75 year old female with diagnosis of urothelial cancer with presented with history of severe right wrist pain. Pain described as a throbbing toothache affecting her sleep and ability to carry out domestic chores.

On examination, she had reduced range of movement and flexion/extension of right wrist, and visible solid swelling to right wrist. Passive movements of wrist resulted in significant pain.

MRI showed large metastatic deposit within the distal radial metadiaphysis with a pathological fracture and significant soft tissue component. Lesion extended into the flexor and extensor compartments and crossed the intraosseous membrane.

Orthopaedics decided not to excise the tumour as morbidity risk too high. Had 5 fractions of radiotherapy with no improvement in pain. Longtec uptitrated to 20 mg BD, average Shortec 5 mg x 3 a day. Pregabalin added as adjuvant however developed increased somnolence so self ceased. Patient placed in elbow cast which provided some relief. Opioid rotated to Hydromorphone 8mg bd and prn 1.3- 2.6mg. Due to severity of pain consultation was had with Orthopaedics about amputation. Case discussed at Complex Pain MDT, decision made to trial a novel anterior and posterior interosseous nerve block to block nerve supply to wrist.

Patient underwent u/s guided 2 separate injections of phenol into the anterior and posterior interosseous nerve. Hydromorphone was reduced to 4mg PO BD post block.

Outcome Excellent results post block, patient weaned off hydromorphone, reported to be pain free and utilising PRN hydromorphone 1.3 mg infrequently, reporting much better quality of life and ability to carry out domestic chores.