Procedure for patients returning for Biers block and manipulation of wrist fractures

There are times when it is not practical for patients with distal radius fractures to undergo Biers block regional anaesthesia and manipulation during their initial attendance.

A protocol has been agreed between the Emergency Department and plaster room staff that describes how these patients should be managed.

Procedure

Once it has been decided by the senior duty clinician that a patient requires manipulation of a distal radius fracture the following day the following procedure should be followed;

• A plaster backslab, broad arm sling and appropriate analgesia should be provided.
• The patient should be given an appointment for the following emergency department clinic at 10:00am.
• Plaster room staff should be made aware of the patient’s arrival at the clinic and should inform the emergency clinic nurse of a time that they will be free to assist with the procedure. It is expected that this time should be as close to 11:00am as is practical.
• At the clinic the patient shall be prepared for the procedure, this includes completion of the appropriate documentation, IV cannulation and consenting.

• Allergy to local anaesthetic
• Children – consider whether appropriate on individual basis
• Hypertension >200mm Hg
• Infection in the limb
• Lymphoedema
• Methemoglobinemia
• Morbid obesity (as the cuff is unreliable on obese arms)
• Peripheral vascular disease
• Procedures needed in both arms
• Raynaud’s phenomenon
• Scleroderma
• Sickle cell disease or trait
• Paget's Disease
• Uncooperative or confused patient

Prilocaine dosage: maximum dose 3mg/kg