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Hematoma block
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8/11/2017 at 2:43:35 PM GMT
Posts: 8
Hematoma block
I was taught when doing a hematoma block to actually 'irrigate the fracture", ie aspirate a couple cc's of blood, inject a cc or two of local, and repeat this process several times. I have found that this technique greatly improves the efficacy of the block. Thoughts? 

Sam Dyer, PA-C, MHS
President PAOS


8/20/2017 at 1:05:08 PM GMT
Posts: 3
I had similar training, to ensure I was in hematoma I would aspirate a few cc. Then inject a few cc, then I would fan the needle out a bit, only a few mm to each side and repeat the process. This has usually produced a good success rate. Although each patient responds diffently to it and gets a different amount of pain control from it.


8/22/2017 at 1:34:47 PM GMT
Posts: 8
Thanks Chuck. It seems to work well for me too. Do you use finger traps for your DR reductions? We have a set in my urgent care and also use an incremental increase in sandbag weights to help. Curious after your reduction and post red films, when do you bring the patient back to follow up? I typically bring them in at one week so there is time to go to CRPP or ORIF prn.

Sam Dyer, PA-C, MHS
President PAOS


8/23/2017 at 2:01:32 PM GMT
Posts: 1
I agree, it's crucial to have the patient return for follow up X-rays in a week or so... as swelling goes down, casts get loose and fractures can shift.


8/24/2017 at 5:27:11 PM GMT
Posts: 8
Do you keep them in a sugar tong for an additional week at that point or switch to a cast?

Sam Dyer, PA-C, MHS
President PAOS


9/4/2017 at 11:51:56 AM GMT
Posts: 3
Thanks for reply,
I do use finger traps in the ER/OR, do not have them in clinic and sometimes just need to use manual traction. I have found the finger traps can sometimes be tricky to use, and when adding progressive weight you need to be careful as to not have them come loose.

Yes like you I add progressive weight, and to be honest most fractures will start to line up and reduce well once you get some muscle relaxation with the traction. This can only be achieved though with a good block so the patient is not fighting it do to pain.

I typically do the reduction with mini c-arm guidance, then bring the patient back weekly for the first 3 weeks to check how well the splint is fitting and the reduction is holding. For me changing the splint or over wrapping depends on the quality and stability of the reduction. If I think unstable but swelling is down at 1 week may over- wrap the splint. If stable then may change at 2 weeks to cast.

What are your thoughts? Curious to know what type of splint and cast you use after reduction and in clinic after follow up visits? I know there is a lot of conflicting evidence regarding cast initially with univalve of cast (typically for peds fracture), or splint with over-warp, also some advocate just short arm cast only and no need for long arm.



9/13/2017 at 1:27:37 AM GMT
Posts: 1
What is reimbursement rate for treating this type of fracture without surgery (CRPP or ORIF) vs. closed treatment as above? Do you, as the PA, do all the procedure and billing ne'er your NPI? For us (single surgeon private practice, me the only PA in north Texas area) we let ER reduce it and splint. See them in a week after swelling is down and set up surgery.


9/14/2017 at 10:34:54 PM GMT
Posts: 8
So to Chuck's earlier post, I do a plaster sugar tong and bring them back in a week. If it doesn't move and I felt I had a good reduction, I will switch to a cast, usually LA x 1-2 weeks then SA. If looks really good, may use a SA right away. I wish I had a c-arm in my clinic, would save me xrays!

I had a SH1 a few weeks ago where the epiphysis was 100% displaced. I was able to reduce it to about 25% of the physis width, but the kid was squirrely and I didn't like it so sent him for CRPP. Just pulled those pins this week actually. Will have to do a post somewhere or maybe will write a case study for the newsletter.

Sam Dyer, PA-C, MHS
President PAOS


9/14/2017 at 10:52:44 PM GMT
Posts: 8
Hi Russell and thanks for the reply. So if I push on it, I charge fracture care. I know some practices charge fracture care for every fracture, but in my neck of the woods the patients get sticker shock when they see the global amount and some even have to make copays (in the global) at f/u apts depending on the insurance. So I only do it if I am actively reducing the fracture. Otherwise it gets itemized. I think the key (depending on your practice rates) is if you are going to see them more than 3-4 times. Less than 3 you will do better with fx care, more then 3-4 you will do better with a global (assuming your changing splints/casts, xrays, etc).

To answer your question, I think the global for a DRF reduction in my office is several hundred? Not sure exact number, but I know it pays well. And everything is billed under my NPI as I am doing walkin urgent care. I mean you're basically charging a surgical CPT code. It is definitely worthwhile to do if you have the right payor mix. One of those is equal to at least 3-4 new back consults I think. Plus it's more fun.

One other thing that used to tick off the docs in my group-one of my predecessors would charge fracture care on every fracture and make the follow up with MD. Guess who couldn't charge an OV b/c was under the global? HA! I know that rule doesn't apply if you send to a hand specialist in the same group. I guess the same goes for a f/u from the ED.




Sam Dyer, PA-C, MHS
President PAOS