaseousClay]

I had phrenic involvement with both of my U/S guided ISBs for my shoulder scopes.

We would probably not do bilateral blocks in our shop, due to the risk of LAST but to each his own. I'm sure volume and/or concentration of LA can be adjusted with the bilateral blocks to decrease the risk but still not something we would do.

ISB is super high risk phrenic nerve palsy. IC studies state 25% but our X-ray study during residency showed much lower incidence of palsy. But yea bilateral blocks prob aren’t necessary. Block the worse side then local.

 

[NICMAN]

Bilateral axillary.

 

[Hork Bajir]

Fluoro-guided cervical epidural anyone?

On a serious note, as someone who recently needed ORIF of a dominant hand radius fracture… Cannot even begin to imagine how much bilateral radius fractures would suck. Functionally a double arm amputee for at least 3-4 months. That’s a life changing injury

 

[dannyboy1]

Prop, roc, tube
We do blocks for wrist fractures when surgeons requests but it’s really not that painful once it’s in a cast. Let the surgeon put skin local for incision.

 

[Intubate]

Prop, roc, tube
We do blocks for wrist fractures when surgeons requests but it’s really not that painful once it’s in a cast. Let the surgeon put skin local for incision.

Why on earth would you intubate a distal radius fracture?
We block 100% of these cases. One surgeon was a holdout who insisted they didnt hurt. He was obviously wrong and has come around.

 

[Mman]

Why on earth would you intubate a distal radius fracture?
We block 100% of these cases. One surgeon was a holdout who insisted they didnt hurt. He was obviously wrong and has come around.

username does not check out

 

[sevo00]

Prop, roc, tube
We do blocks for wrist fractures when surgeons requests but it’s really not that painful once it’s in a cast. Let the surgeon put skin local for incision.

Damn roc and tube? What’s wrong with LMA and spontaneously ventilating?

 

[Mman]

Damn roc and tube? What’s wrong with LMA and spontaneously ventilating?

both ways achieve the same outcome

 

[sevo00]

both ways achieve the same outcome

Yes I am aware. But why give patient a paryltic when they don’t need one for the procedure.

 

[UscGhost]

Prop, roc, tube
We do blocks for wrist fractures when surgeons requests but it’s really not that painful once it’s in a cast. Let the surgeon put skin local for incision.

I find they are in severe pain in the pacu if we don't do a block. So I block everyone.

Nice to do a case with minimal opioids, patient happy and awake in pacu and send them home with no pain for 20-24 hrs

 

[GassYous]

I find they are in severe pain in the pacu if we don't do a block. So I block everyone.

Nice to do a case with minimal opioids, patient happy and awake in pacu and send them home with no pain for 20-24 hrs

Amen. Drives me nuts to have patients crying from pain then basically apneic from drugs when a block is so fast, easy and effective.

 

[Hork Bajir]

Can confirm from personal experience (twice, sadly)… ORIF distal radius hurts like a mother$&@(?!

 

[Urzuz]

99% of the time we don’t block distal radius fractures and patients do fine. Maybe our opioids are stronger out west…

 

[deleted875186]

I would do bilateral axillary, still some shoulder function, would definitely not do bilateral infra or supraclav. Probably depends on the patient and the support at home.

Curious if anyone has done lower concentration blocks in a situation like this, maybe 0.125% bupi or less, and had any motor sparingly with good analgesia?

 

[narcusprince]

Bilateral blocks with dilute bupi 0.25%. General LMA. The surgeon with their splint will knock out ability to protect self from fall.

 

[BobLoblaw78]

I agree with Narcus.

Sounds like this patient needs to invest in a bidet.

 

[nimbus]

Bilateral blocks with dilute bupi 0.25%. General LMA. The surgeon with their splint will knock out ability to protect self from fall.

I use bupiv 0.25% for just about all brachial plexus blocks and get dense motor blocks almost every time. I don’t consider 0.25% to be dilute. Bupiv 0.125% is hit or miss with regard to motor block.

 

[UscGhost]

99% of the time we don’t block distal radius fractures and patients do fine. Maybe our opioids are stronger out west…

I imagine they need 200-300 mcg fentanyl intraop plus 1-2mg Dilaudid in pacu.

And then a couple Vicodin when they get home.

Seems like they would do better with zero narcotics and better pain control with block that takes 5 mins to do..

 

[UscGhost]

Amen. Drives me nuts to have patients crying from pain then basically apneic from drugs when a block is so fast, easy and effective.

