Following statistically methods were employed:

• Measurement of magnitude of difference between values of outcomes in the two groups;

• Measurement of significance of difference:

• Qualitative data analysis by Chi Square or propionate Test,

• Quantitative data analysis by Student T test,

• Quantitative Not normally distributed data by non parametric test like KW statistics;

Pre-anesthetic evaluation was done in both the groups. In all cases Intra venous assess was opened by Intra venous cannula and electronic monitor was connected to continuous record of Pulse rate, Respiratory rate, Blood pressure and Oxygen saturation by Pulse Oximeter. In all cases, hypersensitivity for lignocaine (Xylocaine) was tested. After tests for Xylocaine (Astra Band of Lidocaine Hydrochloride) ₂₉ sensitivity, the A group was given Brachial Plexus Block (dose according to body weight 4.5-7mg/kg ₂₇ ) in the supraclavicular region of the patient whereas the B group was given 1.5% Xylocaine (amount according to body weight-4.5 mg/kg ₂₅,₂₆,₂₇,₂₈ ) at the fracture hematoma site from the dorsal aspect. ₂₄ Prior to the injection of the drugs, the part was painted first with Spirit (95% alcohol), then with 7.5% Povidone iodine. The calculated amount of Xylocaine was taken in 20 ml disposable syringe with 22 ^1/2 Gauze needle. The needle was placed at the fracture hematoma site which was determined by aspirating about 1 to 2 ml of hematoma blood. No massage was done at the fracture site after injection of the drug. The drug was given by Junior Resident (J₁) posted at Fracture Clinic. After ten to fifteen minutes ₂₇ the reduction and immobilization of the fracture was done by Junior Resident blinded to the anesthesia technique ( J₂). Visual Analogue Scale (VAS) was recorded for evaluation of pain before, during, and after reduction by the Junior Resident of Orthopaedics on duty (J₃) blinded to the anesthesia technique used for manipulation of the fracture. Vital parameters like pulse rate, respiratory rate, blood pressure and Oxygen saturation were recorded before, during and after manipulation. Patients requiring rescue analgesics would be labeled as failures.

Quality of reduction was assessed by X- Ray (Roentgenogram) immediate post reduction. The acceptability of the reduction was evaluated by the Consultant surgeon on call blinded to the anesthesia technique used. The radiological criteria were based on Modified Sarmiento Criteria for the post reduction acceptability varying from Perfect, Acceptable and Unacceptable. According to which Perfect reduction consists of Excellent and Good results, Acceptable reduction consists of Fair result; and Unacceptable consists of Poor results. Criteria of radiological assessment are given in table form Table 1.

Figure 1

Table 1: Criteria for anatomical result

Patients were followed up in next day post reduction for neurovascular assessment. Follow up in 10 ^th day, 4 ^th week and 6 ^th week was done to evaluate the post reduction complications.

In the present study Visual Analogue Score during manipulation in the both groups were comparable i.e., 1.7 in the Brachial Plexus group and 2.08 in the Hematoma group. Considering the risk of BPB, HB is much safer and can be done easily in Emergency or OPD with less resources. Singh et al. ₁₁ studied about analgesia for reduction of Colles' fracture by Double Blind RCT between Conventional sedation and Hematoma Group. Sixty six out of 80 consecutive cases with the fracture were studied. Singh et al concluded that pain scores during reduction in the Xylocaine group (i.e. Hematoma Group) were acceptably low, that is < 3 (median = 1.8) as compared to the unacceptably high, that is > 3 pain scores in the conventionally practiced sedation group (median =8.7), at a very high level of clinical and statistical significance. Therefore they concluded that hematoma block by local anesthesia is a safe and effective alternative to sedation in reduction of Colles' fracture. This sole study favors the hematoma block for the reduction in distal radial fractures. The study done by Furia et al. ₁₇ is also comparable with the present study. Results demonstrated pain differential score of 2.7 and 0.8 for the HB group and NHB group. The VAS is 2.7 in this study where as in the present study it is 2.08. In Kendall et al‘s ₁₈ study 72 patients in Bier's block group and 70 patients in the hematoma block group were included. There was no difference in pain score on fracture manipulation as 1.5 in the Bier's Block group and 2.8 in the Hematoma group. But the value of visual analogue scale in their study and the present study is comparable showed in Table 6.

