Effectiveness of intra-articular lidocaine injection for reduction of anterior shoulder dislocation: randomized clinical trial

Abstract

CONTEXT AND OBJECTIVE: Shoulder dislocation is the most common dislocation among the large joints.The aim here was to compare the effectiveness of reduction of acute anterior shoulder dislocation with or without articular anesthesia. DESIGN AND SETTING: Prospective randomized trial conducted in Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp). METHODS: From March 2008 to December 2009, 42 patients with shoulder dislocation were recruited. Reductions using traction-countertraction for acute anterior shoulder dislocation with and without lidocaine articular anesthesia were compared. As the primary outcome, pain was assessed through application of a visual analogue scale before reduction, and one and five minutes after the reduction maneuver was performed. Complications were also assessed. RESULTS: Forty-two patients were included: 20 in the group without analgesia (control group) and 22 in the group that received intra-articular lidocaine injection. The group that received intra-articular lidocaine had a statistically greater decrease in pain over time than shown by the control group, both in the first minute (respectively: mean 2.1 (0 to 5.0), standard deviation, SD 1.3, versus mean 4.9 (2.0 to 7.0, SD 1.5; P < 0.001) and the fifth minute (respectively: mean 1.0; 0 to 3.0; SD = 1.0 versus mean 4.0; 1.0 to 6.0; SD = 1.4; P < 0.001). There was one failure in the control group. There were no other complications in either group. CONCLUSION: Reduction of anterior shoulder dislocation using intra-articular lidocaine injection is effective, since it is safe and diminishes the pain. CLINICAL TRIAL REGISTRATION: ISRCTN27127703. Foi comparada a redução de tração e contra-tração com e sem anestesia intra-articular com lidocaína. Como desfecho primário, a dor foi avaliada por meio da escala visual analógica antes da redução e um e cinco minutos após a redução do ombro. Complicações também foram avaliadas. RESULTADOS: Foram incluídos 42 pacientes: 20 no grupo sem anestesia (grupo controle) e 22 no grupo que recebeu injeção intra-articular de lidocaína. O grupo que recebeu lidocaína intra-articular teve estatisticamente menos dor no primeiro (média = 2,1; 0 a 5,0, desvio padrão, DP, de 1,3, versus média = 4,9; 2,0 a 7,0; DP = 1,5; respectivamente; P < 0,001) e no quinto minutos (média = 1,0; 0 a 3,0; DP = 1,0 versus 4,0; 1,0 a 6,0; DP = 1,4; respectivamente; P < 0,001) após a redução em comparação ao grupo controle. Houve uma falha no grupo controle. Não houve complicações adicionais em ambos os grupos. CONCLUSÃO: A redução da luxação do ombro com o uso de lidocaína intra-articular é efetiva, pois é segura e proporciona menos dor. REGISTRO DE ENSAIO CLÍNICO: ISRCTN27127703 I MD, PhD. Attending Physician in the Shoulder RESUMO

Intra-articular lidocaine versus intravenous sedative and analgesic for reduction of anterior shoulder dislocation

“…IVSA group received an intravenous dose of 0.05 mg/kg midazolam and 1 μg/kg fentanyl and after achievement of proper sedation, underwent reduction. The second group were injected with 20 mL of 1% lidocaine, during 30 s, using an 18–20 gage 0.7 × 40-mm needle, into the shoulder joint about 2 cm below the lateral border of the acromion, towards the glenoid cavity under sterile conditions according to Gleeson and Tamaoki studies 1, 7. In IAL group, reduction was performed 15 min after intra-articular injection.…”

“…Shoulder dislocation is the most common large joint dislocation which is classified to anterior, posterior, and inferior types 1 . Anterior shoulder dislocation accounts for approximately 95% of all shoulder dislocations, that are commonly presented to emergency department (ED) 2, 3, 4.…”

“…Selection of ideal and relatively pain-free reduction method could play a key role in management of shoulder dislocations. Intravenous sedation-analgesia (IVSA) is commonly applied for reduction in EDs and provide a trouble-free condition 1, 4, 6, 7, 8, 9, 10, 11. Studies showed that IVSA can trigger some side effects such as central nervous system and cardio-respiratory depression, which requires close patient monitoring and medical management 4, 6.…”

“…On the other hand, prior reviews had controversies about significant differences between IAL and IVSA in this regard 13 . Despite opposing results in this context, favorable impacts of lidocaine should not be ignored, which include adequate muscle relaxation, less pain and cost, prompt patient discharge, adequacy for patients in whom intravenous access is not easily obtainable, and not needing oxygen saturation monitoring and electrocardiography during or after reduction 1, 4, 10, 14. Few prospective controlled trials have compared IAL and IVSA from the standpoint of effectiveness, safety, time taken, ED overcrowding, and especially pain intensity in acute anterior shoulder dislocation patients in Iran 15 .…”

Intra-articular lignocaine as a means of analgesia during manual reduction of acute anterior shoulder dislocation

“…1 Although several reduction techniques with or without analgesia have been described, ideal reduction method should be simple, quick, effective and nontraumatic, with least pain and complications and cheap. 2 Recently, intra-articular lignocaine (IAL) has been advocated as a means of providing analgesia during manual reduction of acute anterior shoulder dislocation (AASD). 2,3,4 Some authors have suggested that this would be an excellent choice for improved analgesia, in addition to its low costs and low complication rates.…”