I often find that people don't do blocks for a few reasons

1. They don't know how to do them well enough to be fast and efficient
2. The blocks aren't compensated well in their groups. I am aware of many compensation systems that cap the number of units you can get with blocks per day, or only pay a couple units for a block.
3. They are too tired or don't feel like it

 

[Urzuz]

I imagine they need 200-300 mcg fentanyl intraop plus 1-2mg Dilaudid in pacu.

And then a couple Vicodin when they get home.

Seems like they would do better with zero narcotics and better pain control with block that takes 5 mins to do..

Your numbers are way off.

And of course they will have better pain control with a block, but the benefit is marginal.

 

[nimbus]

Your numbers are way off.

And of course they will have better pain control with a block, but the benefit is marginal.

There is also the issue of the block wearing off after the patient gets home with no opioids or any other systemic analgesics on board. Blocks make us look good when the patient is in PACU bright eyed and pain free. But that is not the whole picture. It is important to tell the patients to start their multimodal pain regimen before they go to bed at night even if they are having no pain.

 

[narcusprince]

I often find that people don't do blocks for a few reasons

1. They don't know how to do them well enough to be fast and efficient
2. The blocks aren't compensated well in their groups. I am aware of many compensation systems that cap the number of units you can get with blocks per day, or only pay a couple units for a block.
3. They are too tired or don't feel like it

Agree with number 1. Lots of cats say they can but in reality cannot do nerve blocks. Out of training I was not great. My last 2 years in the Navy I increased my time on the APS service. The navy is excellent at teaching regional anesthesia. Now what keeps me sought after is my speed with nerve blocks.

 

[JOHNBROCHILL]

If the patient has poor lower extremity veins you'll need two antecub IVs. Use left one while right tourniquet is up, use right one while left tourniquet is up. I've found they have a high chance of clotting as well so I prefer to place lower extremity if feasible. I did one last week and between the two IVs and now two blocks it was too ridiculous for me.. LMA all the way patient did fine.

 

[NICMAN]

There is also the issue of the block wearing off after the patient gets home with no opioids or any other systemic analgesics on board. Blocks make us look good when the patient is in PACU bright eyed and pain free. But that is not the whole picture. It is important to tell the patients to start their multimodal pain regimen before they go to bed at night even if they are having no pain.

I understand the NSAIDs, but a lot of people tell these blocked patients to take an opioid before going to bed. Why should they take an Oxycodone when they have zero benefit and all the adverse side effects (other than getting an opioid buzz... which I don't consider a benefit)?

I did close to 1,000 brachial plexus blocks last year and my blocks always last at least 17 hours. Most last close to 24 hours. A good night sleep and entering the pain Time-course vs. Intensity curve much lower down on the slope (thus minimizing the spinal ramp-up phenomenon) can carry significant benefit especially in that 70 year old frail lady from the senior living community.

 

[anbuitachi]

this lady has bilateral radius fractures. how much fall protection do you think she will get with her broken arms

if i were her, id rather fall on my face, than fall on my 2 broken arms

 

[Urzuz]

this lady has bilateral radius fractures. how much fall protection do you think she will get with her broken arms

if i were her, id rather fall on my face, than fall on my 2 broken arms

It isn’t about fall protection. It isn’t even about what gives the best pain control.

Physicians have a tendency to treat their own idiosyncrasies rather than the patient. This person is young and has clearly had a ****ty go at it with bilateral broken arms. Sure, doing bilateral brachial plexus blocks, running 0.5 MAC sevo or just a propofol infusion, seeing 0’s across the board on pain scores, and getting them discharged without so much as a Tylenol may feel great for you. But you’ve relegated this 40 year old to two floppy arms for a day.

Even with their wrists in splints, they can still use their fingers. They can still move their forearms (the elbow isn’t going to be casted). With bilateral blocks, suddenly they have no iPhone. No TV remote. They're completely dependent on a friend / significant other for everything for 24 hours.

Blocking both upper extremities in a healthy 40 year old (with presumably no chronic pain history etc) is idiotic IMO and isn’t treating the patient. Maybe you guys work with ****ty orthopedic surgeons with awful surgical technique, but the vast majority of distal radius fractures do fine with Tylenol, local at the site, and a little opioid thrown on top. Maybe you can convince me to block one arm (either the site that has a more complex fracture or if both sides look the same, maybe their non dominant arm). Both blocking both arms from the get-go is really silly.

If pain control is that big of an issue in PACU, you can always block them afterward. But the reality is I probably need to perform a rescue block on <5% of distal radius fractures (we do a ton and I can’t remember the last one I’ve needed to block in pacu). And the hassle of doing a block in PACU is worth at least giving them a shot at having a semi-functional arm for the day.

