Case vignette
38yo F w/ morbid obesity, heroin use on suboxone p/w L ankle pain and deformity after tripping while skating. No other injuries. Her foot feels a little numb.
BP 150/100, HR 105, R 21, SpO2 99%, T 36.7
Uncomfortable female with swollen, ecchymotic L ankle. Cap refill is 3s in foot, which appears pale and does not have pulses on palpation or doppler. No open wounds. Compartments soft. No pain or laxity at knee, no pain in proximal tib-fib.
What do you see?
XRs: tri-malleolar fracture, comminuted (lateral view isn’t visualized but shows posterior mal fx)
What do you do next?
You are concerned for vascular injury and plan to emergently reduce her fracture. You place a call to Ortho, but they are stuck in the OR the next 2 hours. It's up to you for now.
You talk to the patient about pain control. She is uncomfortable but declines opiates, noting she is on suboxone. She also remembers an "anesthesia problem" during a past appendectomy. On chart review, she had an exceptionally difficult airway requiring fiberoptic intubation in the OR.
Clock is ticking. Do you torture the patient with poor pain control or put her airway at risk?
Neither, of course. You decide the perform a thorough hematoma block, both for immediate pain control and to minimize sedation during reduction. You use US to locate her hematomas.
What do you see?
MSK2 US1: fracture with hematoma. Hyperechoic (bright) line created by bony cortex, with visible disruption at fracture site. Hypoechoic (dark) collection represents hematoma.
MSK2 US2: out of plane approach showing injection of local anesthetic into hematoma (increasing hypoechoic fluid).
What do you do next?
The patient has substantial pain reduction, though not complete. You give her a small dose of versed and deem her ready for reduction.
You reduce and splint her successfully, noting 2+ pulses now palpable. A post-reduction XR is below.
The patient is ultimately admitted with plan for OR with Ortho in the next 24 hours.
Teaching points. You can use POCUS to visualize any fracture. Trace the bone in transverse and longitudinal planes to localize the fracture. In extremity fractures, you can use this technique to find the optimal location for hematoma blocks. This can really improve pain control, often more effectively than opiates -- and without the sedation risk. For example, FOOSH injuries such as Colles' fractures are often reduced with hematoma blocks, gravity-assisted traction using finger traps, and minimal additional narcotics.
You can even use ultrasound to evaluate reduction success (try it next time before your XR or C-arm -- you might be surprised at how well it can predict reduction quality).
Residents: Dr. Ramsey Selbak, Dr. Anna Nabel
Trimal Fracture + Block
July 2018