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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