In the present study, the reduction done under the Hematoma block have high chance of excellent reduction than the Brachial Plexus block as shown by the post reduction radiograph. There were 32 excellent reduction in the HB group and 17 that of in the BPB group, whereas acceptable reduction were 18 and 33 in the HB and the BPB group respectively. In Kendall et al's ₁₈ study, more manipulations were required in the hematoma block group (17/70 v 4/72; P=0.003). Therefore his study favors the Bier's Block group for the perfect reduction than the Hematoma Block group. Ogunlade et al. ₂₂ showed, in his study in 35 patients, significant reduction of the pain following infiltration of 10ml of 2% Xylocaine at the fracture site and all the patients had satisfactory reduction of the fracture. This study also favors the present study. Funk et al. ₁₆ in his prospective trial to compare hematoma blocks alone and hematoma block with sedation with general anesthesia for the reduction of distal radius fractures in adult patients regarding radiological position after reduction showed that “Radiological correction was as good in those patients receiving a hematoma block with or without sedation as in a general anesthesia group”. The waiting and manipulation times and resources costs were greater in those receiving a general anesthesia. The study done by Case R D ₃ showed that there was no significant difference in the number requiring re manipulation between three methods employed in his study: Hematoma block, Bier's Block or General Anesthesia, thereby concluded that hematoma block is a safe method of reducing Colles' fracture.

Regarding complications, the current study shows infection in one case (2%) and post reduction swelling equally in both the groups i.e., 2 in each group comprising 4% overall. The only dreadful complication in the BPB group was sudden bronchial spasm in the elderly lady soon after the injection Xylocaine was administered in the supraclavicular region, requiring intubation and ICU care. But the patient recovered after 12 hrs of ICU care and had spontaneous breathing after 6 hrs and discharged next day. In Singh et al. ₁₁ study, there was no incidence of infection or significant drug toxicity in the Hematoma block group. Furia et al. ₁₇ in his study showed no complications associated with any of the procedure. Based on these three parameters they also concluded that the hematoma block is an effective and safe method for fracture reduction in closed, isolated fractures in selected patients. In Kendall et al's ₁₈ study also there were no complications in either group viz. Bier's block group and Hematoma group. Johnson PQ et al ‘s ₁₀ results revealed no incidence of infection in both group, Hematoma block group and Intravenous Regional Anesthesia (IVRA) group. They concluded that if appropriated precautions are taken, Hematoma Block does not increase the risk of infection. Hennrikus et al ₁₄ in this study showed that there were no complications such as vomiting, respiratory depression, a change in the oxygen saturation level, infection, or nerve injury in 100 children with closed fractures of forearm reduced under nitrous oxide combined with a hematoma block. Funk et al. ₁₆ in his prospective trial comparing three anesthetic technique used for reduction of fracture distal radius showed no complications relates to any of anesthetic methods like hematoma block alone and hematoma block with sedation and general anesthesia.

By discussing and analyzing the study comparing with all the literatures available till date favors the effectiveness and safety of the Hematoma Block in the reduction of the distal forearm fractures. In terms of pain relief, quality of reduction and post reduction complications, it is very feasible in the setting like ours. Therefore “the Hematoma Block” is to be encouraged in our set up for the reduction of the distal forearm fractures.

Finally, the technique developed is of use to surgeons required to reduce the distal forearm fractures especially Colles' fracture in places with scarce anesthesia facilities. This situation is frequent in orthopedic and trauma units in most densely populated developing countries. After appropriate research the technique may become generalizable to other fracture easily infiltrated percutaneously. The study may result in therapy policy change with regard to the use of IV sedation, or the Brachial Plexus Block, or the Bier's Block in such fracture reduction.