Three Part Question
In [adult patients with ankle fracture-dislocation] is [intra-articular lidocaine as effective as intravenous analgesia and sedation] at [facilitating reduction with adequate analgesia]?
An elderly man attends the emergency department with a clinical fracture dislocation of the ankle after a fall. He has got significant co morbidities and a history of recent myocardial infection. You have read that ankle fracture-dislocations can be reduced with intra-articular lidocaine (IAL). You wonder if IAL is as effective as intravenous analgesia and sedation (IVAS) in facilitating reduction and providing adequate analgesia.
Medline 1966–04/10 searched through NLH Search 2.0 using the following terms: [exp ankle injuries/ or exp dislocations/] AND [exp injections, intra-articular/].
The search revealed 75 papers, with one randomized controlled trail directly answering the 3 part question.
|Author, date and country
||Study type (level of evidence)
|White et al,|
|42 skeletally mature patients with ankle fracture dislocation.
IAL(21) v IVAS(21)
||PRCT||Reduction of pain||Pre-intervention pain scores were 9.2 for the IAL group and 9.3 for the IVAS group. Post-intervention scores were 3.6 vs 4.1 (p¼0.71)||Unblinded study with small
numbers. Various sedatives used
|Ease of reduction (SD)||No significant difference between the two groups|
This study suggests that intra-articular lidocaine can be as effective as intravenous analgesia and sedation to facilitate the reduction of ankle fracture-dislocations. This would be a useful alternative technique for use in patients who are high-risk for anaesthetic due to comorbidities, body habitus or a full stomach etc, where urgent reduction is required.
IAL, intra-articular lidocaine; IVAS, intravenous analgesia and sedation; PRCT, prospective randomised controlled trial.
Clinical Bottom Line
Intra-articular lidocaine can be considered as an alternative method to facilitate reduction of fracture-dislocation of an ankle in patients who are high-risk for conscious sedation.
Level of Evidence
Level 1 - Recent well-done systematic review was considered or a study of high quality is available.
- 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; 90:731-4.