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Intra-articular Lidocaine Injection for Shoulder Reductions: A Clinical Review.
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MedLine Citation:
PMID:  23016059     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
CONTEXT: The shoulder is the most commonly dislocated joint, and shoulder dislocations are very common in sports. Many of these dislocations present to the office or training room for evaluation. Usual practice is an attempt at manual reduction without analgesia and then transfer to the emergency department if unsuccessful. The clinical efficacy of intra-articular lidocaine for reduction of anterior shoulder dislocations in the outpatient setting was examined.
EVIDENCE ACQUISITION: An OVID MEDLINE search (1966-present) was performed using the keywords shoulder, reduction, and analgesia as well as shoulder, intra-articular, and lidocaine. Search limits included articles in the English language. Bibliographic references from these articles were also examined to identify pertinent literature.
RESULTS: Six randomized controlled clinical trials were identified that directly addressed this clinical technique. Although the reduction techniques used in these studies were not controlled, there was no statistically significant difference in success rates between groups. The complication rate, length of stay, and costs were significantly less in the intra-articular lidocaine group when compared with the intravenous sedation group.
CONCLUSIONS: According to current evidence, the use of intra-articular lidocaine injection for reduction of anterior shoulder dislocations is not harmful and is likely advantageous in the outpatient clinical setting.
Authors:
Anna L Waterbrook; Stephen Paul
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Sports health     Volume:  3     ISSN:  1941-0921     ISO Abbreviation:  Sports Health     Publication Date:  2011 Nov 
Date Detail:
Created Date:  2012-09-27     Completed Date:  2012-09-28     Revised Date:  2013-05-30    
Medline Journal Info:
Nlm Unique ID:  101518422     Medline TA:  Sports Health     Country:  United States    
Other Details:
Languages:  eng     Pagination:  556-9     Citation Subset:  -    
Affiliation:
Department of Emergency Medicine, University of Arizona, Tucson, Arizona.
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Journal Information
Journal ID (nlm-ta): Sports Health
Journal ID (iso-abbrev): Sports Health
Journal ID (publisher-id): SPH
Journal ID (hwp): spsph
ISSN: 1941-7381
ISSN: 1941-0921
Publisher: SAGE Publications, Sage CA: Los Angeles, CA
Article Information
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© 2011 The Author(s)
epub-ppub publication date: Month: 11 Year: 2011
Print publication date: Month: 11 Year: 2011
Volume: 3 Issue: 6
First Page: 556 Last Page: 559
PubMed Id: 23016059
ID: 3445222
DOI: 10.1177/1941738111416777
Publisher Id: 10.1177_1941738111416777

Intra-articular Lidocaine Injection for Shoulder Reductions : A Clinical Review
Anna L. Waterbrook, MD*
Stephen Paul, MD
Department of Emergency Medicine, University of Arizona, Tucson, Arizona
Department of Family and Community Medicine and Orthopedics, University of Arizona, Tucson, Arizona
*Address correspondence to Anna L. Waterbrook, MD, Assistant Professor, University of Arizona, Department of Emergency Medicine, 2800 East Ajo Way, Tucson, AZ 85713 (e-mail: waterbro1@gmail.com).

The shoulder is the most commonly dislocated joint, and shoulder dislocations are very common in sports. A recent study evaluated 8940 shoulder dislocations and found that 48.3% occurred during sports and recreation.14 Many of these dislocations present to the office or training room for evaluation and treatment. Usual practice is an attempt at manual reduction without analgesia and then transfer to the emergency department if unsuccessful. There have been several prospective studies as well as systematic reviews published in the orthopaedic and emergency medicine literature showing the benefits of intra-articular analgesia for successful shoulder reductions. This method is not commonly discussed in the sports medicine literature despite the fact that this could be an alternative management strategy for athletes that present to the clinic or training room with shoulder dislocations.


Methods

An OVID MEDLINE search (1966-present) was performed using the key words shoulder, reduction, and analgesia. This search yielded 75 articles. An alternative search was used using shoulder, intra-articular, and lidocaine, which yielded 68 articles. Search limits included articles in the English language. Bibliographic references from these articles were also examined to identify pertinent literature. We identified 9 articles that directly addressed this technique, including 6 peer-reviewed research articles4,6-8,10,12 and 3 systematic reviews,3,5,9 which included the 6 research articles.


