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Can acute shoulder dislocations be reduced using intra-articular local anaesthetic infiltration as an alternative to intravenous analgesia with or without sedation?

Three Part Question

In [patients presenting with acute shoulder dislocation] is [intra-articular lidocaine a safe and effective alternative compared to intravenous analgesia, with or without sedation] in [facilitating joint reduction]?

Clinical Scenario

A 42-year-old man presents to the Emergency Department (ED) with an acute anterior shoulder dislocation following a fall. He does not tolerate reduction with nitrous oxide and intravenous (IV) access is not possible. Your Consultant suggests using intra-articular lidocaine (IAL) to aid reduction. You wonder if IAL is a safe and effective alternative to intravenous analgesia with or without sedation.

Search Strategy

The Pubmed, EMBASE and CINAHL databases were searched via the Healthcare Databases Advanced Search interface. Search terms were as follows:

((("intra articular").ti,ab OR ("articular").ti,ab OR ("intra-articular").ti,ab) AND (("block").ti,ab OR ("local anaesthetic").ti,ab OR ("local anaesthesia").ti,ab OR ("lidocaine").ti,ab OR ("lignocaine").ti,ab)) AND (("shoulder dislocation").ti,ab OR ("dislocated shoulder").ti,ab)

A search of the BestBET and Cochrane databases was also conducted.

