Interscalene brachial plexus blocks in the management of shoulder dislocations

Successful Glenohumeral Shoulder Reduction With Combined Suprascapular and Axillary Nerve Block

BACKGROUND

Anterior glenohumeral dislocation is a common injury seen in the emergency department (ED) that sometimes requires procedural sedation for manual reduction. When compared with procedural sedation for dislocation reductions, peripheral nerve blocks provide similar patient satisfaction scores but have shorter ED length of stays. In this case report, we describe the first addition of an ultrasound-guided axillary nerve block to a suprascapular nerve block for reduction of an anterior shoulder dislocation in the ED.

CASE REPORT

A 34-year-old man presented to the ED with an acute left shoulder dislocation. The patient was a fit rock climber with developed muscular build and tone. An attempt to reduce the shoulder with peripheral analgesia was unsuccessful. A combined suprascapular and axillary nerve block was performed with 0.5% bupivacaine, allowing appropriate relaxation of the patient's musculature while providing excellent pain control. The shoulder was then successfully reduced without procedural sedation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Procedural sedation for reduction of anterior shoulder dislocations is time consuming, resource intensive, and can be risky in some populations. The addition of an axillary nerve block to a suprascapular nerve block allows for more complete muscle relaxation to successfully reduce a shoulder dislocation without procedural sedation.

Comparison of interscalene block, general anesthesia, and intravenous analgesia for out-patient shoulder reduction

Purpose

Shoulder dislocation is often associated with intense pain, and requires urgent pain therapy and reduction. Interscalene block, general anesthesia, or intravenous analgesia alone are applied procedures that facilitate shoulder reduction by the surgeon and ease patients’ pain. This study was conducted to compare procedure times, patient satisfaction, side-effects, and clinical outcome of these clinical procedures.

Methods

Retrospective chart analysis was performed for all patients treated at the Emergency Department of a primary care hospital. In addition, standardized telephone interviews were conducted. Subjective clinical outcome and patient satisfaction (SF-36, Quick-DASH, ZUF-8) were measured with the standardized questionnaires.

Results

The shortest overall procedure time [67.5 min (48.8–93.5 min), P = 0.003] was found in patients with interscalene block. The advantage of general anesthesia was the shortest anesthesia induction time [10 min (7.8–10 min), P < 0.0001]; reduction time [6 min (4.3–6 min), P = 0.039]; and time to discharge [90 min (67.5–123.8 min), P = 0.0001] were significantly prolonged in comparison to interscalene block [5 min (1–5 min) and 45 min (2–67.5 min)]. The longest reduction time [11 min (10–13.5 min), P = 0.0008] was seen in patients in the intravenous analgesia group. Overall, patient satisfaction was greater in patients with regional as compared to general anesthesia [measured by ZUF-8: 12 (9–15) vs. 17 (12–24), P = 0.03]. Subjective clinical outcome (SF-36, DASH) was comparable among the three groups. There was one immediately identified esophageal intubation in the general anesthesia group.

Conclusions

Out-patient shoulder reduction can be accomplished no matter whether general anesthesia, regional anesthesia, or intravenous analgesia alone was administered. Clinical outcome as measured by SF-36 and DASH was comparable among the three groups, but the shortest overall procedure time and greater patient satisfaction were found in patients with interscalene block.

Prehospital ultrasound-guided nerve blocks improve reduction-feasibility of dislocated extremity injuries compared to systemic analgesia. A randomized controlled trial

BACKGROUND

Out-of-hospital analgosedation in trauma patients is challenging for emergency physicians due to associated complications. We compared peripheral nerve block (PNB) with analgosedation (AS) as an analgetic approach for patients with isolated extremity injury, assuming that prehospital required medical interventions (e.g. reduction, splinting of dislocation injury) using PNB are less painful and more feasible compared to AS.

