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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]?

Clinical Scenario

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.

Search Strategy

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/].

Search Outcome

The search revealed 75 papers, with one randomized controlled trail directly answering the 3 part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
White et al, 2008, USA	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

Comment(s)

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.

Editor Comment

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.

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; 90:731-4.