Search Outcome

A total of 114 papers were found. After review of the abstracts and full texts, including cross-referencing the bibliographies of potentially relevant papers, 11 were deemed relevant and of suitable quality for inclusion. Of these, there were 9 prospective randomised studies, with 1 retrospective review and 1 prospective, non-randomised study. 1 previous BestBET from 2002 was found.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Suder, P. et al.
52 patients with secondary traumatic shoulder dislocation 26 20ml 1% lidocaine 26- IV pethidine/diazepamProspective, randomisedSuccessful reduction18/26 (IAL) v 22/26 (sedation) p= 0.19Randomisation by sealed envelopes. Small study numbers
Average pain score (visual analogue scale)32.3mm (IAL) v 47.3mm (sedation) p= 0.08
Time for reduction16.1 mins (IAL) v 4.7 mins (sedation) p= 0.001
Complications0 (IAL) v 3 (IV)- respiratory depression p= 0.24
Matthews, D.E. and Roberts, T.
30 patients presenting with acute anterior shoulder dislocation. 15- intra-articular lidocaine 15- IV morphine and midazolamProspective, randomised trialTime of reduction manoeuvre No statistical differencePatients randomised by picking a page at random from the protocol notebook. P values not presented for all results
Difficulty of reduction“Easy” 10 (IAL) v 7 (sedation), “Tough” 5 (IAL) v 6 (sedation) “Very tough” 0 (IAL) v 2 (sedation)
Subjective pain (1-10 Likert scale)4.5 (IAL) v 5.2 (sedation)
Complications0 (IAL) v 3 (sedation)- nausea, flumazenil
Time spent in ED78 mins (IAL) v 186 mins (sedation) p= 0.004)
Total cost$117-133 (IAL) v $159.55-240.55 (sedation)
Kosnik et al.
49 patients presenting with an acute anterior shoulder joint dislocation. 20 – IV analgesia and sedation 29 – Intra-articular lidocaineProspective, randomised non-blinded clinical trialPrimary outcome – successful radiographic reduction 20/20 successfully reduced (IV) v 24/29 (IAL) p = 0.16Low study numbers. Non blinded therefore risk of bias. Unable to achieve target study power – ultimately underpowered study. Level of experience for those managing patient not recorded. Most cases managed by orthopaedics – not a true reflection of ED practice. Risk of significant bias – doctors aware of approach and may unconsciously (or consciously) over or under score for pain and ease of reduction
Secondary outcomes - Ease of reduction (subjective 10-point visual scale)Mean ease of reduction 3.32 (IV) v 4.45 (LA) p = 0.12
Pain associated with reduction (subjective 1-10 scale)Mean pain score 3.95 (IV) v 4.90 (IAL) p = 0.18
Time delay to treatmentMean time delay 3.77 (IV) v 5.71 (IAL) p = 0.49
Reduction success rate at 5.5 hours100% (IV) v78.24% (IAL) p<0.00001
Miller et al.
30 patients aged 18 – 70 years old presenting with acute anterior shoulder joint dislocation. 16 – 20ml intra-articular injection of 1% lidocaine 14 – IV sedation (midazolam and fentanyl)Multi-centre prospective, randomised studyPain intensity (1-10)7 (IAL) v 7.4 (sedation) p = 0.37Small patient numbers. Outcomes not explicitly stated. No long term follow up for complications. Does not state who carried out the intra-articular joint injection. No description of staff education to carry out intra-articular injections effectively and safely
Side-effectsNone observed in either group
Time to discharge75 mins (IAL) v 185 mins (sedation) p<0.01
Cost$0.52 (IAL) v $97.64 (sedation)
Time for reduction (using Stimson weighted bag technique)11.4 mins (IAL) v 8.5 mins (sedation) p = 0.42
Orlinsky et al.
54 patients between the ages of 18-80 years old presenting with anterior shoulder dislocation. 29 – Intra-articular lidocaine 25 – IV analgesia and sedation (Meperidine/Diazepam)Prospective, randomised, non-blinded studyPainImproved pre-reduction pain relief in the IV group compared to intra-articular (p = 0.045)Under-recruited, as aiming for 250 participants. Outcomes not specifically stated
Recovery time post reductionMean time 103 mins (IAL) v 154 mins (IV) p = 0.025
Pradhan et al.
45 patients aged 17 – 55 presenting with acute anterior shoulder dislocation. 23- 20ml 1% intra-articular lidocaine 22- IV propofol +/- pethidineNon-randomised, prospective studyTime to reduce18.82 mins (IAL) v 4.55 mins (sedation) p= <0.01Small study numbers. Reductions carried out by orthopaedic surgeon. Pethidine less commonly used in the UK setting. Patient allocations not obviously stated. No specific results for some outcomes stated – no results for pain intensity
Cost150 rupees (IAL) v Rs. 400 rupees (IV)
Complications0 (IAL) v 2 (sedation)- overnight admission
Moharari et al.
48 patients aged 18 – 80 years old presenting to a single ED with acute traumatic anterior shoulder joint dislocation. 24 - Intra-articular injection (20ml 1% lidocaine) 24 – IV meperidine/diazepamNon-blinded randomised clinical trial Pain score change before injection to after reduction (0-100mm visual scale)66.2mm (IAL) v 70.2mm (sedation) p= 0.47Low study numbers. Some patients in the intra-articular injection group found to have taken additional analgesia, which will affect overall results. No follow-up to assess potential longer term complications
Complications3 (IAL)- drowsiness v 14 (sedation)- drowsiness, respiratory depression, hypotension, headache, nausea, paraesthesia p = 0.001
Time in department 140.6 mins (IAL) v 216.5 mins (sedation) p= 0.018
Hames, McLeod and Millard
44 patients greater than 16 years old presenting with an acute anterior shoulder joint dislocation. 25 - Intra-articular injection (4mg/kg 1% lidocaine) 19 – Intravenous sedation (choice at doctors discretion)Prospective, randomisedLength of ED stay170 mins (IAL) v 145 mins (sedation) p= 0.46Landmark technique for LA joint injection – Potential for poor localisation, particularly in overweight patients. Physicians lacked experience with IAL. No objective method for ensuring analgesia achieved in intra-articular group. Impossible to blind patients/doctors to a particular treatment arm. 52% of those receiving intra-articular lidocaine received pre-procedural analgesia (Morphine, ketorolac or fentanyl) – Reduces reliability of results as not truly due to intra-articular effects alone. Small study size. Of the 242 patients planned for enrolment, only 18.2% (44) were included. Poor follow-up rates: 28/44 (63.6%)
Rate of successful closed reductions48% (IAL) v 100% (sedation) p= <0.001
Patient satisfaction (patient extremely satisfied)48% (IAL) v 79% (sedation)
Ease of reduction (physician extremely satisfied)24% (IAL) v 68% (sedation)
Immediate and delayed complicationsNo immediate/Delayed complications in either group
Cheok, Mohamad and Ahmad
63 patients aged greater than or equal to 15 years presenting with acute anterior shoulder dislocation. 32- intra-articular lidocaine 31- intravenous sedationProspective, randomised studySuccessful reduction81% (IAL) v 100% (sedation) p=0.024Single centre study. Randomisation performed via sealed envelopes
Complications0% (IAL) v 29% (sedation)- respiratory depression, vomiting, allergy, thrombophlebitis p=0.001
Patient satisfaction69% (IAL) v 90% (sedation) p=0.09
Visual analogue scale pain reduction -6.07 (LA) v -5.4 (sedation) p=0.44 for first time dislocation; -4.50 (LA) v – 5.62 (sedation) for recurrent dislocators p= 0.2
Duration of hospitalisation2.2 hours (LA) v 8.1 hours (sedation) p= 0.001
Cost$10 (LA) v $31 (sedation) p=0.00
Kashani et al.
104 patients age d18 – 40 years old presenting with acute anterior shoulder dislocation. 52 – Intra-articular 20ml 1% lidocaine injection 52 – IV sedation and analgesia (Midazolam and fentanyl)Prospective clinical trialPatient satisfaction: complete dissatisfaction9 (IAL) v 0 (sedation) p=0.007. Reason: Patient preference for reduced consciousnessNo evidence to show education on the technique for injecting lidocaine – No baseline equality, with differing colleagues potentially having more experience and better analgesic effects. Use of only one reduction technique (Leidelmeyer) – unlikely to be best approach for every patient therefore affecting pain intensities + satisfaction scores. 45.2% were recurrent dislocators – likely to have an easier patient journey and depending on group assigned, will skew results
Pain intensity during reduction (visual pain scale 0-10)0.29 (IAL) v 2.92 (sedation) p less than 0.001
Discharge within 30 minutes59.6% (IAL) v 19.2% (sedation) p= less than 0.001
Side-effects during and after reduction0 (IAL) v 15 (sedation)- nausea, apnoea, hypoxia, headache No significant complications at 2-week follow-up
Milzman, D. et al.
319 patients with acute anterior shoulder dislocation. 53 – Intra-articular lidocaine 266 – IV conscious sedationRetrospective reviewPrimary outcome: Length of stay in the emergency department251 mins (IAL) v 324 mins (sedation) p= less than 0.001Retrospective study. Initially 566 patients found, many lost due to uncertainties around medications given