METHODS

Thirty patients (aged 18 or older) were randomized to receive either ultrasound-guided PNB (10 mL prilocaine 1%, 10 mL ropivacaine 0.2%) or analgosedation (midazolam combined with s-ketamine or with fentanyl). Reduction-feasibility was classified (easy, intermediate, impossible) and pain scores were assessed using numeric rating scales (NRS 0-10).

RESULTS

Eighteen patients were included in the PNB-group and twelve in the AS-group; 15 and 9 patients, respectively, suffered dislocation injury. In the PNB-group, reduction was more feasible (easy: 80.0%, impossible: 20.0%) compared to the AS-group (easy: 22.2%, intermediate: 22.2%, impossible: 55.6%; p = 0.01). During medical interventions, 5.6% [1/18] of the PNB-patients and 58.3% [7/12] of the AS-patients experienced pain (p<0.01). Recorded pain scores were significantly lower in the PNB-group during prehospital medical intervention (median[IQR] NRS PNB: 0[0-0]) compared to the AS-group (6[0-8]; p<0.001) as well as on first day post presentation (NRS PNB: 1[0-5], AS: 5[5-7]; p = 0.050). All patients of the PNB-group would recommend their analgesic technique (AS: 50.0%, p<0.01).

CONCLUSIONS

Prehospital ultrasound-guided PNB is rapidly performed in extremity injuries with high success. Compared to the commonly used AS in trauma patients, PNB significantly reduces pain intensity and severity.

Regional anaesthesia in trauma

Regional anaesthesia is very effective in alleviating pain due to trauma, and is also used to provide anaesthesia for trauma surgery. It has the advantage of producing localized but complete pain relief, whilst avoiding the side effects of systemic analgesics or anaesthetics. However, regional anaesthetic drugs and techniques have potentially life-threatening complications, which the practitioner must be able to manage. This article discusses the use of regional anaesthesia, and the benefits and disadvantages of specific regional techniques in various traumatic conditions.

Emergent evaluation of injuries to the shoulder, clavicle, and humerus

This article provides a review of the evaluation and treatment of common injuries to the shoulder, humerus, and clavicle in the emergency department (ED) setting. In addition to a focused review of the shoulder's physical examination, topics include common emergent injuries such as glenohumeral dislocations, proximal humerus fractures, and acromioclavicular separations as well as less common, but important injuries including pectoralis and biceps tendon injuries and sternoclavicular dislocations. Accurate recognition and management of these injuries is essential in the optimal care of patients in the ED.

Prospective audit of emergency department transit times associated with entonox analgesia for reduction of the acute, traumatic dislocated shoulder

AIM

To establish current UK practice for the management of the acute traumatic shoulder dislocation with respect to analgesia and reduction manoeuvres. To compare the transit times of patients through an emergency department (ED) after the use of intravenous analgesia and/ or sedation compared to entonox +/- simple oral analgesia.

METHODS

A postal questionnaire was sent to 100 UK ED consultants to establish current practice. The treating clinicians were allowed to choose the method of analgesia provided to reduce the patient's dislocated shoulder, provided the patient was happy with it. They administered either (1) traditional intravenous morphine and/or midazolam or (2) entonox +/- simple oral analgesia to facilitate reduction. A prospective audit was conducted to compare the transit times of the two groups of patients.

RESULTS

The postal questionnaire revealed that intravenous morphine and midazolam are widely used during reduction of the acute shoulder dislocation in the UK. The audit showed that this was associated with a significantly prolonged transit time through the ED, compared to entonox alone, (mean 77 min versus 177 min, respectively, p<0.001) without compromise in reduction success.

CONCLUSION

Entonox +/- simple oral analgesia significantly decreases ED transit times as compared to IV morphine and/or midazolam for the reduction of the acute traumatic dislocated shoulder. Further studies should be done into patient pain scores and into the best combination of oral analgesia and entonox.

