Distal radius fractures are the most common extremity bone fractures that we come across in everyday practice and account for approximately 18 and 25% of all elderly and youth fractures, respectively. The prevalence of distal radius fractures has been growing consistently in recent years and approximately 1.5% of accident and emergency department (A&E) visits are due to distal radius fractures [1–3]. While RTA constitutes a major cause in young people , trivial injury like slip and fall while walking forms the foremost cause in elderly population .Reduction of fracture to its natural anatomy is of foremost importance to gain the maximum possible range of motion. This enables younger age group to get back to their full productive capacity and meanwhile it also makes the elderly population to perform their day-to-day activities without any compromise. In 1986, Knirk and Jupiter pointed out the same in their article entitled ‘intra-articular fractures of the distal end of the radius in young adults’ [4]. Fracture reduction requires manipulation which is a painful maneuver . Providing adequate analgesia during manipulation is crucial for the patient’s comfort, as well as for radiographic post-reduction results, including dorsal tilt, radial inclination and ulnar variance [5, 6]. Various methods of analgesia are available which include – Nerve root block, intravenous regional anesthesia, intramuscular sedation, hematoma block, general anesthesia, and conscious sedation. Among these, hematoma block is a simple, efficacious method for pain management during manipulation and percutaneous Kirschner wires (K-wire) fixation in minor OT or Emergency department. Research indicates that hematoma blocks are a reliable approach to achieving pain relief without an elevated risk of post-procedural infections when compared to other regional blocks [7].Hematoma block is a local anesthetic technique in which analgesia is achieved through direct infiltration of local anesthetic into the fracture hematoma . Local anesthetic diffusion within the hematoma blocks nociceptive afferent fibers at fracture site, attenuating pain generated by periosteal disruption, inflammatory mediator release, and mechanical stimulation during manipulation . By targeting pain transmission locally, hematoma block provides site-specific analgesia without systemic effects. The level of pain relief is measured with Visual Analog Scale (VAS) before, during, and after the procedure [8]. AIMS & OBJECTIVES Primary objective is to measure the effectiveness of pain relief obtained with hematoma block. Secondary objectives include evaluation of quality of reduction achieved and functional outcomes following hematoma block with percutaneous pinning.Also to report complications that develops if any during or following the procedure

The study was a prospective observational study done between June 2024 and June 2025 in Bangalore Medical College & Research Institute , Bengaluru The study was approved by the institutional ethical committee. The study included 80 patients admitted to Bangalore Medical College & Research Institute , Bengaluru. Inclusion critereia • Age between 18 to 65 years • Displaced extra-articular distal end radius fractures • Admitted within 48 h of the trauma Exclusion criteria • Patients below age 18 years and above age 65 years • Compound injuries • Intraarticular involvement • Severe comorbidities • Uncontrolled diabetes • Serious cardiac disease • Patients taking anticoagulant medications • Patients with haematological disorders • Cognitive impairment, needle-phobia, agitation or aggression that may impact on procedural safety. Detailed personal history was taken to exclude the patients not coming under the inclusion criteria as mentioned.Thorough clinical examination was done and fracture was confirmed with the radiograph of the injured wrist. Radiograph was evaluated to include only the extra-articular distal end radius fractures. Finally patients fulfilling the inclusion criteria were admitted on day care basis and managed with percutaneous K-wire fixation under a hematoma block in the emergency operation room. Once the patient was shifted to the operating room patient received a single dose of I V antibiotic (cefoparazone + sulbactam 1.5 g). ECG monitoring and pulse oximetry monitoring were ensured during the entire procedure. PROCEDURE The haematoma block was administered using standard aseptic non-touch technique as follows • Dorsal aspect of wrist is palpated to locate fracture ‘step-off’ site. • Injection site cleansed using disinfectant , sterile field maintained, sterile gloves donned. • Needle inserted approximately 30 degrees to skin just proximal of fracture (approx. 