 

[Arch Guillotti]

If the patient has poor lower extremity veins you'll need two antecub IVs. Use left one while right tourniquet is up, use right one while left tourniquet is up. I've found they have a high chance of clotting as well so I prefer to place lower extremity if feasible. I did one last week and between the two IVs and now two blocks it was too ridiculous for me.. LMA all the way patient did fine.

EJ/IJ.

 

[JOHNBROCHILL]

EJ/IJ.

Yeah definitely that too. Most patients aren’t thrilled on having even an EJ awake. Perhaps my patients are princesses but I would end up going to sleep with a peripheral and then placing EJ/IJ. Either way I’m doing 2 lines.

 

[deleted875186]

It isn’t about fall protection. It isn’t even about what gives the best pain control.

Physicians have a tendency to treat their own idiosyncrasies rather than the patient. This person is young and has clearly had a ****ty go at it with bilateral broken arms. Sure, doing bilateral brachial plexus blocks, running 0.5 MAC sevo or just a propofol infusion, seeing 0’s across the board on pain scores, and getting them discharged without so much as a Tylenol may feel great for you. But you’ve relegated this 40 year old to two floppy arms for a day.

Even with their wrists in splints, they can still use their fingers. They can still move their forearms (the elbow isn’t going to be casted). With bilateral blocks, suddenly they have no iPhone. No TV remote. They're completely dependent on a friend / significant other for everything for 24 hours.

Blocking both upper extremities in a healthy 40 year old (with presumably no chronic pain history etc) is idiotic IMO and isn’t treating the patient. Maybe you guys work with ****ty orthopedic surgeons with awful surgical technique, but the vast majority of distal radius fractures do fine with Tylenol, local at the site, and a little opioid thrown on top. Maybe you can convince me to block one arm (either the site that has a more complex fracture or if both sides look the same, maybe their non dominant arm). Both blocking both arms from the get-go is really silly.

If pain control is that big of an issue in PACU, you can always block them afterward. But the reality is I probably need to perform a rescue block on <5% of distal radius fractures (we do a ton and I can’t remember the last one I’ve needed to block in pacu). And the hassle of doing a block in PACU is worth at least giving them a shot at having a semi-functional arm for the day.

My residency the norm was postop blocks, and I would say well over half of the upper extremities ortho and hand surgeries got them. 5% seems like a gross underestimate. These can be fairly painful surgeries. How about we simply ask the patient if he or she is ok with no hand function for 12-24 hours, make sure they have good support; and then make a decision. They’ll still have control of the shoulder with an axillary block.

 

[Urzuz]

My residency the norm was postop blocks, and I would say well over half of the upper extremities ortho and hand surgeries got them. 5% seems like a gross underestimate. These can be fairly painful surgeries. How about we simply ask the patient if he or she is ok with no hand function for 12-24 hours, make sure they have good support; and then make a decision. They’ll still have control of the shoulder with an axillary block.

Again, maybe there is something to the surgical technique that you are completely glossing over. I am lucky enough to work with very good ortho trauma guys, and uncomplicated distal radius fractures take them 45 minutes skin to skin and we do not block them regularly. You can choose to believe me or not (or the other posters on here who say they don’t regularly block these patients) — that’s your own hubris not letting you understand there are other experiences out there other than your own.

Of course, consenting the patient to the procedure is step 1 for any block. If they aren’t OK with it, it’s dead in the water. But the consent process involves telling them the alternatives - if you pitch the alternative of PO meds as being some sort of hell-on-earth pain they’ll be in, of course they’ll opt for the block. If you pitch the block as being unnecessary in the vast majority of patients and it will leave them with a numb, floppy arm for a day (or in the case that we are discussing in this post, two numb floppy arms) you’ll be surprised how many people would rather have a little pain.

 

[GassYous]

Again, maybe there is something to the surgical technique that you are completely glossing over. I am lucky enough to work with very good ortho trauma guys, and uncomplicated distal radius fractures take them 45 minutes skin to skin and we do not block them regularly. You can choose to believe me or not (or the other posters on here who say they don’t regularly block these patients) — that’s your own hubris not letting you understand there are other experiences out there other than your own.

Of course, consenting the patient to the procedure is step 1 for any block. If they aren’t OK with it, it’s dead in the water. But the consent process involves telling them the alternatives - if you pitch the alternative of PO meds as being some sort of hell-on-earth pain they’ll be in, of course they’ll opt for the block. If you pitch the block as being unnecessary in the vast majority of patients and it will leave them with a numb, floppy arm for a day (or in the case that we are discussing in this post, two numb floppy arms) you’ll be surprised how many people would rather have a little pain.

