The corner pocket shot for distal radius fractures in the emergency department: A single targeted anesthetic injection for distal radius fractures

Background.

Distal radius fractures are a common Emergency Department (ED) presentation and often require procedural sedation for adequate pain control in order to facilitate closed reduction. Ultrasound-guided supraclavicular brachial plexus blocks are classically used for wrist and forearm surgeries, but have begun to be performed in the ED for distal radius fracture reductions. This procedure is not without its complications, including local anesthetic systemic toxicity, complications from needle insertion (peripheral nerve injury, vascular injury, pneumothorax), and phrenic nerve involvement leading to hemidiaphragmatic paralysis. This case series reviews using a single injection with a low volume of anesthetic to mitigate the risk of these complications.

Case Series

Three cases of distal radius fractures presented to the ED requiring reductions. Targeting the C8/T1 nerve roots, low-volume supraclavicular nerve blocks were performed. With concomitant non-opioid analgesia, closed reductions were performed with minimal reported pain. No complications were identified.

Why should an emergency physician be aware of this?

Patients requiring sedation often present to the ED with poorly controlled comorbidities or other contraindications making nerve blocks an excellent alternative. Contrary to the dense surgical anesthesia required by anesthesiologists, the emergency clinician should tailor the block to the specific pathology. In the case of distal radius fracture reductions, we recommend targeting the C8-T1 nerve roots. Through a single targeted injection with accompanying multimodal pain relief, adequate analgesia can be obtained while mitigating the risks that accompany high volume anesthetic and needle redirection.