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results in a much lower success rate.  Larger bones require larger volumes.  

Postreduction x-rays: It takes a while from the time you order a postreduction xray until the patient is actually taken to the x-ray room.  You needn’t always be frustrated by this delay, which can occasionally be lengthy.  Think ahead and order the postreduction x-ray after you have inserted your hematoma block, just prior to performing the reduction.  The sometimes slow process of entering the order, etc., can be taking place while you are performing the reduction, and the patient may be ready to go to x-ray just as you finish molding your splint.

Reduction of dislocations: It is probably much safer for your patient to reduce dislocations after intraarticular injection of anesthetic (which can be surprisingly effective at pain relief) rather than excessive use of intravenous sedatives and narcotics with their attendant dangers.  A dislocated joint is frequently surprisingly easy to inject by introducing the needle on the opposite side from the dislocation (i.e., introducing the needle posteriorly for an anterior dislocation of the shoulder or anteriorly for a posterior dislocation of the hip).  Even the hip, which usually must be aspirated in fluoroscopy, can often be injected without fluoroscopy (when it is dislocated) by introducing the needle lateral to the femoral pulse and walking it off of the pubic ramus until the needle falls into the hip joint (with a located hip, you cannot feel this drop off so that you need fluoro to tell you are in the correct position).  

Injecting a dry joint: Many physicians make the error of trying to insert the needle into the “joint space.”  There is no space there!  It simply appears to be a space on x-ray because of the cartilage.  Trying to insert the needle into the “joint space” results in numerous longitudinal lacerations of the articular cartilage by the needle as you “fish in and out” for the space.  In a joint that does not have an effusion, it is least damaging to direct the needle perpendicularly into the articular cartilage of the convex surface of the joint (i.e., femoral condyle of the knee, talar dome of the ankle, etc.) making one small round hole in the cartilage.  Once the needle is against the subchondral bone, depress the plunger and back the needle out slightly until fluid flows in freely.  This one small round needle hole is much better for the joint than numerous longitudinal lacerations.  

Painless injections:  There are several things that can be done to diminish the pain of an injection:  (1) Rub an anesthetic cream into the area.  Unfortunately this requires a long waiting period.  (2) Ice the area or spray with a cold spray.  (3) Use a sharp needle.  Be aware that putting a needle through a rubber stopper damages its fine, sharp tip and that not all needles are sharp directly out of the package.  A dull needle will cause dimpling of the skin and should be discarded and a sharp needle (which passes easily through the skin without dimpling) used instead.  (4) Inject slowly.  It may well be that the reason a small needle hurts less than a large needle, has as much to do with the fact that it is difficult to inject rapidly, as it does with the size of the needle itself.  (5)


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