The majority of distal radius fractures are managed conservatively using non-operative modalities. For displaced fractures, this protocol typically involves closed reduction under anesthesia followed by forearm immobilization in a plaster cast or splint for approximately six weeks. Various anesthetic modalities are available to facilitate this procedure, including hematoma blocks (direct local anesthetic injection into the fracture site), intravenous regional anesthesia (IVRA or Bier block), and regional nerve blocks (such as radial, median, or ulnar nerve blocks at the elbow or axilla). Additionally, clinicians may utilize brachial plexus blocks, procedural sedation and analgesia (PSA), or general anesthesia via total intravenous techniques or inhalation agents.[1] Each approach carries distinct potential complications and may occasionally provide insufficient anesthesia, analgesia, or muscle relaxation, potentially compromising reduction alignment and clinical outcomes. Procedural sedation and analgesia (PSA) is routinely utilized in both academic and community hospital emergency departments; yet, patients undergoing PSA face potential risks such as respiratory depression and require rigorous, multi-level monitoring. Conversely, the hematoma block (HB) offers a simple, reliable alternative for pain control during the reduction of distal radius fractures.[2] The clinical transition toward utilizing hematoma blocks, largely replacing general anesthesia, has significantly reduced the operational burden on anesthesiologists and minimized the number of patients requiring strict pre-operative fasting or hospital admission. Evidence indicates that hematoma blocks are less resource-intensive, technically simpler, and faster to execute. Comparative data demonstrate no statistically significant differences in manipulation-related pain scores between hematoma blocks and regional nerve blocks.1 Furthermore, when compared directly to procedural sedation, hematoma blocks demonstrate no significant disparities in reduction failure rates, residual deformity, rest pain, or joint stiffness at the eight-week follow-up mark.[1] Despite the clinical utility of hematoma blocks, inherent risks must be considered, including compartment syndrome, intravascular infiltration, and systemic anesthetic-related cardiac or neurological side effects.[3] Although several studies have highlighted the relatively inferior analgesic efficacy of the hematoma block (HB), its clinical adoption has risen significantly over the years due to its favorable safety profile and technical simplicity.[4] The lower efficacy reported in some literature may stem from utilizing a low volume of lidocaine, which can lead to only a partial distribution of the anesthetic solution within the fracture site. Consequently, increasing the volume of the lidocaine solution injected into the hematoma might enhance its analgesic effect.[4] The standard protocol for an HB typically involves 10 mL of 2% lidocaine. Conversely, Younge [5] documented eight patients who developed forearm compartment syndrome following an HB for the manipulation of a displaced distal radius fracture, suggesting that the introduction of additional fluid into the closed space could precipitate compartment syndrome. Additionally, while the potential cardiotoxicity of lidocaine must be considered, Meinig et al. [6] demonstrated that plasma lidocaine levels remain well below the toxic threshold following an HB for distal radius fracture manipulation using lidocaine doses ranging from 2.2 to 2.4 mg/kg. hence any increase in the volume of dosage potentially also increases its toxic threshold. These adverse events are fundamentally linked to the pharmacological properties of the agents used. Lidocaine is frequently utilized due to its rapid onset and predictable pharmacokinetic profile, whereas drug such as bupivacaine provides a more prolonged duration of action with a slower onset. Clinicians may combine these agents to achieve rapid, long-lasting anesthesia. Safe administration requires adherence to weight-based dosing guidelines to avoid exceeding recommended thresholds. In clinical studies, patients are administered concentrations that represent a fraction of the maximum allowable dose to maintain a safety buffer. The maximum recommended dose of lidocaine without epinephrine for a hematoma block is 4.5 mg per kg body weight. The maximum recommended dose of bupivacaine without epinephrine is 2 mg per kg body weight.[3] Both bupivacaine and lidocaine can induce central nervous system (CNS) toxicity by disrupting cerebral cortical inhibitory pathways. This disruption triggers unopposed excitatory mechanisms that can precipitate seizures. Furthermore, concurrent administration can elevate serum concentrations of these agents, likely due to competitive displacement at plasma protein binding sites. Given that certain anesthetics possess higher potency and a narrower therapeutic window, elevated serum levels significantly increase the risk of systemic toxic effects.[3] There is a distinct need for clinical studies to identify an optimal local anesthetic combination that enhances the clinical efficacy of a hematoma block (HB). Ideally, such a regimen would utilize a minimal drug volume and concentration, thereby offering a safer and highly effective alternative to procedural sedation and analgesia (PSA) for managing distal radius fractures. Consequently, this study compares a widely used combination of lidocaine and bupivacaine at a reduced concentration—equivalent to one-eighth of the maximum recommended dose—against the conventional anesthetic standard for an HB, which consists of a 10 mL lidocaine solution administered at 2 mg/kg.

