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HAEMATOMA BLOCKS, THE THEORY AND

PRACTICE:
Haematoma blocks are real magic bullets and useful in a wide range of minimally
operative and non operative orthopaedic procedures, especially in long bone
fractures.
As conservative treatment is gradually disappearing from our current teaching, many
of the trainees are unaware of this magical system producing almost spectacular
results.
This short note and video describe the procedure and the theory behind it.

Pain fibres:
Sensory nerve fibres are of of four types, touch, pain, temperature, and
proprioception.
Pain fibres are important for us to understand the haematoma blocks.
In an extremity, the skin has maximum number of pain fibres. The subcutaneous
tissue has some pain conducting nerve fibrils.
The fascia and muscle have no pain sensation. However they do have a
proprioceptive feel and the patient feels a stretch or pull if these structures are cut or
stretched.
The periosteum is generously endowed with pain fibres.
This is to protect us from loading our bones with forces beyond their endurance. The
combination of proprioceptive and pain fibres, produce the deep, sharp, severe pain
associated with fractures. It would stand to reason that impacted fractures, with
minimal movement are less painful than un-impacted ones.
As fractures per se are painful and manipulations more so, most manipulations and
reductions of fractures are done under general anaesthesia.
Haematoma blocks are a wonderful alternative, much easier, less risky and
inexpensive.

The Technique:
Lignocaine 1% (Xylocaine 1%) is mixed with one to three times its volume of normal
saline to make it between .25 to .5 % dilution.
Appropriate volume ( as shown in the guidelines below) is now injected directly into
the haematoma, under strict aseptic conditions in the operating room.
After ten minutes, all pain is gone an the limb is fit for manipulation.

The volume:
Adults Tibia, humerus, and femur: 12 to 15 ml.
Adults wrist, shoulder and ankle: 5 to 10 ml
Children Tibia, humerus, and femur: 5 to 10 ml
Children wrist, shoulder and ankle: 3 to 6 ml.

The Procedure:
1, Load the syringe with the appropriate volume. Push the needle into the syringe and
lock it tight. We are going to inject under pressure, and we dont want the needle to
detach and the medicine to spray all over. A 22 gauge needle with a 20 cc syringe are
usually used.
2, Decide on the point of injection. If bone is subcutaneous, go direct into it.
Otherwise avoid nerves and vessels. You can go through everything else that comes in
the way.
3, Enter deep enough till the needle touches the bone. Push gently, else the needle tip
might get bent on touching the bone.
4, Suck to ensure that no arterial blood rushes into the syringe.
5, Speak to the patient reassuringly, and put them at ease at this stage as the next step
is going to be painful.

6, Slowly inject the adequate volume into the fracture haematoma.


7, Wait for ten minutes and then see the magic.

Indications:
Fractures among these, which would be otherwise managed by
manipulative reduction under GA.
Neck and shaft of humerus, Supra condylar or other elbow fractures, both bones fore
arm, and all distal radial fracures.
Trochanteric fractures, Shaft of femur, supra condylar femur, all tibial fractures, and
ankle injuries.