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Rungsinaporn V, Innarkgool S, Kongmalai P. Is Ultrasound-guided or Landmark-guided Intra-articular Lidocaine Injection More Effective for Pain Control in Anterior Shoulder Dislocation Reduction? A Randomized Controlled Trial. Clin Orthop Relat Res 2024; 482:1201-1207. [PMID: 38059761 PMCID: PMC11219141 DOI: 10.1097/corr.0000000000002936] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/02/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Effective pain control during reduction of shoulder dislocation is essential for patient comfort. However, there is a lack of comprehensive research comparing the efficacy of different pain management techniques, specifically landmark-guided and ultrasound-guided intra-articular analgesic injections. QUESTIONS/PURPOSES Among patients undergoing closed reduction of a shoulder dislocation, were there differences between an intra-articular shoulder injection placed using anatomic landmarks and an ultrasound-guided intra-articular injection in terms of (1) pain before versus after the injection and pain before injection versus after the reduction, or (2) length of stay in the emergency department and complications of the procedure? METHODS Between August 2021 and March 2023, 28 patients with anterior shoulder dislocation were treated at the emergency department of a tertiary referral care center. They were randomly assigned to either the landmark-guided or ultrasound-guided intra-articular lidocaine injection group. Differences in pain levels between preinjection and postinjection, preinjection and postreduction, length of hospital stay, and complications were assessed and compared between the two groups. Patients were followed for 2 weeks. RESULTS There were no between-group differences in terms of age, gender, baseline pain score, and any other relevant factors. There were no differences between the groups in terms of pain reduction between preinjection and postinjection (landmark-guided: ΔVAS 2.8 ± 1.1, ultrasound-guided: ΔVAS 2.9 ± 1.0, mean difference -0.14 [95% confidence interval -0.97 to 0.68]; p = 0.72) or between preinjection and postreduction (landmark-guided: ΔVAS 6.6 ± 2.1, ultrasound-guided: ΔVAS 5.8 ± 1.8, mean difference 0.79 [95% CI -0.74 to 2.31]; p = 0.30). There were no differences in length of stay in the emergency department (landmark-guided: 162 ± 38 minutes, ultrasound-guided: 184 ± 73 minutes, mean difference 22 minutes [95% CI -67 to 24]; p = 0.33), and no complications were reported in either group during the 2-week follow-up period. CONCLUSION The results of the landmark-guided technique were not different from those of ultrasound-guided injection in terms of lower pain levels, length of stay, and complications. These findings provide valuable guidance for orthopaedic surgeons, enabling them to make informed decisions based on their expertise and available resources. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Visit Rungsinaporn
- Department of Orthopedics, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Thailand
| | - Sirasit Innarkgool
- Department of Orthopedics, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Thailand
| | - Pinkawas Kongmalai
- Department of Orthopedics, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Thailand
- Department of Orthopedics, Faculty of Medicine, Kasetsart University, Bangkok, Thailand
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Hayashi M, Kano K, Kuroda N, Yamamoto N, Shiroshita A, Kataoka Y. Comparative efficacy of sedation or analgesia methods for reduction of anterior shoulder dislocation: A systematic review and network meta-analysis. Acad Emerg Med 2022; 29:1160-1171. [PMID: 35872652 DOI: 10.1111/acem.14568] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/13/2022] [Accepted: 07/20/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND We performed a network meta-analysis (NMA) to compare the efficacy and safety of intravenous sedation (IVS), intraarticular anesthetic injection (IAA), and peripheral nerve block (PNB) as sedation or analgesia methods for the reduction of anterior shoulder dislocation. METHODS We included randomized controlled trials (RCTs) comparing different sedation or analgesia methods for anterior shoulder dislocation reduction. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar databases were searched in October 2021. We conducted a random-effects NMA within a frequentist framework. We evaluated the confidence in each outcome using the CINeMA tool. RESULTS Sixteen RCTs (957 patients) were included. Regarding the primary outcomes, the three methods might result in little to no difference in the immediate success rate of reduction and patient satisfaction. The IAA method had a shorter emergency department length of stay than that of the IVS method (mean difference [MD] -107.88 min, 95% confidence interval [CI] -202.58 to -13.18). In the secondary outcomes, the IAA method had a lower pain score than that of the PNB method (standardized MD -1.83, 95% CI -3.64 to -0.02). The IAA and PNB methods might require a longer time for reduction than that of the IVS method (MD 5.3 min, 95% CI 2.4 to 10.36; MD 15.25, 95% CI 5.49 to 25.01). The three methods might result in little to no difference in the number of reduction attempts and total success rate of reduction. However, the confidence ratings for all treatment comparisons were very low. IAA and PNB had no adverse respiratory events. CONCLUSIONS The results of our NMA indicated that three sedation or analgesia methods (IVS, IAA, and PNB) might result in little to no difference in the success rate of reduction and patient satisfaction. IAA and PNB had no adverse respiratory events.
