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Three Part Question

In [patients with acute traumatic anterior shoulder dislocation] is [intra-articular lidocaine as effective as intravenous analgesia and sedation] at [facilitating reduction and easing pain associated with reduction]?

Clinical Scenario

A middle aged man attends the emergency department having sustained an acute primary anterior shoulder dislocation during a fall. It is impossible to obtain peripheral venous access and you are not able to get him to breathe entonox. You are aware that shoulder dislocations can be reduced with intra-articular lidocaine (IAL). You wonder if IAL is as effective as intravenous analgesia and sedation (IVAS).

Search Strategy

Medline 1966-12/01 using the Ovid interface.
[exp shoulder dislocation OR shoulder dislocation.mp OR "dislocated shoulder".mp] AND [exp anesthesia, intravenous OR exp anesthetics, intravenous OR "intravenous anaesthesia".mp OR exp analgesia OR exp conscious sedation OR exp diazepam OR exp hypnotics and sedatives OR exp midazolam OR exp sedatives, nonbarbiturate OR sedation.mp OR exp narcotics OR narcotics.mp OR exp morphine OR morphine.mp OR exp meperidine OR meperidine.mp OR exp pethidine OR pethidine.mp OR exp lidocaine OR "lidocaine".mp OR "lignocaine".mp OR exp injections, intra-articular OR exp joint diseases OR intraarticular.mp OR exp anesthetics OR exp anesthetics, local OR anesthetics.mp] AND maximally sensitive RCT filter. LIMIT to human AND English.

Search Outcome

146 papers were found, of which 3 were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Suder PA et al, 1995, Denmark	52 patients with secondary traumatic shoulder dislocation patients IAL (26) vs IVAS (26)	PRCT	Pain	Insignificant difference (p=0.08)	Small size
			Subjective evaluation	Insignificant difference (p=0.19)
			Mean time	16.1 + 3.5 vs 4.7 + 2.9 (p=0.001)
			Result of reduction	No significant difference (p=0.19)
Matthews DE and Roberts T, 1995, USA	30 consecutive patients presenting to the emergency department with acute anterior shoulder dislocation IAL (15) vs IVAS (15)	PRCT	Time to reduction, difficulty of reduction, subjective pain	No statistically significant difference	Small size Varied reduction techniques Statistical methods not described
			Time in emergency department	Significant reduction in the IAL group
			Complications	No complications
Kosnick J et al, 1999, USA	49 patients presenting to the emergency department with acute anterior shoulder dislocation IAL (29) vs IVAS (20)	PRCT	Success rate	20/20 for IVAS vs 24/29 for IAL (p=0.07)	Small sample size Varied physician experience Varied reduction techniques
			Ease of reduction (SD)	3.32 (2.36) for IVAS vs 4.45 (2.46) for IAL (p=0.12)
			Pain score (SD)	3.95 (2.39) for IVAS vs 4.90 (2.34) for IAL (p=0.18)

Comment(s)

All studies were small and therefore underpowered. Larger studies are therefore needed.

Clinical Bottom Line

Where intravenous analgesia and sedation needs to be avoided, intra-articular lidocaine should be the analgesic method of choice for reducing shoulder dislocations.

References

1. Suder PA, Mikkelsen JB, Hougaard K, et al. Reduction of traumatic secondary shoulder dislocations with lidocaine. Arch Orthop Trauma Surg 1995;114(4):233-6.
2. Matthews DE, Roberts T. Intraarticular lidocaine versus intravenous analgesic for reduction of acute anterior shoulder dislocations. A prospective randomized study. Am J Sports Med 1995;23(1):54-8.
3. Kosnik J, Shamsa F, Raphael E et al. Anesthetic methods for reduction of acute shoulder dislocations: a prospective randomized study comparing intraarticular lidocaine with intravenous analgesia and sedation. Am J Emerg Med 1999;17(6):566-70.