I must have missed this paper originally published in 2018 in Foot and Ankle International… perhaps my subscription has lapsed.
Either way, I’m intrigued.
These researchers sought to compare intra-articular hematoma blocks (IAHB) vs. procedural sedation to aid in the reduction of displaced ankle fractures (fracture subluxations or dislocations).
This was a retrospective chart review without great methods… but what the hell.
They identified 221 patients that underwent IAHB vs. 114 who got PS over 11 years in their single ED in Minnesota. The primary outcome was rate of successful reduction. But they also looked at reduction attempts, time to successful reduction, length of stay in the ED and some adverse events. However, they did not report on adequacy of pain reduction or patient satisfaction.
A hematoma block was performed using 10 to 12ml of 1% lignocaine without adrenalin that was injected into the tibiotalar joint. Ultrasound guidance was not used (but in my opinion can be helpful).
Patients were not randomised and as such, there were some substantial differences between the groups. As you can discern from the numbers, they liked their hematoma blocks twice as much as procedural sedation. However, more patients with complete dislocations got sedation.
The rate of successful reduction was about the same in both groups. About 70% were reduced with one attempt and 25% more by the second. Overall, there was a 90% success rate.
As for safety, one patient in the procedural sedation group got intubated… yikes!
This study has many limitations and is not high-quality evidence. Nevertheless, it is yet another paper demonstrating the utility and uptake of hematoma blocks for displaced ankle fractures. Even the New England Journal of Medicine has jumped on board with these blocks for ankles.
The beauty of a haematoma block is no need for a resuscitation room and lots of resources. It can quickly be performed by a single provider. In addition, a further reduction attempts can easily take place as the block will last for a while.
MacCormick LM, Baynard T, Williams B, et al. Intra-articular Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle Fractures. Foot & Ankle Int. 2018;39:1162-8. [Link to article]