Intra-articular Lidocaine Injection for Shoulder Reductions: A Clinical Review.

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.

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 articles[4,6-8,10,12] 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.

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

Key: IAL- Intra-articular lidocaine; IVS-Intravenous sedation

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 al[8] reported the highest rate of complications in the IVS group; drowsiness was reported as a complication (5 of 14). Respiratory depression as well as hypotension[8] was seen in 4 studies[6,8,10,12]; 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 IAL[6,7] ($117-$133 vs $159-$240 for the IVS). Miller et al[6] 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 technique[7]). 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 al[11] 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.