Results

All 6 reviewed studies (Table 1) were randomized controlled clinical trials. Each study compared intra-articular lidocaine (IAL) versus intravenous sedation (IVS) for the reduction of anterior shoulder dislocations. The study populations were small, ranging from 30 to 54 participants each.

IAL was used in all 6 studies. Out of the 6 studies, 5 used 20 mL of 1% lidocaine, while 1 study used 4 mg/kg of 1% lidocaine.4 Four studies described the technique for IAL: 2 studies used the posterior approach,4,12 1 the anterior approach,8 and another injected lateral to the acromion through the lateral sulcus.6 In the IVS groups, several agents were used in varying dosages, including morphine, diazepam, meperidine, pethidine, midazolam, and fentanyl.6-8,10,12 There was no significant difference with the agents used for IVS in terms of pain control or complication rate, although complication rate was difficult to assess because each study defined complications differently. None of these studies in the IVS groups used anesthetics now commonly used for procedural sedation.4,8,10,12 The most common agents used today include propofol, ketamine, etomidate, and versed, as well as narcotic analgesics such as morphine and fentanyl.1,2

Complications were reported in 5 of the 6 studies.4,6,8,10,12 Moharari et al8 reported the highest rate of complications in the IVS group; drowsiness was reported as a complication (5 of 14). Respiratory depression as well as hypotension8 was seen in 4 studies6,8,10,12; some patients required reversal agents. In 4 of the 6 IAL studies, there were no complications.4,6,7,12 Drowsiness and agitation were seen in the IAL group.8,10 There were no infections, neurovascular damage, or systemic side effects from lidocaine. Overall, the complication rate in the IAL group was 0.9%, compared with 16.4% in the IVS group.5

There was reduced length of stay in the IAL group (75-166 minutes vs 154-230 minutes for the IVS groups). Two studies showed reduced cost for IAL6,7 ($117-$133 vs $159-$240 for the IVS). Miller et al6 noted that the cost was significantly less for IAL ($0.52) versus IVS ($97.64).

No statistically significant differences were noted in pain control, success rates, or ease of reduction between the IAL and IVS groups despite several methods (Kocher,12 Hippocratic,12 traction-countertraction,4,6,8,10 external rotation,12 scapular rotation,6 modified Stimson technique7). The Hippocratic and Kocher methods are now rarely used because of their complication rate, including fracture, soft tissue damage, and neurovascular compromise.13


Conclusions

There are no statistically significant differences in outcomes (success rate, ease of reduction, and pain control) between the IAL and IVS groups. There were significant differences in length of stay and cost between the 2 groups. IAL is cheaper and requires less time overall. There were also fewer reported complications in the IAL groups. There is a theoretical risk of septic arthritis or systemic lidocaine toxicity; however, there have been no documented cases.

The 6 randomized controlled trials reviewed in this article did not address the effects of chondrolysis and intra-articular local anesthetic. Piper et al11 recently reviewed the effects of local anesthetic on cartilage and noted that most of the current research suggests that the risk of chondrolysis increases with longer exposure and higher concentrations of local anesthetics and that there are very few data on the long-term effects of a single intra-articular anesthetic injection, as was done in the review of our studies. This is an area of needed further research and must be considered with use of intra-articular local anesthetic for shoulder reduction.