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Affiliation(s)
- Minoru Hayashi
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui City, Fukui, Japan
| | - Kenichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui City, Fukui, Japan
| | - Naoto Kuroda
- Department of Pediatrics, Wayne State University, Detroit, Michigan, USA.,Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Japan.,Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Norio Yamamoto
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan.,Department of Orthopedic Surgery, Miyamoto Orthopedic Hospital, Okayama, Okayama, Japan.,Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Akihiro Shiroshita
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan.,Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Aichi, Japan
| | - Yuki Kataoka
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan.,Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan.,Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/Public Health, Kyoto, Japan
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Isobe F, Nakamura K, Yamazaki H, Hayashi M, Itsubo T, Komatsu M, Uchiyama S, Takahashi J. Difficult closed reduction of elbow dislocations: two case reports from a multicenter retrospective chart review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:113-116. [PMID: 37588293 PMCID: PMC10426589 DOI: 10.1016/j.xrrt.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Fumihiro Isobe
- Department of Orthopaedic Surgery, North Alps Medical Center Azumi Hospital, Ikeda, Nagano, Japan
| | - Koichi Nakamura
- Department of Orthopaedic Surgery, North Alps Medical Center Azumi Hospital, Ikeda, Nagano, Japan
| | - Hiroshi Yamazaki
- Department of Orthopaedic Surgery, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Masanori Hayashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Toshiro Itsubo
- Department of Orthopaedic Surgery, Iida Municipal Hospital, Iida, Nagano, Japan
| | - Masatoshi Komatsu
- Department of Orthopaedic Surgery, Red Cross Society Suwa Hospital, Suwa, Nagano, Japan
| | - Shigeharu Uchiyama
- Department of Orthopaedic Surgery, Okaya City Hospital, Okaya, Nagano, Japan
| | - Jun Takahashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
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Sithamparapillai A, Grewal K, Thompson C, Walsh C, McLeod S. Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis. CAN J EMERG MED 2022; 24:809-819. [PMID: 36181665 PMCID: PMC9525937 DOI: 10.1007/s43678-022-00368-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/28/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Anterior shoulder dislocations are commonly treated in the emergency department (ED). Analgesia for reduction is provided by intra-articular lidocaine (IAL) injection or intravenous sedation (IV sedation). The objective of this systematic review and meta-analysis was to compare IAL versus IV sedation for closed reduction of acute anterior shoulder dislocation in the ED. METHODS Electronic searches of MEDLINE and EMBASE (1946-September 2021) were completed and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing IAL and IV sedation for reduction of acute anterior shoulder dislocations among patients ≥ 15 years old in the ED were included. Outcomes of interest included a successful reduction, adverse events, ED length of stay, pain scores, procedure time, ease of reduction, patient satisfaction, and cost. Two reviewers independently screened abstracts, assessed study quality and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RR) with 95% confidence intervals (CIs). RESULTS 12 RCTs were included with a total of 630 patients (IAL = 327; IV sedation = 303). There was no difference in reduction success between IAL and IV sedation (RR 0.93; 95% CI 0.86-1.01, I2 = 69%), significantly lower adverse events with IAL (RR 0.16; 95% CI 0.07-0.33, I2 = 0%), shorter ED length of stay with IAL (mean difference - 1.48; 95% CI - 2.48 to - 0.47, I2 = 93%), no difference in pain scores post-analgesia and no difference in ease of reduction. CONCLUSIONS Intra-articular lidocaine may have similar effectiveness as IV sedation in the successful reduction of anterior shoulder dislocations in the ED with fewer adverse events, shorter ED length of stay, and no difference in pain scores or ease of reduction. Intra-articular lidocaine may be an effective alternative to IV sedation for reducing anterior shoulder dislocations, particularly when IV sedation is contraindicated or not feasible.
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Affiliation(s)
- Arjun Sithamparapillai
- grid.17063.330000 0001 2157 2938Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada
| | - Keerat Grewal
- grid.17063.330000 0001 2157 2938Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada ,grid.512298.5Schwartz/Reisman Emergency Medicine Institute, Toronto, ON Canada ,grid.492573.e0000 0004 6477 6457Sinai Health, Toronto, ON Canada
| | - Cameron Thompson
- grid.512298.5Schwartz/Reisman Emergency Medicine Institute, Toronto, ON Canada ,grid.492573.e0000 0004 6477 6457Sinai Health, Toronto, ON Canada
| | - Chris Walsh
- grid.17063.330000 0001 2157 2938Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada
| | - Shelley McLeod
- grid.512298.5Schwartz/Reisman Emergency Medicine Institute, Toronto, ON Canada ,grid.492573.e0000 0004 6477 6457Sinai Health, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada
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Omer T, Perez M, Berona K, Lam CN, Sajed D, Brandon C, Falkenstein J, Kang T, Mailhot T. Accuracy of Landmark-guided Glenohumeral Joint Injections as Assessed by Ultrasound in Anterior Shoulder Dislocations. West J Emerg Med 2021; 22:1335-1340. [PMID: 34787559 PMCID: PMC8597695 DOI: 10.5811/westjem.2021.3.50266] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/08/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction To determine the accuracy of landmark-guided shoulder joint injections (LGI) with point-of-care ultrasound for patients with anterior shoulder dislocations. Methods Patients with anterior shoulder dislocations who underwent LGI were enrolled at our tertiary-care and trauma center. LGI attempts were recorded by an ultrasound fellowship-trained ED physician who determined if they were placed successfully. Pain and satisfaction scores were recorded. Results A total of 34 patients with anterior shoulder dislocation and their treating ED physicians were enrolled. 41.1% of all LGI were determined to be misplaced (n=14). Patients with successful LGI had a greater decrease in mean pain scores post-LGI. Conclusions LGI had a substantial failure rate in our study. Using ultrasound-guidance to assist intra-articular injections may increase its accuracy and thus reduce pain and the need for subsequent procedural sedation.
