SHOULD THE INTRA-ARTICULAR HAEMATOMA BLOCK BE USED AS AN ALTERNATIVE TO PROCEDURAL SEDATION FOR THE CLOSED REDUCTION OF UNSTABLE ANKLE FRACTURES AND DISLOCATIONS INTHE EMERGENCY DEPARTMENT?

Aims and objectives: To clarify if the intra-articular haematoma block is a viable and safe

option for the manipulation of unstable ankle fractures and dislocations in the Emergency

Department, with expected benefits of time, cost and resource efficiency, when compared

to procedural sedation.

Background: The current first-line approach for the manipulation of unstable ankle injuries

in New Zealand Emergency Departments is procedural sedation. The intra-articular

haematoma block of the ankle is not standard practice and remains relatively unknown.

Design: Integrative literature review.

Method: Seven databases were searched. The search was limited to the English language

and reference lists were reviewed. The Cochrane Risk of Bias tool was used for quality

assessment of the included studies.

Results: Just three studies were identified that met inclusion criteria, only one was a

randomised control trial. Two of the studies were at high risk of bias. The studies found no

significant difference in the rate of successful reduction when the intra-articular

haematoma block was used compared to procedural sedation. Two studies conducted a

patient questionnaire and found no significant difference in pain scores between the

groups. One study found that the intra-articular haematoma block facilitated a timelier

reduction in the case of subluxation, but more attempts to reduce were required when it

was used for dislocation. No adverse events were reported in the intra-articular haematoma

block groups, however, the studies were not longitudinal in nature, so did not measure

outcomes of joint sepsis or chondrolysis. The included studies referred to the evidence for

the haematoma block for wrist fractures and intra-articular anaesthesia for glenohumeral

dislocations as comparable procedures.

Conclusion: Current evidence suggests the intra-articular haematoma block is safe and

effective but is limited by the studies number and quality, therefore further research is

required. A quantified risk of chondrolysis following single dose intra-articular local

anaesthesia should be established before the intra-articular haematoma block is made

standard practice, but it can be considered in situations where the risk of procedural

sedation outweighs the likely very low risk of chondrolysis.