Table 1 Summary of Findings table of included studies

Study design

RCT, 2 groups, parallel design

JADAD score: 4/5

RCT, 2 groups, parallel design

JADAD-score: 5/5

RCT, 2 groups, parallel design

JADAD-score: 5/5

Participants

30 patients with a distal radius fracture which required manipulation and reduction.

• Standard Bier’s block:

Mean age: 56.9 ± 20.1

M/F: 7/8

• Modified Bier’s block:

Mean age: 48.5 ± 20.6

M/F: 9/6

40 ASA I-II patients who were undergoing hand or forearm surgery.

• Standard Bier’s block:

Mean age: 29.8 ± 8.1

M/F: 13/7

• Modified Bier’s block:

Mean age: 36.0 ± 11.0

M/F: 11/9

59 ASA I-III patients having distal upper extremity surgery under IVRA.

• Standard Bier’s block:

Mean age: 40.1 (22–66)

M/F: 7/21

• Modified Bier’s block:

Mean age: 40.8 (22–67)

M/F: 10/18

Interventions

IVRA with upper arm cuff against forearm cuff, same dose of LA.

IVRA was performed with:

• 3 mg/kg of 1% lidocaine made up to 40 mL of solution in both study groups.

IVRA with upper arm cuff against forearm cuff, upper arm gets double dose LA compared to forearm.

IVRA was performed with:

• 3 mg/kg of 0.5% lidocaine with 0.3 mg/kg ketorolac in the upper arm group.

• 1.5 mg/kg of 0.5% lidocaine with 0.15 mg/kg ketorolac in the forearm group.

IVRA with upper arm cuff against forearm cuff, upper arm gets double dose LA compared to forearm. Sedation administered if VAS > 4.

IVRA was performed with:

• 15 ml of 2% lidocaine and 20 mg ketorolac in the upper arm group.

• 8 ml of 2% lidocaine and 10 mg ketorolac in the forearm group.

Surgical procedures

Manipulation and reduction of closed distal radius fractures.

Ganglion excision (3/2), contracture release (2/4), excision biopsy (3/3), open reduction and internal fixation of single bone forearm fracture (5/7), closed reduction and internal fixation (2/0), carpal tunnel release (1/1), foreign body removal (1/1), external fixator application (2/2), nerve repair (1/0)

* (upper arm group/forearm group)

Surgeries in each group were similar and were completed without complications.

Surgeries included ganglion cyst excision, mass

excision, digital nerve repair, metacarpal and digital fracture pinning, and ORIF, ruptured tendon repair, and palmar fasciotomy.

Outcomes

Pre-block and manipulation VAS scores, outcome of the reduction, complications, incidence of LA toxicity.

Quality of surgical anesthesia, sensory onset and regression of block, proximal tourniquet tolerance, VAS at 30 and 60 min. Postoperatively, postoperative analgesic use, incidence of LA toxicity, local complications (tourniquet).

Sedation need based on intraoperative VAS score, PACU bypass.

Tourniquet placement

An upper arm and forearm cuff was applied in all cases in an attempt to blind the patient. Only one of both cuffs was inflated. IVRA with upper arm cuff against forearm cuff, same dose LA.

• Standard Bier’s block:

Inflation of the upper arm cuff.

• Modified Bier’s block:

Inflation of the forearm cuff.

• Standard Bier’s block:

A pneumatic double-cuffed tourniquet (14-cm wide) was placed on the upper operative arm at the point of maximum diameter.

• Modified Bier’s block:

The same tourniquet was positioned 5 cm below the medial epicondyle on the forearm.

The single-cuff pneumatic pressure tourniquet was placed immediately above or below the elbow crease and on the top of a circumferentially placed cotton cast padding before inflation.

Notes

1 patient in the forearm group was admitted for open reduction and internal fixation after failed reduction.

3 patients did not receive allocated intervention:

• n = 2: given narcotic during exsanguinations of arm

• n = 1: surgeon released tourniquet right after block placement