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Affiliation(s)
- Talib Omer
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Michael Perez
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Kristen Berona
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Chun Nok Lam
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Dana Sajed
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Caroline Brandon
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Jeffrey Falkenstein
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Tarina Kang
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Thomas Mailhot
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
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Furuhata R, Kamata Y, Matsumura N, Kono A, Morioka H. Risk factors for failure of reduction of anterior glenohumeral dislocation without sedation. J Shoulder Elbow Surg 2021; 30:306-311. [PMID: 32599286 DOI: 10.1016/j.jse.2020.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although anterior glenohumeral dislocations are common, the reduction procedure is often difficult, requiring sedation or anesthesia. To date, the risk factors for reduction failure without sedation have not been fully investigated. This study aimed to clarify the predictive factors that render the reduction of anterior glenohumeral dislocation without sedation difficult by use of multivariate analyses. METHODS We retrospectively reviewed 156 patients who underwent attempted reduction of anterior glenohumeral dislocation between 2006 and 2019. Patients were included based on the following criteria: traumatic dislocation, undergoing attempted reduction using the traction-countertraction method, and acute dislocation in which reduction was attempted within 2 days of the injury. The dependent variable was set as an irreducible glenohumeral dislocation without sedation, which was defined as a reduction failure in this study. Explanatory variables included age, sex, side of injury, recurrent dislocation, axillary nerve injury, time from dislocation to attempted reduction, greater tuberosity fracture, humeral neck fracture, glenoid rim fracture, and glenohumeral osteoarthritis. We evaluated these outcomes from radiographs and clinical notes. Univariate and multivariate analyses were performed. Baseline variables, which were observed to be significant in the univariate analysis, were included in multivariate models, which used logistic regression to identify independent predictors of reduction failure. RESULTS Of the 156 patients, 25 (16.0%) experienced reduction failure. Multivariate analyses showed that older age (≥55 years) (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.1-10.4; P = .036), greater tuberosity fractures (OR, 3.6; 95% CI, 1.1-12.2; P = .033), and glenoid rim fractures (OR, 11.5; 95% CI, 1.5-87.7; P = .018) were risk factors for reduction failure. CONCLUSIONS Our results demonstrated that multiple factors were associated with unsuccessful reduction of anterior glenohumeral dislocation without sedation. In elderly patients or patients with concurrent greater tuberosity fractures and glenoid rim fractures, reduction failure could occur in the absence of sedation; thus, the administration of sedatives or anesthesia should be considered.
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Affiliation(s)
- Ryogo Furuhata
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.
| | - Yusaku Kamata
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Noboru Matsumura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Aki Kono
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hideo Morioka
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
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7
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Penn DM, Williams O. BET 1: Can acute shoulder dislocations be reduced using intra-articular local anaesthetic infiltration as an alternative to intravenous analgesia with or without sedation? Emerg Med J 2020; 37:725-728. [PMID: 33097554 DOI: 10.1136/emermed-2020-210736.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A short cut review was carried out to establish whether intra-articular injection of local anaesthetic is an effective alternative to intravenous analgesia with or without sedation to facilitate reduction of acute shoulder dislocations. Eleven studies were considered relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these studies are tabulated. The clinical bottom line is that intra-articular injection of local anaesthetic is a safe and effective method of providing procedural analgesia for the reduction of acute shoulder dislocations.
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Affiliation(s)
- Dr Michael Penn
- Northumbria Specialist Emergency Care Hospital, Cramlington, UK
| | - Owen Williams
- Northumbria Specialist Emergency Care Hospital, Cramlington, UK
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8
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Risler Z, Magee MA, Mazza JM, Goodsell K, Au AK, Lewiss RE, Pugliese RS, Ku B. A Three-dimensional Printed Low-cost Anterior Shoulder Dislocation Model for Ultrasound-guided Injection Training. Cureus 2018; 10:e3536. [PMID: 30648069 PMCID: PMC6318112 DOI: 10.7759/cureus.3536] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Anterior shoulder dislocations are the most common, large joint dislocations that present to the emergency department (ED). Numerous studies support the use of intraarticular local anesthetic injections for the safe, effective, and time-saving reduction of these dislocations. Simulation training is an alternative and effective method for training compared to bedside learning. There are no commercially available ultrasound-compatible shoulder dislocation models. We utilized a three-dimensional (3D) printer to print a model that allows the visualization of the ultrasound anatomy (sonoanatomy) of an anterior shoulder dislocation. We utilized an open-source file of a shoulder, available from embodi3D® (Bellevue, WA, US). After approximating the relative orientation of the humerus to the glenoid fossa in an anterior dislocation, the humerus and scapula model was printed with an Ultimaker-2 Extended+ 3D® (Ultimaker, Cambridge, MA, US) printer using polylactic acid filaments. A 3D model of the external shoulder anatomy of a live human model was then created using Structure Sensor®(Occipital, San Francisco, CA, US), a 3D scanner. We aligned the printed dislocation model of the humerus and scapula within the resultant external shoulder mold. A pourable ballistics gel solution was used to create the final shoulder phantom. The use of simulation in medicine is widespread and growing, given the restrictions on work hours and a renewed focus on patient safety. The adage of "see one, do one, teach one" is being replaced by deliberate practice. Simulation allows such training to occur in a safe teaching environment. The ballistic gel and polylactic acid structure effectively reproduced the sonoanatomy of an anterior shoulder dislocation. The 3D printed model was effective for practicing an in-plane ultrasound-guided intraarticular joint injection. 3D printing is effective in producing a low-cost, ultrasound-capable model simulating an anterior shoulder dislocation. Future research will determine whether provider confidence and the use of intraarticular anesthesia for the management of shoulder dislocations will improve after utilizing this model.