Treating the Initial Anterior Shoulder Dislocation—An Evidence-based Medicine Approach

This manuscript presents the best available evidence to answer questions regarding the treatment of the patient with an initial anterior shoulder dislocation. The highest levels of evidence available offer the following conclusions: (1) of the many methods to reduce the dislocated shoulder, little data exist to identify the best method. Recommendations are based on low levels of evidence (levels 4 and 5). (2) Premedication with intra-articular lidocaine has fewer complications and requires a shorter time in the emergency room than intravenous sedation with no detectable differences in reduction success rates (level 1). (3) Postreduction immobilization in external rotation may reduce recurrence (level 2), but immobilization in internal rotation does not (level 1). (4) Arthroscopic surgery significantly reduces recurrence compared to a nonoperative approach (level 1), and (5) there are limited data on features that would allow a safe return to play. Expert opinion suggests that return is allowed when motion and strength are nearly normal, and the athletes can engage in sport-specific activities, however, the athlete is at risk for recurrence while playing (levels 4 and 5).

Intra-articular lignocaine versus Entonox for reduction of acute anterior shoulder dislocation

We assessed, in a prospective randomised trial, the relative analgesic effects of Entonox and intra-articular lignocaine (IAL) in patients with acute anterior dislocation of the shoulder. A statistically significant reduction in pain scores was achieved with IAL (7.9 vs 5.2, P < 0.05), but the effect with Entonox was greater (7.8 vs 2.9, P < 0.001). We conclude that Entonox provides better analgesia than IAL in patients with acute anterior shoulder dislocation.

Anterior glenohumeral dislocations: what to do and how to do it

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Reduction of traumatic secondary shoulder dislocations with lidocaine

The aim of the present study was to evaluate the value of local anaesthesia versus the commonly used intravenous pethidine/diazepam in the reduction of acute secondary shoulder dislocations. Patients with a traumatic secondary dislocation of the shoulder were randomized to either locally injected lidocaine or intravenously injected pethidine/diazepam. The local method was performed with 20 ml of 1% lidocaine. The patients were observed for any complication during and after the procedure, and the methods used were evaluated with a visual analogue scale (VAS). From November 1991 to September 1993, 62 patients were admitted to our departments of whom 52 were included in the study. Average age was 47 years (range 18-89 years) with 24 men and 28 women. Twenty-six patients were randomized to pethidine/diazepam; 22 had a successful reduction, and 4 were failures. Twenty-six patients received lidocaine, of whom 18 were successful and 8 not. Three patients treated with the intravenous method suffered respiratory depression, and one required an antidote. No systemic or local side-effects, no neurovascular damage and no early or late superficial or deep infection were recorded in the lidocaine group. There was no statistical difference between the average VAS value in the two groups. Lidocaine used to reduce acute secondary dislocations of the shoulder is a simple and safe method. It is as effective as the standard intravenous method and is well accepted by patients.

Reduction of traumatic, primary anterior shoulder dislocations with local anesthesia

This study evaluates the use of local anesthesia in the reduction of acute shoulder dislocations. Patients with a primary traumatic dislocation of the shoulder were randomly assigned to receive either local anesthesia or intravenous anesthesia. The patients were observed for any complication during and after the procedure, and the methods used were evaluated with a visual analog scale. In the period from November 1991 to September 1993, 81 patients were admitted to our departments, and 68 patients were included in the study. Average age was 48 years (range 15 to 79 years); 29 men and 39 women were studied. Thirty-five patients were randomly assigned to receive intravenous anesthesia; 33 had a successful reduction, and two had a failed reduction. Thirty-three patients received local anesthesia; 32 had a successful reduction, and one had a failed reduction. Ten patients treated with the intravenous method had respiratory depression, and six required an antidote. No systemic or local side effects and no neurovasculor injuries were recorded. We did not observe any superficial or deep infection in the local anesthetic group. No statistical difference was found between the average visual analog value scale in the two groups. Local anesthesia to reduce acute primary anterior dislocation of the shoulder is a simple and safe method.