References
1.. Bahn EL,Holt KR. Procedural sedation and analgesia: a review and new concepts. Emerg Med Clin North Am. Year: 2005;23:503-51715829394
2.. Baker SN,Weant KA. Procedural sedation and analgesia in the emergency department. J Pharm Pract. Year: 2011;24(2):189-19521712213
3.. Fitch RW,Kuhn JE. Intra-articular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of dislocated shoulder: a systematic review. Acad Emerg Med. Year: 2008;15:703-70818783486
4.. Kosnik J,Shamsa F,Raphael E,Huang R,Malachias Z,Georgiadis GM. Anesthetic methods for reduction of acute anterior shoulder dislocations: a prospective, randomized study comparing intra-articular lidocaine with intravenous analgesia and sedation. Am J Emerg Med. Year: 1999;17(6): 566-57010530535
5.. Kuhn JE. Treating the initial anterior shoulder dislocation-an evidence-based medicine approach. Sports Med Arthrosc. Year: 2006;114:192-19817135968
6.. Matthews DE,Roberts T. Intraarticular lidocaine versus IV analgesic for reduction of acute anterior shoulder dislocations: a prospective randomized study. Am J Sports Med. Year: 1995;23:54-587726351
7.. Miller SL,Cleeman E,Auerbach J,Flatow EL. Comparison of intra-articular lidocaine and intravenous sedation for reduction of shoulder dislocations. J Bone Joint Surg Am. Year: 2002;84:2135-213912473699
8.. Moharari RS,Khademhosseini F,Espandar R,et al. Intra-articular lidocaine versus intravenous meperidine/diazepam in anterior shoulder dislocation: a randomized clinical trial. Emerg Med J. Year: 2008;25:262-26418434457
9.. Ng VK,Hames H,Millward JM. Use of intra-articular lidocaine as analgesia in anterior shoulder dislocation: a review and meta-analysis of the literature. Can J Rural Med. Year: 2009;14(4):145-14919835705
10.. Orlinsky M,Shon S,Chiang C,Chan L,Carter P. Comparative study of intra-articular lidocaine and intravenous meperidine/diazepam for shoulder dislocations. J Emerg Med. Year: 2002;22(3):241-24511932085
11.. Piper SL,Kramer JD,Kim HT,Feeley BT. Effects of local anesthestics on articular cartilage [ published online ahead of print April 22, 2011. ]. Am J Sports Med.
12.. Suder PA,Mikkelsen JB,Hougaard K,Jensen PE. Reduction of traumatic secondary shoulder dislocations with lidocaine. Arch Orthop Trauma Surg. Year: 1995;114:233-2367662481
13.. Ufberg JW,McNamara RM. Management of common dislocations. In: Roberts JR,Hedges JR eds. Clinical Procedures in Emergency Medicine. 5th ed.Philadelphia, PA: Saunders Elsevier; Year: 2009:869-908
14.. Zacchilli MA,Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am. Year: 2010;92(3):542-54920194311

Tables
[TableWrap ID: table1-1941738111416777] Table 1. 
Study Level of Evidence Number Enrolled Success Rate Complications Length of Stay Ease ofReduction Cost Pain Control Treatment
Matthews 1995 A, RCT 30 No statistical significance between groups IAL-0IVS-3 IAL-78 minutesIVS- 186 minutes No statistical significance betweengroups IAL-$ 117-133IVS-$159-240 No statistical significance between groups 20mL 1% lidocaine;Morphine 10mg and midazolam 2mg
Suder 1995 A, RCT 52 IAL-18/26IVS-22/26 IAL-0IVS-3 Not reported Not reported Not reported No statistical significance between groups 20 mL 1% lidocaine;IV pethadine/ diazepam
Kosnik 1999 A, RCT 49 No statistical significance between groups IAL-0IVS-1 Not reported No statistical significance between groups Not reported No statistical significance between groups 4 mg/kg 1% lidocaine;10-30 mg diazepam and 5 to 20 mg morphine
Miller 2002 A, RCT 30 100% IAL-0IVS-0 IAL-75 min +/- 48 minIVS-185 min +/-26 min No statistical significance between groups IAL-$0.52IVS-$97.64 No statistical significance between groups 20mL lidocaine;2mg midazolam100ug fentanyl
Orlinsky 2002 A, RCT 54 100% IAL-1IVS-1 IAL-103 min +/-63 minIVS-154 +/- 76 min IAL-7% pain interferedIVS- 5% pain interfered Not reported No statistical significance between groups 20mL 1% lidocaine;1-2mg/kg meperidine and 5 to 10 mg diazepam
Moharari 2008 A, RCT 48 100% IAL-3IVS-14 IAL-140.6SminIVS-216 min No statistical significance between groups Not reported No statistical significance between groups 20 mL 1% lidocaine;25 mg meperidine and 5mg diazepam

table-fn1-1941738111416777Key: IAL- Intra-articular lidocaine; IVS-Intravenous sedation



Article Categories:
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Article Categories:
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Keywords: shoulder, analgesia, lidocaine, intra-articular, reduction.

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