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Affiliation(s)
- Zachary Risler
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Mark A Magee
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Jacob M Mazza
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Kelly Goodsell
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Arthur K Au
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Resa E Lewiss
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | | | - Bon Ku
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
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MacCormick LM, Baynard T, Williams BR, Vang S, Xi M, Lafferty P. Intra-articular Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle Fractures. Foot Ankle Int 2018; 39:1162-1168. [PMID: 29860875 DOI: 10.1177/1071100718780693] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Initial treatment for a displaced ankle fracture is closed reduction and splinting. This is typically performed in conjunction with either an intra-articular hematoma block (IAHB) or procedural sedation (PS) to assist with pain control. The purpose of this study was to compare the safety of IAHB to PS and evaluate the efficiency and efficacy for each method. METHODS A retrospective chart review for ankle fractures requiring manipulation was performed for patients seen in a level I trauma center from 2005 to 2016. The primary outcome was rate of successful reduction. Several secondary outcome measures were defined: reduction attempts, time until successful reduction, time spent in the emergency department (ED), rate of hospital admission, and adverse events. The analysis included 221 patients who received IAHB and 114 patients who received PS. RESULTS The demographics between the 2 groups were similar, with the exception that more patients with a dislocation received PS, which prompted a subgroup analysis. This analysis demonstrated that patients with an ankle fracture and associated tibiotalar joint subluxation underwent closed reduction in a shorter period of time with the use of an IAHB compared with those receiving PS. In patients sustaining a tibiotalar fracture dislocation, patients receiving PS were successfully reduced with 1 reduction attempt more frequently than those receiving IAHB. Orthopedic surgeons also had higher rates of success on first attempt compared with ED providers. CONCLUSION Both IAHB and PS were excellent options for analgesia that resulted in high rates of successful closed reduction of ankle fractures with adequate safety. IAHB can be considered a first-line agent for patients with an ankle fracture and associated joint subluxation. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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Affiliation(s)
- Lauren M MacCormick
- 1 Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Taurean Baynard
- 2 Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, USA
| | - Benjamin R Williams
- 1 Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Sandy Vang
- 2 Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, USA
| | - Min Xi
- 2 Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, USA
| | - Paul Lafferty
- 2 Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, USA
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Gould FJ. An Effective Treatment in the Austere Environment? A Critical Appraisal into the Use of Intra-Articular Local Anesthetic to Facilitate Reduction in Acute Shoulder Dislocation. Wilderness Environ Med 2018; 29:102-110. [PMID: 29373217 DOI: 10.1016/j.wem.2017.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 09/11/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
Abstract
Acute shoulder dislocation is a common injury in the outdoor environment. The objective of this systematic review of the literature was to determine if intra-articular local anesthetic (IAL) is an effective treatment that could have prehospital application. A methodical search of MEDLINE, PubMed, and EMBASE databases targeted publications from January 1, 1990 until January 1, 2017. Eligible articles compared IAL with other analgesic techniques in patients 16 years or older experiencing acute glenohumeral dislocation. Reduction success, complications, and patient-reported outcome measures underwent comparison. All identified publications originated from the hospital setting. Procedural success rates ranged widely among randomized control trials comparing IAL with intravenous analgesia and sedation (IAL 48-100%, intravenous analgesia and sedation 44-100%). A pooled risk ratio [RR] favored intravenous analgesia and sedation (RR 0.91, 95% confidence interval [CI] 0.84-0.98), but there was significant inconsistency within the analysis (I2 = 75%). IAL provided lower complication rates (4/170, 2%) than intravenous analgesia and sedation (20/150, 13%) (RR 1.11, 95% CI 1.04-1.19, I2 = 63%). One trial found a clinically relevant reduction in visual analogue pain scores when comparing IAL against no additional analgesia in the first minute (IAL 21±13 mm; control 49±15 mm; P<0.001) and fifth minute (IAL 10±10 mm; control 40±14 mm, P<0.001) after reduction. The results suggest that IAL is an effective intervention for acute anterior shoulder dislocation that would have a place in the repertoire of the remote physician. Further research might be beneficial in determining the outcomes of performing IAL in the prehospital setting.
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Affiliation(s)
- Fraser John Gould
- British Antarctic Survey Medical Unit, South Georgia & the South Sandwich Islands.
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11
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Kashani P, Asayesh Zarchi F, Hatamabadi HR, Afshar A, Amiri M. Intra-articular lidocaine versus intravenous sedative and analgesic for reduction of anterior shoulder dislocation. Turk J Emerg Med 2016; 16:60-64. [PMID: 27896323 PMCID: PMC5121259 DOI: 10.1016/j.tjem.2016.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 02/03/2016] [Accepted: 04/10/2016] [Indexed: 11/29/2022] Open
Abstract
Objective This prospective clinical trial was performed to compare the safety and efficiency of intra-articular lidocaine (IAL) versus intravenous sedative and analgesic (IVSA) in reduction of anterior shoulder dislocation. Materials and methods Patients with anterior shoulder dislocation were randomly divided into 2 groups to receive IAL and IVSA. One group patients received an intravenous dose of 0.05 mg/kg midazolam and 1 μg/kg fentanyl, while the other group received 20 mL intra-articular lidocaine (1%). Patient satisfaction (via a standard 5-choice questionnaire), pain score (based on visual analog scale ranging from 0 to 10 points), comfort reduction, recovery time, and side effects were recorded and compared between the two groups before, during and after the reduction procedure. Results Totally 104 patients with acute anterior shoulder dislocation and the mean age of 28.75 ± 7.24 years were included (86.5% male). There was no statistically significant difference between IAL and IVSA groups regarding age (p = 0.45) and gender (p = 0.25). A total of forty-seven (45.2%) patients, distributed in both groups, had a history of anterior shoulder dislocation. A significant difference was seen with regard to diminished pain intensity during reduction in IAL group (p < 0.001); Complications including nausea, apnea, hypoxia and headache were only observed in IVSA group, and there was no adverse effect in IAL group; increased patient satisfaction in IVSA group (p = 0.007); similar success rate at first attempt of reduction in both groups, and a shorter time to discharge in IAL group (p < 0.001). Conclusion It seems that the use of intra-articular lidocaine for reduction of anterior shoulder dislocation is effective, safe, and time saving in the emergency department and has few complications. It can be considered as the first line analgesia in managing anterior shoulder dislocation.
