Anesthetic methods for reduction of acute shoulder dislocations: A prospective randomized study comparing intraarticular lidocaine with intravenous analgesia and sedation

doi:10.1016/S0735-6757(99)90197-3

The American Journal of Emergency Medicine

Volume 17, Issue 6, October 1999, Pages 566-570

https://doi.org/10.1016/S0735-6757(99)90197-3 Get rights and content

Abstract

A prospective, randomized, nonblinded clinical trial was undertaken to evaluate whether local intraarticular lidocaine injection (IAL) is equally effective in facilitating reduction of acute anterior shoulder dislocations (AASD) as intravenous analgesia/sedation (IVAS). The setting was an urban, Level 1, trauma center. Patients enrolled presented to the emergency department (ED) with radiographically confirmed AASD and were randomized either to the IVAS group or the IAL group. Ease of reduction and pain associated with reduction were measured subjectively using a 10-point scale. There were 49 patients entered into the study, 20 in the IVAS group and 29 in the IAL group. There was no statistically significant difference between mean ± SD pain scores of 3.32 ± 2.39 in the IVAS group and 4.90 ± 2.34 in the IAL group (P = .18), or mean ± SD ease of reduction scores of 3.32 ± 2.36 in the IVAS group and 4.45 ± 2.46 in the IAL group (P = .12). Although IVAS tended to have a higher success rate (20 of 20) than IAL (25 of 29) in this study, Kaplan-Meier estimates for delayed time-events curves applying the log-rank test showed that this difference was not statistically significant overall (P = .16). However, with reduction rate evaluated as a function of time delay in seeking treatment, patients presenting 5.5 hours after dislocation were more likely to fail treatment with IAL (P = .00001). Additionally, half of the patients in the IAL group who had experience with IVAS did not favor IAL. Emergency physicians should be aware of IAL as an alternative technique that may be considered in patients when there are reasons to avoid systemic analgesia or sedation.

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Cited by (55)

