SUPraclavicular Block for Emergency Reduction of Upper Limb Injuries Versus Bier Block (SUPERB Trial)

Background

Anyone who has worked in an Emergency Department (ED) will be familiar with the challenge of reducing a fractured or dislocated forearm. It’s a very common emergency medicine problem that we see here in Virchester, but it’s also one that tests our ability to balance pain control, safety, and efficiency. We want to achieve an effective reduction, restore anatomy, and immobilise the limb, all while minimising distress for the patient and disruption for the department. In the past these patients went to theatre in many places, but the pressures on emergency lists now means that there is increasing pressures to do them in the ED. I started off doing Bier’s blocks in the ED on a dedicated list and it was great. They worked really well down in the ED theatre (yes, we had one for minor procedures) with a Bier’s block machine and a radiographer who would pop in to do the imaging in real time to check reductions. Those days are long gone, as is the Bier’s blovck machine. It’s largely been replaced by haematoma blocks (which are often rubbish, or at least very badly done) or sedation (pretty much the most common technique I use and see). Sedation is great, but you really want to get it right first time, and lots of people have cautions or contradindications in a busy ED.

So, there are traditionally three main approaches to analgesia and anaesthesia for this situation. First, procedural sedation: effective, familiar, but resource-intensive, requiring airway monitoring, multiple staff, and a recovery period. Second, Bier’s block (intravenous regional anaesthesia, or IVRA): widely used, effective, and relatively safe, but not without risks (local anaesthetic toxicity, cuff failure, discomfort) and contraindications. Third, haematoma block: simple and quick, but often inadequate in terms of analgesia.

Another approach might be here as over the past decade, emergency physicians have increasingly adopted ultrasound-guided regional anaesthesia. The supraclavicular brachial plexus block has been described as the “spinal of the upper limb” because of its dense and predictable anaesthesia. Anaesthetists have long used it in theatre for operative fixation of upper limb fractures. But can we safely and effectively bring this technique into the ED? And if so, how does it compare to the established Bier block? You can learn how to do the block here.

The SUPERB trial (SUPraclavicular Block for Emergency Reduction of Upper Limb Injuries Versus Bier Block) set out to answer that question. The abstract is below, but as always go do the hard work yourself. Read the full paper and come to your own conclusions.

Abstract

Objectives: To assess the effectiveness of ultrasound-guided supraclavicular block (UGSCB), performed by emergency physicians, for closed reduction of upper limb fractures or dislocations when compared with Bier block (BB).

Methods: This was an open-label, noninferiority randomised controlled trial. Adults aged ≥ 18 years presenting to an urban district ED with distal radius and/or ulnar fractures requiring emergent reduction were included. Patients were randomised to either UGSCB using 0.75% ropivacaine or BB using 0.5% lignocaine or 0.5% prilocaine, performed by emergency physicians. The primary outcome was patient-reported maximal pain during closed reduction measured via a 10 cm visual analogue scale (VAS), with a noninferiority margin of 2 cm. Secondary outcomes included post-reduction pain at 1-h and adverse events.

Results: We enrolled 78 patients with 39 per group. Intention-to-treat analysis showed that maximal pain during closed reduction following UGSCB was noninferior compared with that after BB (UGSCB: median 0.1 cm, interquartile range [IQR] 0 to 2.1; BB: 0.6 cm, IQR 0 to 3.3; difference in medians -0.5 cm, 95% Confidence Interval [95% CI] -1.7 to 0.7 cm; p_{noninferiority} < 0.001). Pain at 1-h post-intervention was significantly lower in the UGSCB (difference in median -1.8 cm, 95% CI -2.6 to -1.0). There were no between-group differences in adverse events (Odds ratio 2.1; 95% CI 0.18 to 24).

Conclusions: Emergency physician-performed UGSCB provides safe and effective regional anaesthesia that was non-inferior to BB for maximal pain during closed reduction, with the potential advantage of prolonged analgesia.

What kind of study is this?

This was an open-label, noninferiority randomised controlled trial conducted in a single Australian ED. The design is important here. A superiority trial would ask, “Is supraclavicular block better than Bier block?” Instead, the investigators framed the question as, “Is supraclavicular block at least not worse than Bier block, within a clinically acceptable margin?”

That approach makes sense. Bier block is already a standard of care in many EDs. To justify adopting UGSCB (ultrasound-guided supraclavicular block), it only needs to be as good in terms of pain control, while potentially offering other benefits, such as prolonged analgesia, applicability when Bier block is contraindicated, and avoiding tourniquet pain. Obviously I would prefer them to have had a sedation arm in this trial as that’s what I see, but this is their comparison and that’s fine.