SOURCE OF DATA The study was conducted on 50 patients with clinically and radiologically confirmed cases of distal end radius fracture in Department of Orthopedics, General Hospital, Gundlupete, Chamarajanagar. INCLUSION CRITERIA 1. Age: Above 18 years of either sex with clinically diagnosed cases of distal end radius fracture (extra articular fractures/ Frykman classification type I and II) 2. Clinical history of trauma, pain and restriction ROM of the wrist less than 24 hours. 3. Minimally displaced fracture or displaced fracture with stable fracture pattern which can be expected to unite within acceptable radiographic parameters 4. Patients unwilling for reduction under sedation or operative intervention 5. Patients who give consent to participate in study. EXCLUSION CRITERIA 1. Failed cases of closed reduction under other anesthetic techniques like sedation, regional block etc. 2. Systemic disease such as cardiac illness, seizure disorders, compromised cardio pulmonary status 3. Known hypersensitivity to lidocaine hydrochloride or bupivacaine 4. Current skin or soft tissue infection near the possible injection site. 5. Patients with any bleeding disorder or on anti-coagulant drugs Previous local surgery STUDY POPULATION This is prospective randomized, single blind, controlled study. This study was conducted in general taluk hospital, Gundlupete. Following informed consent, 50 patients with clinically and radiologically confirmed distal radius fractures were enrolled in the study. The cohort was randomized and equally assigned into two groups of 25 patients each. A detailed medical history was elicited from each participant, followed by a thorough clinical examination to evaluate their general systemic health, localized wrist condition, and neurovascular status. PROCEDURE AND STUDY GROUPS Patients received a local anaesthetic hematoma block, followed by manual manipulation, fracture reduction, and immobilisation using a plaster of Paris (POP) cast. THE HEMATOMA BLOCK INJECTION was performed with the patient placed in either a lateral decubitus or a sitting position. A 22-gauge needle was inserted dorsally, 3 cm proximal to the fracture site, at a 30-degree angle. After penetrating the skin, the needle was advanced directly into the fracture site. Accurate positioning was confirmed by aspirating dark blood from the hematoma. Following confirmation, the selected local anesthetic agent was slowly injected into the fracture hematoma over a 30-second interval. STUDY GROUP I (traditional standardized local anesthetic drug) Local anesthetic drug 2% lidocaine 2mg per kg body weight diluted with normal saline to 10 ml volume STUDY GROUP II (combination of local anesthetic drugs) Combination of Local anesthetic drugs, 2% lidocaine 1mg per kg body weight and 0.5% bupivacaine 0.25mg per kg body weight, diluted with normal saline to 10 ml volume MANIPULATION AND FRACTURE REDUCTION: Patients were placed in a supine position, and manual manipulation was initiated 10 minutes after the block. The Visual Analogue Scale (VAS) score was recorded during the manipulation process. The distal fracture fragment was disimpacted using axial traction combined with an exaggeration of the deformity at the fracture site. Continuous traction and counter-traction were then maintained to realign the distal fragment with the proximal fragment, while direct manual pressure was applied over the distal radius. POST PROCEDURE PERIOD Before the procedure, patients are counselled on the visual analogue scale (VAS)[7]. This scoring system evaluates pain levels before, during, and immediately after the reduction process. To analyze the quality of the reduction, X-rays are performed immediately after the procedure and one week later. These images measure specific anatomical parameters, including radial tilt, dorsal tilt, and ulnar migration. Post-reduction alignment acceptability is categorized as perfect, acceptable, or unacceptable based on the Modified Sarmiento Criteria.