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Intra-Articular Block Compared with Conscious Sedation for Closed Reduction of Ankle Fracture-DislocationsA Prospective Randomized Trial
Brian J. White, MD1; Michael Walsh, PhD1; Kenneth A. Egol, MD1; Nirmal C. Tejwani, MD1
1 Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 550 First Avenue, NBV 21W-37, New York, NY 10016. E-mail address for N.C. Tejwani: nirmal.tejwani@nyumc.org
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Jamaica Hospital Medical Center and Bellevue Hospital, New York, NY

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Apr 01;90(4):731-734. doi: 10.2106/JBJS.G.00733
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Abstract

Background: Ankle fracture-dislocations require urgent reduction to protect the soft tissues, to minimize articular injury, and to allow swelling to decrease. Conscious sedation is commonly used to provide analgesia for closed reduction of this injury. We hypothesized that an intra-articular block of the ankle would provide similar analgesia and the ability to reduce the ankle with a lower risk than conscious sedation.

Methods: Between September 2005 and January 2007, forty-two patients with an ankle fracture-dislocation presented to our emergency department and were enrolled in a prospective randomized study. The patients were given either conscious sedation or an intra-articular lidocaine block for the reduction and for the application of a plaster splint. After the reduction maneuver, the patients used a visual analog pain scale to rate the level of pain before, during, and after the procedure, from 1 (no pain) to 10 (severe pain). The senior authors reviewed the injury and reduction radiographs to confirm the reduction of the ankle joint.

Results: Twenty-one patients were randomized to each group. There was no difference in demographic data or fracture patterns between the groups. Both the sedation and the block reduced the pain to a similar degree. The pain reduction (the initial pain level minus the level of pain after medication was given or injected) was an average (and standard deviation) of 4.6 ± 3.3 for the block group and 4.2 ± 3.5 for the sedation group (p = 0.64). The average change in the level of pain between the initial presentation and during the reduction was 3.6 ± 3.8 for the block group and 4.1 ± 3.3 for the sedation group. Overall, there was no difference in analgesia provided by these two methods (p = 0.71). An acceptable reduction was achieved for forty-one of the forty-two patients with one failure in the sedation group. The average time for ankle reduction and stabilization in a splint was 81.5 minutes for the sedation group and 63.8 minutes for the block group.

Conclusions: Compared with conscious sedation, an intra-articular lidocaine block provides a similar degree of analgesia and sufficient analgesia to achieve closed reduction of ankle fracture-dislocations.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Nirmal C. Tejwani, M.D.
    Posted on April 29, 2008
    Dr. Tejwani, et al. respond to Dr. Rogers, et al.
    NYU Hospital for Joint Diseases, New York, NY 10016

    We thank Dr. Rogers and associates 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 feel 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 initiation of the consult (resident notified) to the time when the ankle was reduced and placed in a splint with a post reduction x-ray 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 set-up 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 pre-requisite 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 utilize lidocaine for the reduction of both intra-articular distal radius 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 pre-hospital analgesia 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, only Emergency Physicians dosed, administered and monitored the patients.

    Benedict A Rogers, MA, MSc, MRCGP, MRCS
    Posted on April 24, 2008
    Intra-Articular Block Compared with Conscious Sedation for Closed Reduction of Ankle Fracture-Disloc
    St Peter's Hospital, Chertsey, UK

    To The Editor:

    We read with interest the paper by White et al.(1) entitled “Intra-Articular Block Compared with Conscious Sedation for Closed Reduction of Ankle Fracture-Dislocations”. We would like to make the following points:

    1. 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 haemarthrosis, how can the clinician be sure that the blood filled needle hub is correctly positioned in haematoma rather than in an intravenous space?

    2. The reported average time for reduction was long at 63 to 81 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 skin(2-3). In our emergency department such fracture dislocations are reduced as soon as possible, without delaying for radiographic confirmation(3). Secondly, if the procedure actually did take 60-80 minutes, should conscious sedation be administered for so long in the emergency department, or would the operating room environment be more suitable?

    3. For patients presenting to the emergency department with an acutely painful condition, that may have necessitated narcotic analgesia prior to arrival in hospital, how certain can the reader be that the patients ‘provided informed consent’ for participation in this study?

    4. Articular cartilage is sensitive to pH changes(4). The intra- articular injection of acidic local anaesthetics (ie. 1% lidocaine as used in this study) risks damage and infection to articular cartilage in knees(5). Is the use of intra-articular local anaesthetic advisable in a situation where cartilage has may already have sustained traumatic injury?

    5. The study does not detail how much, if any, analgesia was administered prior to treatment either by paramedics or on arrival to hospital? Further, conscious sedation using benzodiazepines or propofol with narcotics causes anterograde amnesia(6) and as such the validity of subjective pain scores for the sedation period must be questioned.

    6. Due to well documented complications associated with propofol sedation, eg. hypoxaemia(7), cardiovascular instability(8), and pain on injection(9), its use in emergency department procedures by physicians other than anaesthesiologists is controversial(10). Further, this study does not clarify if the sedation was performed by a physician trained in administering the anesthetic and present with the patient during the entire procedure.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. White BJ, Walsh M, Egol KA, Tejwani NC. Intra-articular block compared with conscious sedation for closed reduction of ankle fracture- dislocations. A prospective randomized trial. J Bone Joint Surg Am. 2008;90:731-734.

    2. Khan, Malik AA, Agarwal M, Dalal R. Delayed open reduction and internal fixation of a neglected fracture dislocation of the ankle. Int J Clin Pract. 2007;61:594-595.

    3. Payne, Kinmont JC, Moalypour SM. Initial management of closed fracture-dislocations of the ankle. Ann R Coll Surg Engl. 2004;86:177-181.

    4. Wilhelm, Shao ZH, Housley TJ, Seperack PK, Baumann AP, Gunja- Smith Z, Woessner JF, Jr. Matrix metalloproteinase-3 (stromelysin-1). Identification as the cartilage acid metalloprotease and effect of pH on catalytic properties and calcium affinity. J Biol Chem. 1993;268:21906- 21913.

    5. Desai AS, R Sreekumar, Board TN, Raut VV. Does Intra-articular Steroid Infiltration Increase Rate of Infection In Subsequent Total Knee Replacements? British Association of Surgery of the Knee. 2008 . . Ref Type: Conference Proceeding.

    6. Parworth, Frost DE, Zuniga JR, Bennett T. Propofol and fentanyl compared with midazolam and fentanyl during third molar surgery. J Oral Maxillofac Surg. 1998;56:447-453.

    7. Zed, bu-Laban RB, Chan WW, Harrison DW. Efficacy, safety and patient satisfaction of propofol for procedural sedation and analgesia in the emergency department: a prospective study. CJEM. 2007; 9:421-427.

    8. Hug, Jr., McLeskey CH, Nahrwold ML, Roizen MF, Stanley TH, Thisted RA, Walawander CA, White PF, Apfelbaum JL, Grasela TH. Hemodynamic effects of propofol: data from over 25,000 patients. Anesth Analg. 1993;77:S21-S29.

    9. Johnson, Harper NJ, Chadwick S, Vohra A. Pain on injection of propofol. Methods of alleviation. Anaesthesia 1990; 45:439-442.

    10. Green. Propofol for emergency department procedural sedation-- not yet ready for prime time. Acad Emerg Med. 1999; 6:975-978.

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