To The Editor:
We read with interest the paper "Intra-Articular Block Compared with Conscious Sedation for Closed Reduction of Ankle Fracture-Dislocations. A Prospective Randomized Trial" (2008;90:731-4), by White et al. We would like to make the following points:Acute ankle fracture-dislocations are associated with substantial swelling, making the identification of anatomical landmarks required for an intra-articular injection difficult and enhancing the risk of intravascular injection. Hence, in the presence of distorted anatomy and a hemarthrosis, how can the clinician be sure that the blood-filled needle hub is correctly positioned in hematoma rather than in an intravenous space?The reported average time for reduction was long at sixty-three to eighty-one minutes. The methods stated that "time for reduction" was defined from "the time at which the consultation was requested and the time when the fracture-dislocation was reduced." There is no information on how long the actual reduction procedure took. This raises two points of concern. Firstly, an acute ankle fracture-dislocation is an orthopaedic emergency and prolonged delay of over one hour risks neurovascular damage to the soft tissues, especially the skin1,2. In our emergency department, such fracture-dislocations are reduced as soon as possible, without delaying for radiographic confirmation2. Secondly, if the procedure actually did take sixty to eighty minutes, should conscious sedation be administered for so long in the emergency department, or would the operating room environment be more suitable?For patients presenting to the emergency department with an acutely painful condition, which may have necessitated narcotic analgesia prior to arrival at the hospital, how certain can the reader be that the patients "provided informed consent" for participation in this study?Articular cartilage is sensitive to pH changes3. The intra-articular injection of acidic local anesthetics (i.e., 1% lidocaine as used in this study) risks damage and infection to articular cartilage in knees4. Is the use of intra-articular local anesthetic advisable in a situation in which cartilage may already have sustained traumatic injury?The study does not detail how much, if any, analgesia was administered prior to treatment either by paramedics or on arrival to the hospital. Further, conscious sedation with use of benzodiazepines or propofol with narcotics causes anterograde amnesia5 and as such the validity of subjective pain scores for the sedation period must be questioned.Due to well-documented complications associated with propofol sedation, e.g., hypoxemia6, cardiovascular instability7, and pain on injection8, its use in emergency department procedures by physicians other than anesthesiologists is controversial9. Further, this study does not clarify if the sedation was performed by a physician who was trained in administering the anesthetic and was present with the patient during the entire procedure.
Acute ankle fracture-dislocations are associated with substantial swelling, making the identification of anatomical landmarks required for an intra-articular injection difficult and enhancing the risk of intravascular injection. Hence, in the presence of distorted anatomy and a hemarthrosis, how can the clinician be sure that the blood-filled needle hub is correctly positioned in hematoma rather than in an intravenous space?
The reported average time for reduction was long at sixty-three to eighty-one minutes. The methods stated that "time for reduction" was defined from "the time at which the consultation was requested and the time when the fracture-dislocation was reduced." There is no information on how long the actual reduction procedure took. This raises two points of concern. Firstly, an acute ankle fracture-dislocation is an orthopaedic emergency and prolonged delay of over one hour risks neurovascular damage to the soft tissues, especially the skin1,2. In our emergency department, such fracture-dislocations are reduced as soon as possible, without delaying for radiographic confirmation2. Secondly, if the procedure actually did take sixty to eighty minutes, should conscious sedation be administered for so long in the emergency department, or would the operating room environment be more suitable?
For patients presenting to the emergency department with an acutely painful condition, which may have necessitated narcotic analgesia prior to arrival at the hospital, how certain can the reader be that the patients "provided informed consent" for participation in this study?
Articular cartilage is sensitive to pH changes3. The intra-articular injection of acidic local anesthetics (i.e., 1% lidocaine as used in this study) risks damage and infection to articular cartilage in knees4. Is the use of intra-articular local anesthetic advisable in a situation in which cartilage may already have sustained traumatic injury?
The study does not detail how much, if any, analgesia was administered prior to treatment either by paramedics or on arrival to the hospital. Further, conscious sedation with use of benzodiazepines or propofol with narcotics causes anterograde amnesia5 and as such the validity of subjective pain scores for the sedation period must be questioned.
Due to well-documented complications associated with propofol sedation, e.g., hypoxemia6, cardiovascular instability7, and pain on injection8, its use in emergency department procedures by physicians other than anesthesiologists is controversial9. Further, this study does not clarify if the sedation was performed by a physician who was trained in administering the anesthetic and was present with the patient during the entire procedure.