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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. 1995 Denmark	52 patients with secondary traumatic shoulder dislocation 26 20ml 1% lidocaine 26- IV pethidine/diazepam	Prospective, randomised	Successful reduction	18/26 (IAL) v 22/26 (sedation) p= 0.19	Randomisation by sealed envelopes. Small study numbers
			Average pain score (visual analogue scale)	32.3mm (IAL) v 47.3mm (sedation) p= 0.08
			Time for reduction	16.1 mins (IAL) v 4.7 mins (sedation) p= 0.001
			Complications	0 (IAL) v 3 (IV)- respiratory depression p= 0.24
Matthews, D.E. and Roberts, T. 1995 USA	30 patients presenting with acute anterior shoulder dislocation. 15- intra-articular lidocaine 15- IV morphine and midazolam	Prospective, randomised trial	Time of reduction manoeuvre	No statistical difference	Patients 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)
			Complications	0 (IAL) v 3 (sedation)- nausea, flumazenil
			Time spent in ED	78 mins (IAL) v 186 mins (sedation) p= 0.004)
			Total cost	$117-133 (IAL) v $159.55-240.55 (sedation)
Kosnik et al. 1999 USA	49 patients presenting with an acute anterior shoulder joint dislocation. 20 – IV analgesia and sedation 29 – Intra-articular lidocaine	Prospective, randomised non-blinded clinical trial	Primary outcome – successful radiographic reduction	20/20 successfully reduced (IV) v 24/29 (IAL) p = 0.16	Low 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 treatment	Mean time delay 3.77 (IV) v 5.71 (IAL) p = 0.49
			Reduction success rate at 5.5 hours	100% (IV) v78.24% (IAL) p<0.00001
Miller et al. 2002 USA	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 study	Pain intensity (1-10)	7 (IAL) v 7.4 (sedation) p = 0.37	Small 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-effects	None observed in either group
			Time to discharge	75 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. 2002 USA	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 study	Pain	Improved 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 reduction	Mean time 103 mins (IAL) v 154 mins (IV) p = 0.025
Pradhan et al. 2006 Nepal	45 patients aged 17 – 55 presenting with acute anterior shoulder dislocation. 23- 20ml 1% intra-articular lidocaine 22- IV propofol +/- pethidine	Non-randomised, prospective study	Time to reduce	18.82 mins (IAL) v 4.55 mins (sedation) p= <0.01	Small 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
			Cost	150 rupees (IAL) v Rs. 400 rupees (IV)
			Complications	0 (IAL) v 2 (sedation)- overnight admission
Moharari et al. 2007 Iran	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/diazepam	Non-blinded randomised clinical trial	Pain score change before injection to after reduction (0-100mm visual scale)	66.2mm (IAL) v 70.2mm (sedation) p= 0.47	Low 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
			Complications	3 (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 2011 Canada	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, randomised	Length of ED stay	170 mins (IAL) v 145 mins (sedation) p= 0.46	Landmark 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 reductions	48% (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 complications	No immediate/Delayed complications in either group
Cheok, Mohamad and Ahmad 2011 Malaysia	63 patients aged greater than or equal to 15 years presenting with acute anterior shoulder dislocation. 32- intra-articular lidocaine 31- intravenous sedation	Prospective, randomised study	Successful reduction	81% (IAL) v 100% (sedation) p=0.024	Single centre study. Randomisation performed via sealed envelopes
			Complications	0% (IAL) v 29% (sedation)- respiratory depression, vomiting, allergy, thrombophlebitis p=0.001
			Patient satisfaction	69% (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 hospitalisation	2.2 hours (LA) v 8.1 hours (sedation) p= 0.001
			Cost	$10 (LA) v $31 (sedation) p=0.00
Kashani et al. 2016 Turkey	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 trial	Patient satisfaction: complete dissatisfaction	9 (IAL) v 0 (sedation) p=0.007. Reason: Patient preference for reduced consciousness	No 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 minutes	59.6% (IAL) v 19.2% (sedation) p= less than 0.001
			Side-effects during and after reduction	0 (IAL) v 15 (sedation)- nausea, apnoea, hypoxia, headache No significant complications at 2-week follow-up
Milzman, D. et al. 2019 Netherlands	319 patients with acute anterior shoulder dislocation. 53 – Intra-articular lidocaine 266 – IV conscious sedation	Retrospective review	Primary outcome: Length of stay in the emergency department	251 mins (IAL) v 324 mins (sedation) p= less than 0.001	Retrospective study. Initially 566 patients found, many lost due to uncertainties around medications given

Comment(s)

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.

References

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.