The study was open-label, meaning neither clinicians nor patients were blinded to the intervention. This is common in procedural trials (as it’s impossible to do otherwise) but introduces some risk of bias, especially when patient-reported outcomes (like pain scores) are the primary endpoint.

The trial was registered prospectively, followed a published protocol, and reported according to CONSORT guidelines all green flags for methodological rigour.

Tell me about the patients

The trial recruited adult patients (≥18 years) presenting with distal forearm fractures (radius and/or ulna) requiring closed reduction. These were exactly the sort of patients we see on a busy shift: older women with fragility fractures after a fall, younger patients with more forceful mechanisms, and everything in between.

In total, 78 patients were randomised: 39 to UGSCB and 39 to Bier block. Baseline characteristics were well matched. The mean age was around 60–64 years, and about 80% of participants were women. All had distal radius fractures; a minority had associated ulnar fractures. Baseline pain scores before intervention were comparable between groups.

It’s worth noting who was excluded. Patients with contraindications to either technique (e.g., chronic lung disease for supraclavicular block, uncontrolled hypertension for Bier block, anticoagulation, or open fractures) were not included. This is important because in real-world ED practice, some of those patients might benefit from having alternative techniques available.

What were the measured outcomes in this study?

The primary outcome was patient-reported maximal pain during closed reduction, measured on a 10 cm visual analogue scale (VAS). The noninferiority margin was set at 2 cm, based on prior literature suggesting this represents a clinically meaningful difference.

The secondary outcomes included:

• Pain at one hour post-procedure.
• Patient satisfaction.
• ED length of stay.
• Procedural time.
• Opioid use (pre- and in-hospital).
• Adverse events (including local anaesthetic toxicity, cuff problems, pneumothorax).
• Failure of the initial block and need for rescue intervention.
• Follow-up pain and satisfaction at 24–72 hours, plus need for operative management.

This is a comprehensive outcome set, capturing not just efficacy but safety, feasibility, and patient experience.

What are the main results?

Here’s the headline: supraclavicular block was noninferior to Bier block for pain control during closed reduction.

Some details:

• Median maximal pain during reduction was 0.1 cm in the UGSCB group vs 0.6 cm in the Bier block group.
• The estimated difference in median pain was –0.5 cm (95% CI –1.7 to 0.7).
• The noninferiority hypothesis was strongly supported (p < 0.001).

Secondary outcomes showed:

• Pain at one hour: lower in the UGSCB group (median difference –1.8 cm, 95% CI –2.6 to –1.0).
• Patient satisfaction: very high in both groups, no significant difference.
• ED length of stay: slightly shorter with UGSCB (median –41 minutes), though not statistically significant.
• Opioid use: no difference.
• Procedural time: UGSCB took ~23 minutes, Bier block ~30 minutes (though only recorded in a subset).
• Adverse events: low and similar between groups. In UGSCB, one patient had a prolonged block (~18 hours) and one vasovagal syncope. In Bier’s block, one patient had cuff bruising. No serious events, no cases of local anaesthetic systemic toxicity, and no pneumothoraces.
• Failure rates: low and similar — 2 in UGSCB, 3 in Bier block.

So the story is consistent: both techniques are safe and effective, with UGSCB perhaps offering the edge in terms of prolonged analgesia.

Can we believe the methods and results?

This was a well-conducted trial, but as always, there are some caveats.

Strengths:

• Randomised controlled design, prospective registration, and published protocol all enhance validity.
• Clear definition of outcomes, using validated pain scales.
• Pragmatic approach: procedures performed by ED consultants and trainees after limited training, reflecting what might be feasible in real life.
• Noninferiority design appropriately chosen.

Limitations:

• Single centre, small sample size. With 78 patients, this is enough to answer the primary question but underpowered to detect rarer complications. It also limits generalisability beyond this Australian ED.
• Open label. Patients and clinicians knew which intervention they received, which could influence reported pain or satisfaction scores.
• Narrow population. Although the trial allowed for various upper limb injuries, in practice all participants had distal forearm fractures. We can’t assume the findings apply equally to shoulder or elbow reductions.
• Training and expertise. The blocks were performed by ED clinicians who had received specific training and credentialing. In departments without that experience, success rates and safety might differ.
• Outcome focus. Pain during reduction is the right primary outcome, but the study didn’t assess adequacy of reduction (radiographic outcomes) , although operative management rates were similar.

