(P66) Ultrasound Guided Axillary Brachial Plexus Block for ED Closed Reduction of Forearm Fracture

Chief Complaint : Left Wrist Injury

History of Present Illness : This is an otherwise healthy 15yo male who presented to a critical access emergency department for evaluation of left forearm injury sustained while sliding arms first into a base while playing baseball. He immediately experienced severe pain and deformity to his forearm. EMS immobilized the forearm prior to arrival. He arrived to the emergency department without sensory loss distal to the injury and was able to move all of his fingers. He denied any other injuries.

Pertinent Physical Exam: Well Appearing adolescent male who appeared to be in some discomfort related to his left forearm injury. There was marked deformity to the forearm, but skin was intact with no bleeding. He had sensation to the distribution of radial, median, and ulnar nerves on the hand. Flexion, extension, abduction and adduction of all fingers was limited but intact.

Pertinent Laboratory Data: Initial radiographs demonstrated markedly displaced and overriding fracture of the left distal radial diaphysis.

Case Discussion: Patient arrived to critical access facility located approximately 2hrs-2.5hrs by ground to nearest trauma center and had initial radiographs performed at 1620 although he officially was registered as a patient at 1637. ER physician assistant initially evaluated the patient and consulted orthopedic surgeon who was able to evaluate the patient in the emergency department within 20 minutes of being contacted. Expedited transfer to trauma center in this limited resource area was not possible by ground, although air transport by helicopter was an option. Orthopedic surgeon advised closed reduction was indicated and could obviate the need for transfer. Anesthesiologist and OR staff was not available due to the time of day. Emergency physician was consulted for pain management for the procedure. Risks, benefits and alternatives for procedural sedation versus ultrasound guided regional anesthesia were discussed with the patient and his parents who elected USGRA. An ultrasound guided axillary brachial plexus block was performed from approximately 1730-1745. A dense block of the forearm was achieved and reduction initiated by surgeon at approximately 1800. The procedure required several attempts, with an initial reduction deemed inadequate by the surgeon. Adequate reduction was completed at approximately 1821 with immobilizing plaster splint applied and final xrays at 1834. Patient was discharged home at 1953 neurovascularly intact with 1 week followup appointment scheduled. 6 week post reduction images demonstrated good outcome per surgeon and are included.
Discussion - This case demonstrates successful ultrasound guided regional anesthesia in the emergency department performed by emergency physician to facilitate a difficult orthopedic procedure. The risks to the patient of prolonged sedation in the emergency department was avoided and a significant amount of nursing time was spared in this limited resource facility.

References and Acknowledgements (Optional): Image depicting Axillary Brachial Plexus Block courtesy of NYSORA.COM