Written by Jonathan Brewer
Intra-articular lidocaine (IAL) is a safe alternative for the reduction of anterior shoulder dislocations and may have similar efficacy to intravenous (IV) sedation, with fewer adverse events and shorter ED length of stay.
Why does this matter?
Anterior shoulder dislocations are a common complaint in the emergency department (ED). IV sedation has long been one of the mainstays of providing analgesia for these painful complaints requiring reduction. However, IV sedation is not without its risks and may be contraindicated in some higher-risk patients. This paper describes the efficacy of an alternative, and easy-to-perform, approach to analgesia.
I block, you block, we all block
This systematic review and meta-analysis included 12 RCT’s (630 patients; IAL = 327, IV sedation = 303) between 1946 and September 2021 that compared IAL and IV sedation for the reduction of acute anterior shoulder dislocations among patients ≥ 15 years old in the ED. Outcomes included a successful reduction, adverse events, ED length of stay, pain scores, procedure time, ease of reduction, patient satisfaction, and cost.
Within these studies, there was no difference in reduction success, RR 0.93 (95%CI 0.86-1.01), pain scores post-analgesia, and ease of reduction. However, there were significantly lower adverse events with IAL, RR 0.16 (95%CI 0.07-0.33) along with a shorter ED length of stay, mean difference –1.48 hours (95%CI –2.48 – 0.47).
Overall, it appears that by simply injecting 15-20 cc of 1% lidocaine without epinephrine into the shoulder, safe – yet effective -analgesia can be achieved for these painful complaints. While no procedure is completely without risk, I will definitely be carrying this in my armamentarium from here on out.
Editor’s note: It’s easy to do, because of the large step-off between the acromion and humeral head. I inject from a lateral approach, ~1 cm inferior to the acromion. ~Clay Smith
Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis. CJEM. 2022 Dec;24(8):809-819. doi: 10.1007/s43678-022-00368-z. Epub 2022 Oct 1.