1 cm) on the dorsal aspect along the plane of the radius injecting local anaesthetic in small amounts as needle advanced toward fracture. The needle was dorsally introduced up to the fracture after confirmation under the c-arm. • 5 mL of lidocaine 2% with 5 mL of 0.5% bupivacaine was injected at the site of fracture. • Aspiration of blood mixed with fat globules of the bone marrow was confirmatory of needle placement into the fracture hematoma • Subsequently, the needle was removed while gradually administering the anesthetic medication. • Infiltration of a small amount of cocktails was also done at the entry points of K-wire. • Pause for 10–15mins to allow for maximum effectiveness of anaesthetic prior to reducing the fracture Part was painted and draped. Manipulation and reduction were done after 10-15 min of infiltration of the cocktail , later which K-wire fixation was done .Pre-operative, intra-operative, and post-operative (after 3 h) VAS scores were assessed for pain. Reduction and fixation of the fracture were confirmed under C-arm Intra-operatively.Post-operatively while discharged patient received a single dose of IV antibiotics and 3 days of oral antibiotics to avoid any risk of infection. K wire dressing was done for next 3 days at hospitals and later daily pin-track care was taught to the patient’s relative for dressings at home or nearby health care provider. K-wire removal was done on 6 weeks post-operative. During this period, standard sponge ball exercises and protected passive wrist range of motion exercises were started. After K-wire removal patient was started with active circumduction exercises and strengthening exercises. On 1-month, 2- month, and 6-month follow-up reduction was reassessed for quality of reduction, any secondary displacement, signs of union on radiograph , and complications if any. Quality of reduction was assessed using the Sarmiento radiological score [9, 10] (modified Lidstrom criteria) as excellent, good, fair, or poor (Table 1). At 6 months and 1 year follow-up, each patient was assessed for wrist function by the Modified Mayo Wrist score [11] and DASH score [12].

Table 1 Characteristics Frequency ($n = 80$) / Mean ± SD Percentage (%) Gender Male 46 57.5% Female 34 42.5% Side Affected Right 51 63.75% Left 29 36.25% Fracture Displacement Dorsal 62 77.5% Volar 18 22.5% Clinical Timelines Procedure time (min) 32.27 ± 6.22 — Time from end of reduction to discharge (hrs) 3.32 ± 1.02 — ED length of stay (hrs) 4.10 ± 2.14 — Table 2 Phase VAS Score (mean ± SD) Pre-operative 6.65 ± 1.92 Intra-operative 0.91 ± 0.45 Post-operative (3 h) 1.92 ± 0.74 Table 3 Functional Score 6 Months (mean ± SD) 1 Year (mean ± SD) P-value Modified Mayo Wrist Score 72.0 ± 8.1 90.0 ± 7.1 p < 0.05 DASH Score 25.0 ± 6.1 14.0 ± 3.7 p < 0.05 Table 4 Radiological Fracture Features Pre-reduction (mean ± SD) Post-reduction (mean ± SD) P-value Dorsal tilt (deg) 22.4 ± 9.7 −1.6 ± 1.3 p < 0.05 Volar tilt (deg) -7.5 ± 2.6 6.2 ± 1.1 p < 0.05 Radial inclination (deg) 17.2 ± 6.8 25.2 ± 1.5 p < 0.05 Radial shortening (mm) 6.1 ± 4.1 1.2 ± 1.7 p < 0.05 A total of 80 patients with displaced extra-articular fractures of the distal end of the radius were included in this prospective observational study. All patients fulfilled the predefined inclusion criteria and underwent closed reduction and percutaneous K-wire fixation under a hematoma block. The study was conducted between June 2024 and June 2025 at Bangalore Medical College & Research Institute , Bengaluru. The study population comprised 46 male and 34 female patients. The right wrist was involved in 51 patients, whereas 29 patients had fractures of the left wrist. Among the fractures, 62 demonstrated dorsal displacement and 18 demonstrated volar displacement(Table1 & Figure 1). The mean duration of the operative procedure was 32.27 ± 6.22 minutes. The mean interval between completion of the reduction procedure and discharge was 3.32 ± 1.02 hours, while the mean emergency department length of stay was 4.10 ± 2.14 hours. Pain assessment (Table 2 & Figure 1) Pain was assessed using the Visual Analog Scale (VAS) before the procedure, intraoperatively, and three hours postoperatively. The mean preoperative VAS score was 6.65 ± 1.92. Following administration of the hematoma block, the mean intraoperative VAS score decreased markedly to 0.91 ± 0.45. At three hours postoperatively, the mean VAS score was 1.92 ± 0.74. Thus, the hematoma block was associated with substantial reduction in pain during manipulation