Acute anterior shoulder joint dislocation is a common ED presentation, with an incidence of 17 per 100 000 (Hames, McLeod and Millard, 2011). IAL was first recognised by Suder et. al in 1995 as an alternative to IV analgesia and/or sedation for facilitating reduction of such injuries. A 2002 BestBET suggested that use of IAL reduced time spent in ED, although no statistically significant differences in pain relief or ease of reduction were found (Dhinakharan and Ghosh, 2002). There has since been further published evidence investigating IAL as a method for reducing acute anterior shoulder joint dislocations. There is conflicting evidence currently as to whether IAL provides better pain relief. Miller et al., Kashani et al. and Mohari et al. found a statistically insignificant improvement in pain relief in the IAL group. However, Orlinsky et al. showed a statistically significant improvement in pain relief in the IV group. Overall patient satisfaction is higher in the IV group, as shown by Hames et al., Cheok et al. and Kashani et al. However, patient preference for reduced consciousness was noted as the primary driver for this. Overall first-time success of reduction was higher in those receiving IV analgesia and/or sedation, which was mirrored by an overall improved ease of reduction as rated by the care provider. The majority of studies demonstrated a statistically significant reduction in discharge time in those patients receiving IAL. Furthermore, there were no documented significant side-effects or complications in the IAL group. In the IV group, a number of papers reported significant side-effects, including respiratory depression and reduced GCS, commonly resulting in hospital admission. Overall cost was found to be significantly lower in the IAL group. A number of approaches to IAL were carried out, including anterior, posterior, lateral, ultrasound guided and landmark guided. Furthermore, a varying degree of experience amongst physicians was evident, alongside differences in the depth of initial teaching given. These are all likely to have had an impact on the analgesic effects of the block given. It is also likely to explain why first-time reductions were lower in the IAL group.

Editor Comment

Since the BestBET published in 2002 by Dhinakharan and Ghosh there have been another five systematic reviews/meta-analyses: Fitch et al. 2008, Ng et al. 2009, Wakai et al. 2011, Jiang et al. 2014, and most recently Fraser 2018. There are almost as many reviews as there are primary studies. There has also been a study of intra-articular local anaesthetic versus no analgesia which concluded that the injections did indeed reduce pain compared to no analgesia. The conclusions in this BET are similar to those reached by Fraser in his 2018 review.