An Effective Treatment in the Austere Environment? A Critical Appraisal into the Use of Intra-Articular Local Anesthetic to Facilitate Reduction in Acute Shoulder Dislocation
2018, Wilderness and Environmental Medicine
Citation Excerpt :
One RCT was excluded because it looked exclusively at secondary dislocations,12 the definition of which was unclear in the manuscript. A total of 4 meta-analyses6,13–15 and 8 RCTs16–23 compared the use of IAL with IVAS. One RCT compared IAL with nitrous oxide,24 and another compared IAL against use of no additional analgesia.25
Acute shoulder dislocation is a common injury in the outdoor environment. The objective of this systematic review of the literature was to determine if intra-articular local anesthetic (IAL) is an effective treatment that could have prehospital application. A methodical search of MEDLINE, PubMed, and EMBASE databases targeted publications from January 1, 1990 until January 1, 2017. Eligible articles compared IAL with other analgesic techniques in patients 16 years or older experiencing acute glenohumeral dislocation. Reduction success, complications, and patient-reported outcome measures underwent comparison. All identified publications originated from the hospital setting. Procedural success rates ranged widely among randomized control trials comparing IAL with intravenous analgesia and sedation (IAL 48–100%, intravenous analgesia and sedation 44–100%). A pooled risk ratio [RR] favored intravenous analgesia and sedation (RR 0.91, 95% confidence interval [CI] 0.84–0.98), but there was significant inconsistency within the analysis (I² = 75%). IAL provided lower complication rates (4/170, 2%) than intravenous analgesia and sedation (20/150, 13%) (RR 1.11, 95% CI 1.04–1.19, I² = 63%). One trial found a clinically relevant reduction in visual analogue pain scores when comparing IAL against no additional analgesia in the first minute (IAL 21±13 mm; control 49±15 mm; P<0.001) and fifth minute (IAL 10±10 mm; control 40±14 mm, P<0.001) after reduction. The results suggest that IAL is an effective intervention for acute anterior shoulder dislocation that would have a place in the repertoire of the remote physician. Further research might be beneficial in determining the outcomes of performing IAL in the prehospital setting.
Intra-articular lidocaine versus intravenous sedative and analgesic for reduction of anterior shoulder dislocation
2016, Turkish Journal of Emergency Medicine
Citation Excerpt :
Among them, more attention was paid to IAL use compared to IVSA. Results of a prospective randomized study comparing IAL with IVSA by Kosnik et al showed no statistically significant difference between the 2 groups for reduction of acute anterior shoulder dislocation regarding mean pain and ease of reduction scores, or success rates.24 In our study, mean pain intensity during reduction in IAL group was significantly lower than IVSA, indicating that IAL could be preferable to IVSA for reduction of acute anterior shoulder dislocation.
This prospective clinical trial was performed to compare the safety and efficiency of intra-articular lidocaine (IAL) versus intravenous sedative and analgesic (IVSA) in reduction of anterior shoulder dislocation.
Patients with anterior shoulder dislocation were randomly divided into 2 groups to receive IAL and IVSA. One group patients received an intravenous dose of 0.05 mg/kg midazolam and 1 μg/kg fentanyl, while the other group received 20 mL intra-articular lidocaine (1%). Patient satisfaction (via a standard 5-choice questionnaire), pain score (based on visual analog scale ranging from 0 to 10 points), comfort reduction, recovery time, and side effects were recorded and compared between the two groups before, during and after the reduction procedure.
Totally 104 patients with acute anterior shoulder dislocation and the mean age of 28.75 ± 7.24 years were included (86.5% male). There was no statistically significant difference between IAL and IVSA groups regarding age (p = 0.45) and gender (p = 0.25). A total of forty-seven (45.2%) patients, distributed in both groups, had a history of anterior shoulder dislocation. A significant difference was seen with regard to diminished pain intensity during reduction in IAL group (p < 0.001); Complications including nausea, apnea, hypoxia and headache were only observed in IVSA group, and there was no adverse effect in IAL group; increased patient satisfaction in IVSA group (p = 0.007); similar success rate at first attempt of reduction in both groups, and a shorter time to discharge in IAL group (p < 0.001).
It seems that the use of intra-articular lidocaine for reduction of anterior shoulder dislocation is effective, safe, and time saving in the emergency department and has few complications. It can be considered as the first line analgesia in managing anterior shoulder dislocation.
Point-of-Care Ultrasound in Diagnosis and Treatment of Luxatio Erecta (Inferior Shoulder Dislocation)
2016, Journal of Medical Ultrasound
Citation Excerpt :
It also presented a large target to aim for when attempting to provide anesthesia with intraarticular lidocaine (IAL) as seen in Figure 3. The IAL approach for anesthesia during closed shoulder dislocation reduction has been shown to produce equal analgesia when compared to IV analgesia [8,9]. First described in 1991 it has many advantages including reducing the need for procedural sedation with its associated risks and decreasing length of ED stay [2,10].
Point-of-care-ultrasound (POC-US) is an increasingly popular tool in the assessment of a wide variety of emergency department patients. In this case report we discuss how POC-US aided in the diagnosis and treatment of inferior shoulder dislocation, a rare presentation of a common emergency department complaint.
A 69-year-old female presented to the emergency department with severe shoulder pain after a ground level fall. Her arm was held overhead with her shoulder trapped in abduction. POC-US confirmed the diagnosis of inferior shoulder dislocation, guided glenohumeral intraarticular anesthesia, and confirmed successful reduction.
Why an emergency physician should be aware of this: POC-US is a useful tool for the emergency physician when confronted with shoulder dislocation. US not only confirms the dislocation, but also differentiates between anterior versus posterior versus inferior dislocation. POC-US can guide the placement of intraarticular lidocaine for anesthesia which then potentially reduces time, expense, and risk of procedural sedation. Finally, POC-US may reduce failed reductions by providing immediate visual confirmation and in the case of reductions performed under sedation, may prevent the need for repeat sedation.
Intra-articular lidocaine versus intravenous analgesia and sedation for manual closed reduction of acute anterior shoulder dislocation: An updated meta-analysis
2014, Journal of Clinical Anesthesia
Citation Excerpt :
Three recent systematic reviews [6,19,20] comparing IVAS and IAL reported that IAL was advantageous over IVAS with respect to lower complication rates and similar success rates of reduction and pain relief. The 7 RCTs [10–16] comparing the two anesthesia methods from 1994 to 2008 were consistent in their conclusions. Although both anesthesia methods were effective, IAL was recommended for manual closed reduction of anterior shoulder dislocation due to its clinical advantages, including lower systematic side effects [13,16], excellent anesthesia efficacy [11–13], reduced total costs [11,12] and, especially, similar success in reduction rates [10–16].
To compare intra-articular lidocaine (IAL) with intravenous analgesia and sedation (IVAS) for manual closed reduction of acute anterior shoulder dislocation.
Meta-analysis.
Metropolitan medical university.
A literature search was conducted of PubMed, Ovid and Cochrane Library, to identify randomized controlled trials (RCTs) published from January 1, 1990 to September 1, 2012, that compared IAL with IVAS for manual closed reduction of acute anterior shoulder dislocation. Effective data were pooled using fixed-effects or random-effects models with mean differences (MDs) and risk ratios (RRs) for continuous and dichotomous variables, respectively.
Nine RCTs comprising 438 patients were analyzed. Statistical analyses showed that IAL was superior to IVAS with respect to lower complication risk (P < 0.00001) and shorter mean hospital length of stay (P = 0.03). No significant differences were noted in success of joint reduction (P = 0.16), patient satisfaction (P = 0.12), or postreduction pain relief (P = 0.76). However, IAL required more time than IVAS from injection to reduction (P < 0.00001). Subgroup analyses showed that IVAS was associated with higher risks of respiratory depression (P < 0.0001), vomiting (P = 0.04), and thrombophlebitis (P = 0.008), but no statistical differences were identified in nausea (P = 0.06), hypotension (P = 0.10), drowsiness (P = 0.45), or headache (P = 0.29).
Intra-articular lidocaine injection may be safer than IVAS because there are fewer risks of postoperative complications with IAL. Both techniques are similarly effective for manual closed reduction of acute anterior shoulder dislocation.
Can intra-articular lidocaine supplant the need for procedural sedation for reduction of acute anterior shoulder dislocation?
2012, Annals of Emergency Medicine
Sedation and analgesia in emergency structure. Which sedation and/or analgesia for painful treatments?
2012, Annales Francaises d'Anesthesie et de Reanimation

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^☆: Presented at the Michigan American College of Emergency Physicians' annual scientific assembly July 1996.

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Original contributionAnesthetic methods for reduction of acute shoulder dislocations: A prospective randomized study comparing intraarticular lidocaine with intravenous analgesia and sedation☆

Abstract

Am J Emerg Med

J Shoulder Elbow Surg

Injury

Ann Emerg Med

Intraarticular lidocaine versus intravenous analgesia in the reduction of dislocated shoulders

Orthop Trans

Original contribution
Anesthetic methods for reduction of acute shoulder dislocations: A prospective randomized study comparing intraarticular lidocaine with intravenous analgesia and sedation☆