and K-wire fixation, with low pain scores persisting during the early postoperative period. Radiological outcome(Table 4 & Figure 4) Radiological parameters demonstrated significant improvement following reduction and K-wire fixation. The mean dorsal tilt improved from 22.4 ± 9.7° before reduction to −1.6 ± 1.3° after reduction (p < 0.05). In fractures demonstrating volar tilt, the mean value improved from −7.5 ± 2.6° pre-reduction to 6.2 ± 1.1° post-reduction (p < 0.05). Mean radial inclination increased from 17.2 ± 6.8° before reduction to 25.2 ± 1.5° following reduction (p < 0.05). Similarly, radial shortening decreased from 6.1 ± 4.1 mm pre-reduction to 1.2 ± 1.7 mm post-reduction (p < 0.05). These findings indicate that satisfactory restoration of the major radiographic parameters of distal radius alignment was achieved following manipulation and percutaneous K-wire fixation. Functional outcome (Figure 2,3 & Table 3) Functional assessment was performed using the Modified Mayo Wrist Score and the Disabilities of the Arm, Shoulder and Hand (DASH) score at six months and one year. The mean Modified Mayo Wrist Score improved from 72 ± 8.1 at six months to 90 ± 7.1 at one year, with the difference being statistically significant (p < 0.05). In contrast, the mean DASH score decreased from 25 ± 6.1 at six months to 14 ± 3.7 at one year (p < 0.05). The improvement in the Modified Mayo Wrist Score and reduction in the DASH score indicate progressive recovery of wrist function and reduction in upper-extremity disability during follow-up. Patients underwent radiographic and clinical assessment at one, two, and six months to evaluate maintenance of reduction, secondary displacement, union, and complications. K-wire removal was performed at six weeks, following which active wrist circumduction and strengthening exercises were initiated.

The management of displaced distal radius fractures aims to restore anatomical alignment while providing adequate pain control and facilitating early functional recovery. Although several methods of analgesia are available for fracture manipulation, including intravenous regional anesthesia, sedation, nerve blocks, and general anesthesia, the hematoma block is particularly attractive in settings where a simple, localized, and cost-effective technique is desirable. In the present study, hematoma block was used to facilitate closed reduction and percutaneous K-wire fixation in 80 patients with displaced extra-articular distal radius fractures. The principal finding of this study was the marked reduction in pain following administration of the hematoma block. The mean VAS score decreased from 6.65 ± 1.92 before the procedure to 0.91 ± 0.45 intraoperatively. This represents a substantial reduction in procedural pain and suggests that the hematoma block provided effective analgesia during fracture manipulation and K-wire fixation. The low postoperative VAS score of 1.92 ± 0.74 at three hours further indicates that satisfactory early postoperative analgesia was achieved. The mechanism is consistent with the local action of the anesthetic within the fracture hematoma, where blockade of nociceptive afferent fibers reduces pain arising from periosteal injury, inflammatory mediators, and mechanical manipulation. The findings are consistent with previous reports supporting hematoma block as an effective method of analgesia for distal radius fracture reduction. Myderrizi and Mema (9) reported that hematoma block can provide effective pain relief during distal radius fracture reduction, while Johnson and Noffsinger (7)evaluated its safety in distal forearm fractures. The present study extends this clinical application to a setting in which fracture reduction is followed by percutaneous K-wire fixation rather than manipulation alone. An important advantage of the technique is that it permits fracture management with minimal systemic sedation. In the present study, patients were managed in an emergency operation-room/day-care setting with ECG and pulse-oximetry monitoring, and the mean time from completion of reduction to discharge was only 3.32 ± 1.02 hours. The mean emergency department length of stay was 4.10 ± 2.14 hours. These findings suggest that hematoma block-assisted K-wire fixation may be particularly useful in a day-care or minor operating-room setting, potentially facilitating efficient patient turnover while avoiding the recovery requirements associated with deeper sedation or general anesthesia. The radiological results also demonstrate effective restoration of fracture alignment. There was a statistically significant