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Affiliation(s)
- Parvin Kashani
- Department of Emergency Medicine, Loghmane Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Asayesh Zarchi
- Department of Emergency Medicine, Loghmane Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Hatamabadi
- Safety Promotion & Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Afshar
- Department of Management, Mofateh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Marzieh Amiri
- Department of Emergency Medicine, Shahid Beheshti Hospital, Guilan University of Medical Sciences, Anzali, Iran
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Hames H, McLeod S, Millard W. Intra-articular lidocaine versus intravenous sedation for the reduction of anterior shoulder dislocations in the emergency department. CAN J EMERG MED 2015; 13:378-83. [DOI: 10.2310/8000.2011.110495] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACTObjective:The objective was to compare intra-articular lidocaine (IAL) versus intravenous sedation (IVS) for the reduction of acute, anterior shoulder dislocations in the emergency department (ED) in terms of ED length of stay, rate of successful reductions, patient satisfaction, and complications.Methods:This was a prospective, randomized trial. Patients in the IAL group received 4 mg/kg (up to 200 mg) of 1% lidocaine injected into the glenohumeral joint using a lateral approach. Patients in the IVS group received medications for sedation as per the discretion of the treating physician. Follow-up was arranged within 2 weeks of the ED visit to assess for complications.Results:Forty-four patients (25 IAL, 19 IVS) were included. This trial was stopped early owing to a combination of unexpected findings in success, resource limitations, and difficulty in patient enrolment. Median time from first physician assessment to patient discharge was not different between the IAL (170 minutes) group and the IVS (145 minutes) group (Δ –25 minutes; 95% CI –32, 70;p= 0.46). There was a significantly lower rate (p< 0.001) of successful closed reduction in the IAL group (48%) compared to the IVS group (100%). Patient satisfaction and physician ease of reduction were higher in the IVS group compared to the IAL group (p< 0.05). There were no reported complications in either group at time of reduction or follow-up.Conclusions:There was no difference in ED length of stay between groups. There was a lower rate of successful reductions and lower satisfaction scores in the IAL group.
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Berendes TD, Pilot P, Nagels J, Vochteloo AJH, Nelissen RGHH. Survey on the management of acute first-time anterior shoulder dislocation amongst Dutch public hospitals. Arch Orthop Trauma Surg 2015; 135:447-54. [PMID: 25697813 PMCID: PMC4365281 DOI: 10.1007/s00402-015-2156-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Indexed: 10/31/2022]
Abstract
INTRODUCTION The primary aim of this study was to record how orthopaedic surgeons are currently managing acute first-time anterior shoulder dislocation (AFASD) 8 years after introduction of the Dutch national guideline: "acute primary shoulder dislocation, diagnostics and treatment" in 2005. The second aim was to evaluate how these surgeons treat recurrent instability after AFASD. MATERIALS AND METHODS An online questionnaire regarding the management of AFASD and recurrent shoulder instability was held amongst orthopaedic surgeons of all 98 Dutch hospitals. RESULTS The overall response rate was 60%. Of the respondents, 75% had a local protocol for managing AFASD, of which 28% had made changes in their treatment protocol after the introduction of the national guideline. The current survey showed wide variety in the overall treatment policies for AFASD. Twenty-seven percent of the orthopaedic surgeons were currently unaware of the national guideline. The variability in treatment for AFASD was present throughout the whole treatment from which policy at the emergency department; when to operate for recurrent instability; type of surgical technique for stabilization and type of fixation of the labrum. As for the treatment of recurrent instability, the same variability was seen: 36% of the surgeons perform only arthroscopic procedures, 7% only open and 57% perform both open and arthroscopic procedures. CONCLUSIONS Despite the introduction of the national guideline for the initial management of AFASD in 2005, still great variety among orthopaedic surgeons in the Netherlands was present. As for the surgical stabilization technique, the vast majority of the respondents are performing an arthroscopic shoulder stabilization procedure at the expense of the more traditional open procedure as a first treatment option for post-traumatic shoulder instability.
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Affiliation(s)
- T. D. Berendes
- Department of Orthopaedics, Meander Medical Centre, Maatweg 3, Postbox 1502, 3800 BM Amersfoort, The Netherlands ,Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | - P. Pilot
- Department of Orthopaedics, Reinier de Graaf Hospital, Delft, The Netherlands
| | - J. Nagels
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - R. G. H. H. Nelissen
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, The Netherlands
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Abstract
The shoulder joint has the greatest range of motion of any joint in the body. However, it relies on soft-tissue restraints, including the capsule, ligaments, and musculature, for stability. Therefore, this joint is at the highest risk for dislocation. Thorough knowledge of the shoulder's anatomy as well as classification of dislocations, anesthetic techniques, and reduction maneuvers is crucial for early management of acute shoulder dislocation. Given the lack of comparative studies on various reduction techniques, the choice of technique is based on physician preference. The orthopaedic surgeon must be well versed in several reduction methods and ascertain the best technique for each patient.
