N.C. Tejwani and B.J. White reply:
We thank Mr. Rogers and Mr. Rang for their interest and for raising important points regarding our study. We are pleased to respond to their concerns.
We agree that these injuries are associated with substantial swelling, which worsens with time. However, we believe that, despite the swelling, the medial aspect of the tibia is usually well palpable with ankle fracture-dislocations. Also, as nearly all of these dislocations are lateral, the medial joint space is actually widened and this makes injection easier than it would be in an intact ankle. Furthermore, neurovascular structures are displaced laterally in the direction of the dislocated talus and foot, which also decreases their risk of injury.
We defined the time for reduction as the time from the initiation of the consultation (when the resident was notified) to the time when the ankle was reduced and placed in a splint with a postreduction radiograph confirming that the ankle was reduced. The actual reduction procedure required only a short period of time. The reason for using the total time was to include the setup and drug administration time and also to reflect the "real world" experience of the total time it takes for the whole procedure including response time.
Every patient included in this study was fully alert at the time of consent. All risks and benefits of the two methods of analgesia were explained at length, and patients verbalized their understanding and agreement. This was a necessary prerequisite for enrollment in our study.
Lidocaine is routinely injected into knee, shoulder, and ankle joints for both diagnostic and therapeutic purposes without complications. Several cited studies in our paper utilized lidocaine for the reduction of both intra-articular distal radial fractures and glenohumeral dislocations. While the concern for further articular damage may exist, this must be balanced against the risk of medication used for conscious sedation.
The documentation and detail of analgesia administered before hospitalization is outside the scope of our study.
In our hospitals, sedation is administered by emergency physicians who are trained in the use of sedative medications. For the sedation arm of our study, the dosage and administration of the sedative medications and the monitoring of the patients were done only by emergency physicians.
These letters originally appeared, in slightly different form, on . They are still available on the web site in conjunction with the article to which they refer.