Clinical Bottom Line

IAL is a safe and effective method of providing procedural analgesia for the reduction of acute shoulder dislocations. Compared to IV analgesia with or without sedation, IAL offers a cheaper and less resource dependent alternative, facilitating quicker ED discharge. It is associated with fewer complications, and patients experience a similar level of procedural pain. IAL should therefore be considered as an analgesic strategy, particularly in patients deemed as a high anaesthetic risk.


  1. Suder, P. et al. Reduction of traumatic secondary shoulder dislocations with lidocaine Archives of Orthopaedic and Trauma Surgery 1995; pages: 233-236
  2. Matthews, D.E. and Roberts, T. Intraarticular lidocaine versus intravenous analgesic for reduction of acute anterior shoulder dislocations. A prospective randomized study The American Journal of Sports Medicine 1995; pages: 54-58
  3. Kosnik et al. Anesthetic methods for reduction of acute shoulder dislocations: a prospective randomized study comparing intraarticular lidocaine with intravenous analgesia and sedation The American Journal of Emergency Medicine 1999; pages: 566-570
  4. Miller et al. Comparison of intra-articular lidocaine and intravenous sedation for reduction of shoulder dislocations: a randomized, prospective study The Journal of Bone and Joint Surgery American Volume 2002; pages: 2135-2139
  5. Orlinsky et al. Comparative study of intra-articular lidocaine and intravenous meperidine/diazepam for shoulder dislocations The Journal of Emergency Medicine 2002; pages: 241-245
  6. Pradhan et al. Reduction of acute anterior shoulder dislocations: comparing intraarticular lignocaine with intravenous anesthesia Journal of the Nepal Medical Association 2006; pages: 223-227
  7. Moharari et al. Intra-articular lidocaine versus intravenous meperidine/diazepam in anterior shoulder dislocation: a randomised clinical trial Emergency Medicine Journal 2007; pages: 262-264
  8. Hames, McLeod and Millard. Intra-articular lidocaine versus intravenous sedation for the reduction of anterior shoulder dislocations in the emergency department Canadian Journal of Emergency Medicine 2011; pages: 378-383
  9. Cheok, Mohamad and Ahmad. Pain relief for reduction of acute anterior shoulder dislocations: a prospective randomized study comparing intravenous sedation with intra-articular lidocaine Journal of Orthopaedic Trauma 2011; pages: 5-10
  10. Kashani et al. Intra-articular lidocaine versus intravenous sedative and analgesic for reduction of anterior shoulder dislocation Turkish Journal of Emergency Medicine 2016; pages: 60-64
  11. Milzman, D. et al. Intra-articular lidocaine versus IV conscious sedation for closed reduction of shoulder dislocation Crticial Care Medicine 2019; pages: 629
  12. Dhinakharan SR, Ghosh A. Intra-articular lidocaine for acute anterior shoulder dislocation reduction Emergency Medicine Journal Mar 2002, 19 (2) 142-143;
  13. Fitch RW, Kuhn JE. Intraarticular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for eduction of the dislocated shoulder: a systematic review. Acad Emerg Med. 2008;15(8):703-8.
  14. Ng VK, Hames H, Millard WM. Use of intra-articular lidocaine as analgesia in anterior shoulder dislocation: a review and meta-analysis of the literature. Can J Rural Med. 2009;14(4):145-9.
  15. Wakai A, O'Sullivan R, McCabe A. Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults. Cochrane Database Syst Rev. 2011;(4):CD004919.
  16. Jiang H, Hu YJ, Zhang KR et al. Intra-articular lidocaine versus intravenous analgesia and sedation for manual closed reductionof acute anterior shoulder dislocation: a review and meta-analysis. J Clin Anaes. 2014;26(5):350-9.
  17. Gould FJ. 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. Wilderness & Environmental Medicine 2018;29:102-110.
  18. Tamoaki MJ, Faloppa F, Wajnsztejn A et al. Effectiveness of intra-articular lidocaine injection for reduction of anterior shoulder dislocation: randomized clinical trial. Sao Paulo Med J. 2012;130(6)367-72.