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Intra-articular lidocaine versus intravenous analgesia and sedation for manual closed reduction of acute anterior shoulder dislocation: an updated meta-analysis. J Clin Anesth 2014; 26:350-9. [PMID: 25066879 DOI: 10.1016/j.jclinane.2013.12.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 12/17/2013] [Accepted: 12/19/2013] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To compare intra-articular lidocaine (IAL) with intravenous analgesia and sedation (IVAS) for manual closed reduction of acute anterior shoulder dislocation. DESIGN Meta-analysis. SETTING Metropolitan medical university. MEASUREMENTS A literature search was conducted of PubMed, Ovid and Cochrane Library, to identify randomized controlled trials (RCTs) published from January 1, 1990 to September 1, 2012, that compared IAL with IVAS for manual closed reduction of acute anterior shoulder dislocation. Effective data were pooled using fixed-effects or random-effects models with mean differences (MDs) and risk ratios (RRs) for continuous and dichotomous variables, respectively. MAIN RESULTS Nine RCTs comprising 438 patients were analyzed. Statistical analyses showed that IAL was superior to IVAS with respect to lower complication risk (P < 0.00001) and shorter mean hospital length of stay (P = 0.03). No significant differences were noted in success of joint reduction (P = 0.16), patient satisfaction (P = 0.12), or postreduction pain relief (P = 0.76). However, IAL required more time than IVAS from injection to reduction (P < 0.00001). Subgroup analyses showed that IVAS was associated with higher risks of respiratory depression (P < 0.0001), vomiting (P = 0.04), and thrombophlebitis (P = 0.008), but no statistical differences were identified in nausea (P = 0.06), hypotension (P = 0.10), drowsiness (P = 0.45), or headache (P = 0.29). CONCLUSIONS Intra-articular lidocaine injection may be safer than IVAS because there are fewer risks of postoperative complications with IAL. Both techniques are similarly effective for manual closed reduction of acute anterior shoulder dislocation.
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Tezel O, Kaldirim U, Bilgic S, Deniz S, Eyi YE, Ozyurek S, Durusu M, Tezel N. A comparison of suprascapular nerve block and procedural sedation analgesia in shoulder dislocation reduction. Am J Emerg Med 2014; 32:549-52. [DOI: 10.1016/j.ajem.2014.02.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 02/10/2014] [Accepted: 02/10/2014] [Indexed: 10/25/2022] Open
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Abstract
Anterior shoulder dislocation is the most common joint dislocation seen in the emergency department. Although emergency medicine providers use several techniques for reduction, each method is associated with potential discomfort for the patient. In addition, pain from the dislocated shoulder causes muscle spasm that impedes reduction. Therefore, both analgesia and procedural sedation are often used to reduce pain and enable reduction. Intra-articular injection of lidocaine has demonstrated efficacy in reduction of pain and facilitation of shoulder reduction compared with analgesia and sedation. Intra-articular lidocaine may also reduce time to successful reduction of shoulder dislocations.
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Ultrasound-guided intra-articular lidocaine block for reduction of anterior shoulder dislocation in the pediatric emergency department. Pediatr Emerg Care 2014; 30:217-20. [PMID: 24589815 DOI: 10.1097/pec.0000000000000095] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a case of successful reduction of an anterior shoulder dislocation after ultrasound-guided intra-articular lidocaine (IAL) block with subsequent sonographic confirmation of reduction. Current literature suggests that IAL can provide similar levels of analgesia as intravenous sedation, and IAL block is associated with lower complication rates and shorter emergency department stays. However, these studies may be limited by uncertainty about the accuracy of landmark-based glenohumeral injections. The use of beside ultrasound may improve the effectiveness of IAL block for reduction of anterior shoulder dislocation and provide a mechanism for immediate postreduction evaluation of the placement of the humeral head.
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Abstract
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.
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Affiliation(s)
- Anna L Waterbrook
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona
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Hunter B, Wilbur L. Can Intra-articular Lidocaine Supplant the Need for Procedural Sedation for Reduction of Acute Anterior Shoulder Dislocation? Ann Emerg Med 2012; 59:513-4. [DOI: 10.1016/j.annemergmed.2011.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 10/10/2011] [Accepted: 11/01/2011] [Indexed: 11/16/2022]
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[Sedation and analgesia in emergency structure. Which sedation and/or analgesia for painful treatments?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:340-2. [PMID: 22440817 DOI: 10.1016/j.annfar.2012.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tamaoki MJS, Faloppa F, Wajnsztejn A, Archetti Netto N, Matsumoto MH, Belloti JC. Effectiveness of intra-articular lidocaine injection for reduction of anterior shoulder dislocation: randomized clinical trial. SAO PAULO MED J 2012; 130:367-72. [PMID: 23338733 PMCID: PMC10522322 DOI: 10.1590/s1516-31802012000600003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Revised: 07/05/2011] [Accepted: 04/16/2012] [Indexed: 11/21/2022] Open
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.
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Affiliation(s)
- Marcel Jun Sugawara Tamaoki
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil.