[8] Within this framework, perfect reductions include excellent and good outcomes, acceptable reductions denote fair outcomes, and unacceptable reductions represent poor clinical results. Criteria of radiological assessment are shown in below table. Final dorsal angle Loss of radial length Loss of radial tilt score Neutral Neutral < 3 0-4 0 0-4 0 1-10 3-6 5-9 1 11-14 7-11 10-14 2 > 14 > 11 > 14 4 Criteria of Radiological Assessment. Criteria for acceptable reduction based on Sarmiento et al; 0 excellent, 1-3 good, 4-6 fair, 7-12 poor Following the procedure, patients were monitored in the emergency or day-care ward for approximately two hours to detect and record any complications. Monitored procedure-related adverse events included distal sensory or motor deficits, vascular insufficiency, local infection, nausea, vomiting, respiratory distress, weakness from tendon injuries, ECG abnormalities, and seizures. If follow-up radiographs revealed a sub-optimal or unacceptable reduction, the clinical findings and subsequent treatment options—such as reduction under sedation or surgical intervention—were discussed with the patient. Additionally, patients who developed any post-procedure complications or adverse effects were admitted to the hospital for further observation and management. FOLLOW UP Following the reduction, patients received analgesics and anti-edema therapy for the first five days. Clinical and functional progress was monitored during scheduled follow-up visits at 1, 3, 6, and 24 weeks post-procedure. At each interval, patients were evaluated and guided on essential physical therapy regimens and home-based exercise protocols. STATISTICAL METHODS The data in this study underwent both descriptive and inferential statistical analyses. Continuous variables are expressed as mean ± standard deviation (minimum–maximum), whereas categorical variables are reported as frequencies and percentages [Number (%)]. Statistical significance was evaluated using a threshold of 5% (\(\alpha = 0.05\)). Appropriate non-parametric tests were implemented to evaluate the study's ordinal or non-normally distributed variables. Statistical software The Statistical software namely SAS 9.2, SPSS 16.0, socscistatistics calculators, and MedCalc 9.0.1 were used for the analysis of the data and Microsoft word and Excel have been used to generate tables .

STUDY DESIGN: A COMPARATIVE TWO GROUP STUDY Table1: Age distribution of patients studied Age in years Group I Group II No. % No. % 18-30 1 4.0 0 0 31-40 8 32.0 6 24.0 41-50 10 40.0 11 44.0 51-60 5 20.0 7 28.0 61-70 1 4.0 1 4.0 Total 25 100.0 25 100.0 Mean±SD 55.1 ± 9.17 56.4 ± 7.14 Samples are age matched with Student t test. The result is not significant at p <.05. Mean age of this study is 55.88 ± 8.08 (28–68 years) Table 2: Demographic and Baseline Characteristics of the Study Cohort Demographic details Group I Group II TOTAL PARTICIPANTS No % No % No % Gender Female 17 68.0 14 56.0 31 62.0 Male 08 32.0 11 44.0 19 38.0 Total 25 100.0 25 100.0 50 100.0 Dexterity right 13 52.0 18 72.0 31 62.0 left 12 48.0 07 28.0 19 38.0 Total 25 100.0 25 100.0 50 100.0 Table 3: Occupation distribution in two groups of patients studied Occupation Group I Group II No % No % Farmer 7 28.0 6 24.0 Housewife 14 56.0 11 44.0 Private Business 2 8.0 4 16.0 Government servant 1 4.0 0 0 Labourer 1 4.0 2 8.0 Total 25 100.0 25 100.0 Outcome measures(PAIN)- VAS Group I Group II Before reduction Mean (sd) During reduction Mean (sd) Difference Mean (sd) Before reduction Mean (sd) During reduction Mean (sd) Difference Mean (sd) Pain (VAS) 6.96 (1.42) 1.16 (1.02) 5.8 (1.84) 6.84 (1.43) 1.44 (0.96) 5.4 (1.7) Comparison b/n before & during reduction within the group(I/II) In Wilcoxon Signed-Rank Test, the paired differences are statistically significant (p = < 0.001) In Wilcoxon Signed-Rank Test, the paired differences are statistically significant (p = < 0.001) Comparsion between Group I AND Group II In Mann-Whitney U Test, at the 0.05 significance level, the improvement in VAS scores between two groups are Not Statistically Significant (p = 0.126). Table 4: Comparison of Pre-Treatment and Intra-Procedural Baseline Outcome Measures Outcome measures (PAIN)- VAS Group I Group II Before reduction Mean (sd) After reduction Mean (sd) Difference Mean (sd) Before reduction Mean (sd) After reduction Mean (sd) Difference Mean (sd) Pain (VAS) 6.96 (1.42) 2.56 (1.08) 4.4 (1.7) 6.84 (1.43) 1.96 (0.93) 4.8 (1.57) Comparison b/n before & during reduction within the group(I/II) In Wilcoxon Signed-Rank Test, the paired differences are statistically significant (p = < 0.001) In Wilcoxon Signed-Rank Test, the paired differences are statistically significant (p = < 0.001) Comparsion between Group I AND Group II In Mann-Whitney U Test, at the 0.05 significance level, the improvement in VAS scores between two groups are Statistically Significant (p = 0.028). Table 5: Comparison of Pre-Treatment Baseline and Post-Procedural Outcome Measures (30 Minutes Post- Reduction) Table 6: Post-Reduction Radiological Outcomes Based on the Modified Sarmiento Criteria Grading of radiological reduction Group I Group II No. % No. % Excellent 2 8.0 3 12.0 Good 19 76.0 20 80.0 Fair 4 16.0 2 8.0 Poor 0 0 0 0 Total 25 100.0 25 100.0