From a methodological standpoint, this was a clean, well-executed study. The main limitation is external validity: can the same results be replicated in different settings, with different operators, and across a broader spectrum of injuries?

Should we change practice based on this study?

That depends on your local context. If you already use Bier block, this trial suggests supraclavicular block is a safe and effective alternative, with the added bonus of extended analgesia. It doesn’t mean you should abandon Bier block, it remains simple, reliable, and familiar to many clinicians. But UGSCB can be added to your toolkit, especially when Bier block is contraindicated (e.g., severe hypertension, vascular disease) or where prolonged analgesia is desirable.

If you don’t currently use UGSCB in your ED, this trial provides good evidence to support introducing it, provided appropriate training, governance, and safety systems are in place. The trial’s training model was minimal (a one-hour session plus supervised practice), but remember that those clinicians were already experienced with ultrasound procedures. Wider implementation may require more robust training, supervision, and credentialing.

For departments where procedural sedation is the default, UGSCB may offer a resource-sparing alternative — though we still need head-to-head comparisons of UGSCB vs sedation.

So the answer is: not a practice-changing trial on its own, but it expands the evidence base. It nudges UGSCB further into the mainstream of ED regional anaesthesia.

Another appraoch that’s worth mentioning is the supracondylar block which I learned over at IFEM and which I’ve tried a few times since with variable success. It’s arguably less difficult, but probably does not cover as much of the distal forearm as I would like. I’m still considering it for select patients, but as yet. I’m not using it routinely.

Summary

The SUPERB trial is the first randomised controlled trial comparing ultrasound-guided supraclavicular block with Bier block for distal forearm fracture reduction in the ED. It shows that:

• Both techniques provide excellent analgesia.
• UGSCB is noninferior to Bier block for pain control.
• UGSCB provides lower pain at one hour, likely due to prolonged effect of ropivacaine.
• Adverse events and failure rates are low and similar.
• Patient satisfaction is very high with both approaches.

For emergency physicians, this adds weight to the argument that ultrasound-guided regional anaesthesia is safe, feasible, and effective in the ED. It doesn’t mean Bier block is obsolete, but it does mean we have another high-quality option for managing forearm fracture reductions.

As always, the take-home message is about having multiple tools in the kit. Bier block, supraclavicular block, sedation, and haematoma block all have their place. The art is in choosing the right technique for the right patient in the right context.

References and further reading

1. Tsao H, Tang C, Cureton A, Maskell L, Trembath M, Jones P, Snelling PJ. SUPraclavicular Block for Emergency Reduction of Upper Limb Injuries Versus Bier Block (SUPERB): An open-label, noninferiority randomised controlled trial. Emerg Med Australas. 2025;37:e70069.
2. Kendall JM, Allen P, Younge P, Meek SM, McCabe SE. Haematoma block or Bier’s block for Colles’ fracture reduction in the accident and emergency department: which is best? J Accid Emerg Med. 1997;14:352–6.
3. Oakley B, Busby C, Kulkarni S, Arnold SJ, Kulkarni SS, Ollivere BJ. Manipulation of distal radius fractures: a comparison of Bier’s block vs haematoma block. Ann R Coll Surg Engl. 2023;105:434–40.
4. Fauteux-Lamarre E, Burstein B, Cheng A, Bretholz A. Reduced length of stay and adverse events using Bier block for forearm fracture reduction in the paediatric emergency department. Pediatr Emerg Care. 2019;35:58–62.
5. Stone MB, Wang R, Price DD. Ultrasound-guided supraclavicular brachial plexus nerve block vs procedural sedation for the treatment of upper extremity emergencies. Am J Emerg Med. 2008;26:706–10.
6. Shalaby M, Sahni R. Supraclavicular brachial plexus block: the unsung hero of emergency department regional anaesthesia. Clin Exp Emerg Med. 2023;10:342–4.
7. Gitman M, Fettiplace MR, Weinberg GL, Neal JM, Barrington MJ. Local anaesthetic systemic toxicity: a narrative literature review and clinical update on prevention, diagnosis, and management. Plast Reconstr Surg. 2019;144:783–95.
8. Australasian College for Emergency Medicine. Curriculum: Fellowship of the Australasian College for Emergency Medicine. Melbourne: ACEM; 2022.
9. Supracondylar blocks: https://www.emra.org/emresident/article/ultrasound-guided-supracondylar-block