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Blaivas M, Adhikari S, Lander L. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad Emerg Med 2011; 18:922-7. [PMID: 21883635 DOI: 10.1111/j.1553-2712.2011.01140.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Emergency physicians (EPs) are beginning to use ultrasound (US) guidance to perform regional nerve blocks. The primary objective of this study was to compare length of stay (LOS) in patients randomized to US-guided interscalene block or procedural sedation to facilitate reduction of shoulder dislocation in the emergency department (ED). The secondary objectives were to compare one-on-one health care provider time, pain experienced by the patient during reduction, and patient satisfaction between the two groups. METHODS This was a prospective, randomized study of patients presenting to the ED with shoulder dislocation. The study was conducted at an academic Level I trauma center ED with an annual census of approximately 80,000. Patients were eligible for the study if they were at least 18 years of age and required reduction of a shoulder dislocation. A convenience sample of patients was randomized to either traditional procedural sedation or US-guided interscalene nerve block. Procedural sedation was performed with etomidate as the sole agent. Interscalene blocks were performed by hospital-credentialed EPs using sterile technique and a SonoSite MicroMaxx US machine with a high-frequency linear array transducer. Categorical variables were evaluated using Fisher's exact test, and continuous variables were analyzed using the Wilcoxon rank sum test. RESULTS Forty-two patients were enrolled, with 21 patients randomized to each group. The groups were not significantly different with respect to sex or age. The mean (±SD) LOS in the ED was significantly higher in the procedural sedation group (177.3 ± 37.9 min) than in the US-guided interscalene block group (100.3 ± 28.2 minutes; p < 0.0001). The mean (±SD) one-on-one health care provider time was 47.1 (±9.8) minutes for the sedation group and 5 (±0.7) minutes for the US-guided interscalene block group (p < 0.0001). There was no statistically significant difference between the two groups in patient satisfaction or pain experienced during the procedure. There were no significant differences between groups with respect to complications such as hypoxia or hypotension (p = 0.49). CONCLUSIONS In this study, patients undergoing shoulder dislocation reduction using US-guided interscalene block spent less time in the ED and required less one-on-one health care provider time compared to those receiving procedural sedation. There was no difference in pain level or satisfaction when compared to procedural sedation patients.
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Affiliation(s)
- Michael Blaivas
- Department of Emergency Medicine, Northside Hospital-Forsyth, Cuming, GA, USA.
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Wakai A, O'Sullivan R, McCabe A. Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults. Cochrane Database Syst Rev 2011; 2011:CD004919. [PMID: 21491392 PMCID: PMC8859829 DOI: 10.1002/14651858.cd004919.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is conflicting evidence regarding the use of intra-articular lignocaine injection for the closed manual reduction of acute anterior shoulder dislocations. A systematic review may help cohere the conflicting evidence. OBJECTIVES To compare the clinical efficacy and safety of intra-articular lignocaine and intravenous analgesia (with or without sedation) for reduction of acute anterior shoulder dislocation. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 1), MEDLINE (1950 to March 2010), and EMBASE (1980 to March 2010). We searched Current Controlled Trials metaRegister of Clinical Trials (compiled by Current Science) (March 2010). We imposed no language restriction. SELECTION CRITERIA Randomized controlled trials comparing intra-articular lignocaine (IAL) with intravenous analgesia with or without sedation (IVAS) in adults aged 18 years and over for reduction of acute anterior shoulder dislocation. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. Where possible, data were pooled and relative risks (RR) and mean differences (MD), each with 95% confidence intervals (CI), were computed using the Cochrane Review Manager statistical package (RevMan). MAIN RESULTS Of 1041 publications obtained from the search strategy, we examined nine studies. Four studies were excluded, and five studies with 211 participants were eligible for inclusion. There was no difference in the immediate success rate of IAL when compared with IVAS in the closed manual reduction of acute anterior shoulder dislocation (RR 0.95; 95% CI 0.83 to 1.10). There were significantly fewer adverse effects associated with IAL compared with IVAS (RR 0.16; 95% CI 0.06 to 0.43). The mean time spent in the emergency department was significantly less with IAL compared with IVAS (MD 109.46 minutes; 95% CI 84.60 to 134.32). One trial reported significantly less time for reduction with IVAS (105 seconds; 95% CI 84.0 to 126.1) compared with IAL (284.6 seconds; 95% CI 185.3 to 383.9). One trial reported no joint infection associated with intra-articular lignocaine injection and no mortality associated with either IAL or IVAS. AUTHORS' CONCLUSIONS We observed no significant difference between IAL and IVAS with regard to the immediate success rate of reduction, pain during reduction, post-reduction pain relief and reduction failure. Compared to IVAS, IAL may be less expensive and may be associated with fewer adverse effects and a shorter recovery time.
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Affiliation(s)
- Abel Wakai
- Division of Population Health Sciences (PHS), Royal College of Surgeons in IrelandEmergency Care Research Unit (ECRU), HRB Centre For Primary Care Research123 St. Stephen's GreenDublin 2Ireland
| | - Ronan O'Sullivan
- Our Lady's Children's Hospital CrumlinNational Children's Research CentreDublinIreland12
- Cork University HospitalCorkIreland
| | - Aileen McCabe
- HRB Centre For Primary Care Research, Division of Population Health Sciences (PHS), Royal College of Surgeons in IrelandEmergency Care Research Unit (ECRU)123 St. Stephen's GreenDublin 2Ireland
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Pain relief for reduction of acute anterior shoulder dislocations: a prospective randomized study comparing intravenous sedation with intra-articular lidocaine. J Orthop Trauma 2011; 25:5-10. [PMID: 21164304 DOI: 10.1097/bot.0b013e3181d3d338] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The aim was to compare the effectiveness of intra-articular lidocaine (IAL) versus intravenous Demerol and Diazepam (IVS) in reduction of acute anterior shoulder dislocation. DESIGN This is a prospective randomized study. SETTING Emergency room setting. PATIENTS Thirty-one dislocations reduced with IVS, whereas 32 patients were reduced using IAL. MAIN OUTCOME MEASUREMENTS The visual analog pain scale was used before analgesic administration and during the closed manipulative reduction. Length of time since dislocation, frequency of dislocation, ease of reduction, patient satisfaction, adverse effects, and duration of hospitalization were recorded. RESULTS The IVS group had a 100% success rate, whereas the IAL group had a 19% (six of 32) failure rate (P = 0.024). However, there was no significant difference in terms of pain relief (P = 0.23) or patient satisfaction (P = 0.085) between both groups. In addition, patients in the IAL group had a shorter duration of hospitalization and no reported complications, whereas the intravenous group had a longer hospital stay and a 29% complication rate. The cost of IAL was 32% less than the cost for IVS. CONCLUSION IAL was more cost effective than the IVS method. IAL provided adequate pain relief and fewer complications and is a viable option for analgesia during reduction of acute shoulder dislocation.