A total of 50 patients presenting with distal radius fractures met the inclusion criteria and were enrolled in this study. The study population comprised 31 females (62.0%) and 19 males (38.0%), with a collective mean age of 55.88 ± 8.08 years (range: 28–68 years). Anatomically, the majority of the injuries involved the right wrist (62.0%), while the remaining 38.0% occurred on the left side. The mean duration from injury to hospital presentation was 8.9 ± 3.17 hours. In terms of occupational distribution, exactly half of the cohort were homemakers (n = 25/50; 50.0%). Following randomization, the demographic and baseline clinical characteristics were balanced and highly comparable between Group I and Group II, demonstrating no statistically significant differences between the two study branches (p > 0.05). This study focused on the management of patients presenting with extra-articular distal radius fractures. The primary therapeutic goal was to achieve acceptable anatomical reduction using an optimal anesthetic technique, followed by immobilization in a plaster of Paris cast for six weeks. To facilitate this, the chosen anesthetic modality must provide profound analgesia and sufficient muscle relaxation. Additionally, an ideal technique for outpatient or day-care procedures should minimize the need for continuous monitoring while avoiding systemic complications or adverse effects. Consequently, the hematoma block (HB) is widely utilized as a practical alternative to procedural sedation and analgesia (PSA). However, recent meta-analyses indicate that the clinical efficacy of the current standard HB protocol—consisting of 10 mL of lidocaine administered at 2 mg/kg body weight—remains inferior to PSA. While increasing the volume and dose of lidocaine can enhance the block's efficacy, this approach invariably elevates the risk of procedure-related complications. Therefore, we conducted this study to evaluate whether a combination of lidocaine and bupivacaine could improve clinical efficiency over the standard single-drug regimen. To minimize potential complications associated with this combination, the total volume was restricted to 10 mL, and the drug concentrations were limited to one-eighth of their maximum recommended weight-based dosages. When comparing pain severity using the Visual Analogue Scale (VAS) from the pre-treatment baseline to the intra-procedural reduction phase, a statistically significant reduction in pain was observed within both treatment groups (p < 0.05). However, no statistically significant difference in analgesic efficacy was demonstrated between the two groups. This finding suggests that both the standard lidocaine regimen and the low-dose lidocaine-bupivacaine combination provide comparable and equivalent pain relief during the manual manipulation and reduction phases of fracture management. Longitudinal evaluation of Visual Analogue Scale (VAS) scores from pre-treatment baseline to 30 minutes post-reduction revealed a statistically significant reduction in pain within both study cohorts (p < 0.05). Notably, the low-dose lidocaine-bupivacaine combination group demonstrated a statistically significant advantage in analgesic efficacy over the standardized single-drug lidocaine group at this time point. This finding indicates that the combination regimen provides superior, sustained pain relief in the immediate post-reduction phase of fracture management. This prolonged analgesic effect is likely attributable to the extended duration of action inherent to bupivacaine, or potential pharmacological synergism between the co-administered agents, culminating in significantly better post-procedural VAS scores. These results are comparable to results from other studies on hematoma block efficiency. G K Singh et al[9], observed the pain scores during reduction in the local anesthetic group (median = 1.8) were significantly less than those in the sedation group (median = 8.7), P < 0.001 using the Wilcoxon rank sum test. and concluded that Hematoma block by local anesthetic is a safe and effective alternative to sedation in reduction of Colles fracture. A study by L Funk et al [10] observed VAS during reduction was 3.7 in hematoma block, post reduction pain score was greater with hematoma block and concluded Radiological correction was as good in those patients receiving a haematoma block with or without sedation as a general anaesthetic. Ogunlade et al [11] reported significant pain relief with haematoma block during reduction of distal radius fracture. There