improvement in dorsal/volar tilt, radial inclination, and radial shortening after reduction. Restoration of dorsal tilt from 22.4 ± 9.7° to −1.6 ± 1.3°, improvement in radial inclination from 17.2 ± 6.8° to 25.2 ± 1.5°, and reduction in radial shortening from 6.1 ± 4.1 mm to 1.2 ± 1.7 mm indicate that satisfactory correction of the principal parameters of distal radius alignment was achieved. These radiological findings are clinically important because restoration of distal radial anatomy is associated with preservation of wrist mechanics and functional movement. The importance of achieving an appropriate reduction is particularly relevant in view of the established relationship between residual deformity and functional outcome in distal radius fractures. The functional results demonstrated continued improvement beyond the early postoperative period. The Modified Mayo Wrist Score increased significantly from 72 ± 8.1 at six months to 90 ± 7.1 at one year. At the same time, the DASH score decreased from 25 ± 6.1 to 14 ± 3.7. Because higher Modified Mayo scores represent better wrist function whereas lower DASH scores indicate less disability, the direction of change in both measures supports progressive functional recovery during the first postoperative year. These findings suggest that satisfactory fracture reduction and stabilization with percutaneous K-wires, combined with subsequent rehabilitation, can result in good medium- to long-term functional outcomes. The progressive functional improvement may also be related to the rehabilitation protocol used in the study. Protected passive wrist range-of-motion exercises and sponge-ball exercises were initiated during the period of K-wire fixation, followed by active circumduction and strengthening exercises after K-wire removal at six weeks. This staged rehabilitation approach allows protection of the fracture during the initial healing period while subsequently facilitating restoration of wrist movement and strength. The procedural technique used in this study incorporated infiltration of local anesthetic not only into the fracture hematoma but also around the K-wire entry sites. A combination of 5 mL of 2% lidocaine and 5 mL of 0.5% bupivacaine was administered at the fracture site after confirmation of needle placement by aspiration of blood mixed with bone-marrow fat globules. A waiting period of 10–15 minutes was allowed before manipulation. This protocol provides both relatively rapid onset of analgesia from lidocaine and a longer duration of local anesthesia from bupivacaine. The study also demonstrates the practical feasibility of performing percutaneous K-wire fixation under hematoma block. The mean procedure time was 32.27 ± 6.22 minutes. The relatively short procedural duration, combined with the short post-procedure observation period, supports the potential utility of this technique in appropriately selected patients with extra-articular distal radius fractures. Nevertheless, the findings should be interpreted in light of the study design. This was a prospective observational study without a control group receiving an alternative analgesic technique. Therefore, although the substantial reduction in VAS scores supports the effectiveness of hematoma block, the present data do not permit direct comparison of hematoma block with intravenous sedation, regional anesthesia, or general anesthesia. Similarly, the study cannot establish superiority of hematoma block over these alternatives. In addition, the available study data do not provide a numerical distribution of Sarmiento radiological grades, rates of secondary displacement, radiographic union, or individual complications. Although these outcomes were included in the follow-up assessment protocol, their numerical results are not presented in the supplied dataset and therefore cannot be used to quantify the complication or union rates.

In this prospective series of 80 patients, hematoma block provided effective analgesia during manipulation and percutaneous K-wire fixation of displaced extra-articular distal radius fractures. The procedure was associated with a substantial reduction in VAS pain scores, satisfactory correction of radiological parameters, and significant improvement in functional outcomes between six months and one year. Within the limitations of an observational study without a comparative control group, these findings support hematoma block as a simple, effective, and feasible analgesic technique for percutaneous fixation of appropriately selected distal radius fractures.

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