Don't agree. I always tell the patient that the block is not necessary and that they will have trouble using their arms. Also tell them about possible eyelid drooping or losing the sensation of breathing. I've only had one patient opt out of the block out of hundreds.

 

[Urzuz]

Don't agree. I always tell the patient that the block is not necessary and that they will have trouble using their arms. Also tell them about possible eyelid drooping or losing the sensation of breathing. I've only had one patient opt out of the block out of hundreds.

I’m not arguing about your experience - I have enough to humility to believe you. But clearly we are using different words and consent techniques since my patients seem to always opt for not getting a block (with the possibility of getting a rescue block in the pacu - something that they rarely need).

In any event, I don’t think there is anything necessarily wrong in blocking distal radius fractures regularly. I think it’s unnecessary in my practice setting, but to each their own. I think blocking uncomplicated bilateral distal radius fractures preoperatively is ridiculous in an otherwise young, healthy patient.

 

[deleted875186]

I’m not arguing about your experience - I have enough to humility to believe you. But clearly we are using different words and consent techniques since my patients seem to always opt for not getting a block (with the possibility of getting a rescue block in the pacu - something that they rarely need).

In any event, I don’t think there is anything necessarily wrong in blocking distal radius fractures regularly. I think it’s unnecessary in my practice setting, but to each their own. I think blocking uncomplicated bilateral distal radius fractures preoperatively is ridiculous in an otherwise young, healthy patient.

Agreed, probably quality of surgeon, patient demographic, etc, has a lot to do with it.

I would also add, surgeons preference for blocks and what they tell the patient before we even see them probably also has a big influence on whether patient wants a block or not.

 

[Urzuz]

Agreed, probably quality of surgeon, patient demographic, etc, has a lot to do with it.

I would also add, surgeons preference for blocks and what they tell the patient before we even see them probably also has a big influence on whether patient wants a block or not.

100% agree.

 

[Pappy Van Propofol]

I don’t understand not blocking 100% of single sided distal radius fractures except for contraindications or the patient declined. It’s 24+ hrs of a zero pain score. No opioids. No risk of over-sedation. One good night of sleep. Bilateral fractures, I would pick the non-dominant arm and make it numb.

 

[DocMcCoy]

I don’t understand not blocking 100% of single sided distal radius fractures except for contraindications or the patient declined. It’s 24+ hrs of a zero pain score. No opioids. No risk of over-sedation. One good night of sleep. Bilateral fractures, I would pick the non-dominant arm and make it numb.

Some PP shops don’t roll that way. Blocks are OR time in my shop. 10 minutes to a 30 min case matter (whether it should or not). Surgeons and admin happy with local/multimodal sans block +\- norco for the ride home. Also blocks aren’t zero risk. (BTW, I’m pro regional).

 

[narcusprince]

I don’t understand not blocking 100% of single sided distal radius fractures except for contraindications or the patient declined. It’s 24+ hrs of a zero pain score. No opioids. No risk of over-sedation. One good night of sleep. Bilateral fractures, I would pick the non-dominant arm and make it numb.

Prince Yeshua I block whoever the surgeons want blocked in my shop. Unless anticoagulant issues. The surgeons make the call on blocks.

 

[nimbus]

Some PP shops don’t roll that way. Blocks are OR time in my shop. 10 minutes to a 30 min case matter (whether it should or not). Surgeons and admin happy with local/multimodal sans block +\- norco for the ride home. Also blocks aren’t zero risk. (BTW, I’m pro regional).

Block in preop while they’re mopping. Adds no time at all. Unless they don’t mop between cases which I’ve seen At our place I can block, eat a bag of chips, poop, and even wash my hands before the patient rolls back.

 

[GassYous]

Block in preop while they’re mopping. Adds no time at all. Unless they don’t mop between cases which I’ve seen At our place I can block, eat a bag of chips, poop, and even wash my hands before the patient rolls back.

I don't see the need to mop for many cases. Cataracts, manipulations, etc. In reality I can block and sleep faster than most of my partners even if their patients had preop blocks

 

[woopedazz]

Maybe I'm a simpleton, and live in a dream world, but I lold at sending this patient home with 2 floppy arms to avoid giving them 3-5 Oxycodone tablets.

GA, LMA, Spont vent, surgical LA infiltration, probably 200 fent during the case, couple of oxys after waking, then out the door.

 

[nimbus]

Maybe I'm a simpleton, and live in a dream world, but I lold at sending this patient home with 2 floppy arms to avoid giving them 3-5 Oxycodone tablets.

GA, LMA, Spont vent, surgical LA infiltration, probably 200 fent during the case, couple of oxys after waking, then out the door.

But do you get paid extra to block?