was dramatic reduction of the mean VAS from 6.6 ± 1.6 to 1.79 ±0.66. Kehinde et al [12] showed that there was a marked reduction in the average pain score during fracture reduction in HB group compared to S group (2.9 ± 1.2 versus 4.6 ± 1.0) and the average post-reduction pain score was relatively lower in HB group than S group (3.4 ± 1.6 versus 3.8 ±1.6). Radiological evaluation based on the Modified Sarmiento Criteria demonstrated that all patients across both study groups achieved either perfect or acceptable fracture reduction. Specifically, perfect reduction was attained in 84.0% of patients in Group I and 92.0% of patients in Group II. These successful radiological outcomes indicate that both anesthetic regimens provided sufficient analgesia and muscle relaxation, thereby enabling the surgeon to perform adequate manual manipulation and anatomical alignment. Additionally, the highly favourable radiological results may be influenced by the specific injury profiles enrolled in this trial. By strictly limiting our inclusion criteria to extra-articular distal radius fractures—corresponding to Frykman classification types I and II—the inherent stability of these specific fracture patterns likely facilitated more predictable and acceptable closed reductions. Our results are comparable to the results of other studies reporting that adequate reduction can be achieved with Hematoma block. [2,13,14,15] Complications In the current study, the most frequently observed adverse events were mild nausea and vomiting, which occurred in five patients overall (two in Group I and three in Group II). These symptoms were successfully managed using standard antiemetic therapy and a proton pump inhibitor (PPI). For precautionary monitoring and safety, these five individuals were admitted to the ward for 24 hours of observation. Notably, there were no reported incidents of hypersensitivity or anaphylaxis associated with the administered local anesthetics. Furthermore, none of the patients in either cohort experienced localized complications—such as infection, compartment syndrome, neurovascular deficits, or secondary loss of fracture reduction—nor did any patients manifest systemic toxicities. Strength and Limitation The principal strengths of this study include its prospective, randomized design and the strict standardization of both interventions, which ensured a reliable framework for comparison. However, several limitations must be acknowledged. First, the total sample size of 50 patients represents a relatively small cohort for comparing treatment modalities in distal radius fractures—one of the most prevalent upper extremity injuries. Nevertheless, our pilot findings provide valuable baseline data that can strengthen future multi-center studies with larger patient populations.Second, while our findings demonstrate clinical and radiological efficacy, the cost-effectiveness and systemic benefits of this combined local anesthetic regimen need to be evaluated against individual monotherapies using rigorous multi-level analysis. Ultimately, the integration of this technique into daily clinical practice will depend on resolving these socioeconomic and operational questions. Finally, variations in injection techniques, alternative drug preparations, and diverse weight-based dosing strategies remain unexamined in this trial and warrant thorough investigation in future clinical research.

A hematoma block using a local anesthetic is a safe and effective technique for providing adequate analgesia during the manipulation and reduction of distal radius fractures. Because this method features a rapid onset and a smooth, predictable recovery without severe side effects, patients tolerate it well. Additionally, it is a cost-effective procedure that can be performed directly in the emergency department, eliminating the need for the prolonged monitoring required by other anesthetic techniques. This makes the hematoma block a highly acceptable anesthetic option for patients with systemic diseases or comorbidities. Our study demonstrated that immediate post-reduction pain management is superior when the hematoma block utilizes a combination of lidocaine and bupivacaine at minimal therapeutic doses, without any increase in procedure- or drug-related adverse effects. Consequently, using a minimal volume and concentration of this combination provides a highly effective alternative to the traditional dosage of lidocaine alone (typically 2 mg/kg of body weight in a 10 mL volume) for blocking distal radius fractures.

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