Chapter 2: Anesthesia and Analgesia

INTRODUCTION

The relief of pain and suffering is one of the most important acts that a physician undertakes. Pain relief following orthopedic injuries should be provided universally and promptly, with rare exception. In addition, throughout this book, there are descriptions of fracture and dislocation reductions as well as soft-tissue repairs that will require significant anesthesia to perform successfully and compassionately. As such, this chapter serves as a reference for the safe and effective use of pain medications, procedural sedation, local anesthesia, and regional anesthesia used in emergency orthopedics. Finally, the clinical use of heat and cold is reviewed in patients with orthopedic injuries.

PAIN MANAGEMENT

The largest study to date of patients with closed fractures of the extremities or clavicle revealed that one-third of these patients did not receive pain medications while in the emergency department (ED).¹ Underuse of analgesics after orthopedic injuries is well documented in the literature.^2–7 Groups at risk for "oligoanesthesia" include pediatric patients,⁴ minority ethnic groups,⁵ and women.⁸ Children younger than 2 years seem to be at higher risk than school-age children.⁴

Despite the frequent underuse of analgesics by physicians, there is evidence that practice habits can change. One study documented that physicians prescribed pain medications following orthopedic injuries with a 95% compliance rate when an aggressive educational program was instituted.⁹

Once the decision has been made to give an analgesic agent, the next question is which analgesic to provide. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with healing fractures, as these agents have been shown to diminish bone formation, healing, and remodeling.¹⁰

The evidence for the use of nonsteroidal agents in patients with soft-tissue injuries is not as clear. NSAID use in blunt muscle trauma (especially the quadriceps) will decrease the incidence of heterotopic ossification. The majority of randomized controlled studies have shown a benefit for the use of an NSAID after various sprains and strains, although the positive effect is not universally noted. The use of an NSAID after exercise-induced muscle injury may also be beneficial for short-term recovery of muscle function.¹¹ In general, the use of an NSAID in soft-tissue injury is recommended for its potential to stimulate collagen synthesis and the early phases of skin and ligament repair.¹⁰

Of the opioid analgesics, codeine is the weakest agent, and in one study, it was no better than a placebo.¹² Other oral narcotic medications include hydromorphone (Dilaudid), hydrocodone (Vicodin, Lorcet), and oxycodone (Percodan, Percocet). Complications include constipation, nausea, and vomiting. Patients should be instructed not to drive while taking these medications, although up to 7% of patients admit to doing just the same, despite warnings.²

PROCEDURAL SEDATION AND ANALGESIA

The physician treating emergent orthopedic injuries will use procedural sedation and analgesia (PSA) frequently. It ...