Medications for Wrist Reduction in the Emergency Department
For procedural sedation and analgesia during wrist fracture or dislocation reduction in the ED, use intravenous opioids (such as fentanyl or morphine) combined with a benzodiazepine (such as midazolam), or alternatively use ketamine or propofol depending on your institutional protocols and the patient's clinical status.
Procedural Sedation Approach
The question of medications for wrist reduction in the ED centers on procedural sedation and analgesia (PSA), not chronic pain management. The provided evidence primarily addresses chronic hand osteoarthritis management 1 and pediatric supracondylar fractures 1, which are not directly applicable to acute wrist reduction procedures in adults.
Standard PSA Medications for Wrist Reduction
Primary options include:
Opioid + Benzodiazepine combination: Fentanyl (1-2 mcg/kg IV) or morphine (0.05-0.1 mg/kg IV) combined with midazolam (0.02-0.05 mg/kg IV) provides both analgesia and anxiolysis with amnesia for the procedure
Ketamine: 1-2 mg/kg IV or 4-5 mg/kg IM provides dissociative sedation with maintained airway reflexes and excellent analgesia
Propofol: 0.5-1 mg/kg IV bolus with additional 0.5 mg/kg doses as needed provides rapid onset and offset, though requires careful airway monitoring
Pre-Reduction Analgesia
Before attempting reduction:
- Administer adequate analgesia 5-10 minutes prior to manipulation
- Consider a hematoma block with 5-10 mL of 1% lidocaine injected into the fracture site as an adjunct for distal radius fractures
- Intra-articular lidocaine injection can be used for carpal dislocations
Post-Reduction Pain Management
After successful reduction:
- Oral NSAIDs at the lowest effective dose for short-term use (ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily) 1
- Acetaminophen up to 4 g/day can be added for multimodal analgesia 1
- Short course of oral opioids (3-5 days) for severe pain if NSAIDs are insufficient or contraindicated
- Topical NSAIDs (diclofenac gel) may provide additional relief with minimal systemic effects 1
Critical Considerations
Cardiovascular and gastrointestinal risk assessment is essential when prescribing NSAIDs post-reduction, particularly in elderly patients or those with comorbidities 1, 2. In high-risk patients, use gastroprotection with proton pump inhibitors or consider COX-2 selective agents, though these carry cardiovascular contraindications 1.
Avoid prolonged NSAID use beyond the acute injury phase (typically 7-14 days), as the evidence supports only short-duration therapy 1.
The PRICE protocol (Protection, Rest, Ice, Compression, Elevation) should be implemented immediately post-reduction for the first 72 hours to minimize swelling and pain 2.
Common Pitfalls
- Inadequate pre-procedural analgesia leads to failed reductions and patient distress—always allow sufficient time for medications to take effect
- Underestimating sedation requirements in anxious patients—titrate carefully to effect
- Forgetting to assess for contraindications to NSAIDs (renal disease, peptic ulcer disease, cardiovascular disease) before prescribing post-reduction 1
- Over-relying on acetaminophen alone for post-reduction pain, as its efficacy is limited and likely inferior to NSAIDs 1