SCOPE OF THE PROBLEM

Fracture and dislocation reduction procedures are common in emergency and acute care populations, particularly in the emergency department (ED). These procedures cause considerable patient discomfort and are often accomplished without the assistance of an orthopedist.

Achieving adequate analgesia during the acute management of fractures and dislocations should be a high priority for the emergency physician. By achieving this goal, the clinician will alleviate patient pain and anxiety, increase the likelihood of successful injury management, and enhance patient and provider satisfaction.

CLINICAL ASSESSMENT

In assessing which pain and/or sedation modality best meets the patient's needs, many factors should be considered including fracture location, the presence or absence of nerve or vascular injury, patient age, pain tolerance, comorbidities, and the individual physician comfort level with regional anesthesia and procedural sedation techniques. For nerve or vascular compromise injuries, clinicians have little time for lengthy procedures and may rely on sedation, parental analgesia, or regional anesthesia with a fast-acting anesthetic to emergently reduce these injuries. Physician judgment combined with individual patient needs will typically dictate the best approach to alleviate pain and anxiety during reduction procedures.

PAIN/SEDATION CONSIDERATIONS

When choosing a local anesthetic for a given procedure, the onset of clinical effects, duration of analgesia, and toxicity should be paramount in the decision-making process. Lidocaine continues to be the most popular anesthetic owing to its rapid onset, availability, and familiarity. Both bupivacaine and ropivacaine offer a longer duration of action with the latter being significantly less cardiotoxic.