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Grabinsky A, Sharar SR. Regional anesthesia for acute traumatic injuries in the emergency room. Expert Rev Neurother 2010; 9:1677-90. [PMID: 19903026 DOI: 10.1586/ern.09.110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since the introduction of cocaine in 1884, regional nerve block procedures have been used in anesthesia practice for over 100 years. While almost all medical specialties use simple regional anesthesia techniques, anesthesia providers use a wider variety of more specific nerve block techniques than any other speciality. Anesthesiologists have assumed a vital role in recent military conflicts and, together with surgeons and emergency physicians, have introduced regional anesthesia techniques for the treatment and transport of injured soldiers. While such techniques have only been applied to a limited extent in civilian emergency settings, it is likely that current military experience will enhance future use of regional anesthesia techniques for the care of trauma patients in the civilian prehospital and emergency room settings.
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Affiliation(s)
- Andreas Grabinsky
- Department of Anesthesiology, Harborview Medical Center, #359724, 325 Ninth Avenue, Seattle, WA 98104, USA.
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Wajnsztejn A, Sugawara Tamaoki MJ, Netto NA, Belotti JC, Matsumoto MH, Faloppa F. TREATMENT OF TRAUMATIC GLENOHUMERAL DISLOCATION: A CROSS-SECTIONAL STUDY. REVISTA BRASILEIRA DE ORTOPEDIA (ENGLISH EDITION) 2009; 44:391-6. [PMID: 27004185 PMCID: PMC4783679 DOI: 10.1016/s2255-4971(15)30268-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objective: The aim of the present study was to investigate Brazilian orthopedists' opinions regarding the main aspects of the treatment of glenohumeral traumatic dislocation and compare these to literature's current concepts. Methods: Two hundred questionnaires containing 13 items were randomly distributed to orthopedists who were attending a Brazilian orthopedics congress; 158 were filled, in correctly and were considered in this study. Results: The preferred maneuver was traction-countertraction (60.8%). Among the respondents, 68.4% stated that glenohumeral dislocation reduction was achieved in the first attempt in 90% of the cases. The first attempt of reduction occurred mainly in the Emergency room (96.5%). Seventy-nine individuals (50%) reported that they do not use any analgesic prior to reduction. The majority of the participants immobilize their patients after the reduction (98.1%). 75.4% of them keep their patients immobilized from 2 to 3 weeks. Conclusion: Generally, Brazilian orthopaedists perform tractioncountertraction maneuvers, achieving reduction in the first attempt in more than 90% of the cases in the Emergency room. No previous analgesic agent is used prior to reduction. Immobilization of the patient is made with a Velpeau dressing or a sling for 2 to 3 weeks.
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Fitch RW, Kuhn JE. Intraarticular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of the dislocated shoulder: a systematic review. Acad Emerg Med 2008; 15:703-8. [PMID: 18783486 DOI: 10.1111/j.1553-2712.2008.00164.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anterior shoulder dislocations commonly present to the emergency department (ED). The time associated with procedural sedation for the reduction of anterior shoulder dislocations can be lengthy and may require use of additional personnel. Complications associated with intravenous (IV) medications for procedural sedation are well documented. OBJECTIVES The aim was to determine if intraarticular lidocaine (IAL) injection is as effective as IV procedural sedation with narcotics and benzodiazepines for reduction of anterior shoulder dislocations. METHODS This was a systematic review of randomized controlled trials (RCTs). The authors performed a PubMed, EMBASE, and Cochrane database search using key words: "shoulder dislocation" and "reduction" and retrieved every RCT published that compared the use of IV sedation to IAL as medication for reduction. Each manuscript was reviewed and the results of each was compared regarding medications used, success of reduction, complications, pain perceived, ease of reduction, and time spent in the ED. RESULTS Six Level 1 RCTs were identified. No studies showed a statistically significant difference in success rate between IAL versus IV sedation. The complication rate was significantly higher in the IV sedation groups (p < 0.001), and the total time spent in the ED was longer for the IV sedation group. CONCLUSIONS The use of IAL for reduction of anterior shoulder dislocations should be strongly considered as a first line therapy because it is effective and safe and may potentially reduce time spent in the ED.
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White BJ, Walsh M, Egol KA, Tejwani NC. Intra-articular block compared with conscious sedation for closed reduction of ankle fracture-dislocations. A prospective randomized trial. J Bone Joint Surg Am 2008; 90:731-4. [PMID: 18381308 DOI: 10.2106/jbjs.g.00733] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ankle fracture-dislocations require urgent reduction to protect the soft tissues, to minimize articular injury, and to allow swelling to decrease. Conscious sedation is commonly used to provide analgesia for closed reduction of this injury. We hypothesized that an intra-articular block of the ankle would provide similar analgesia and the ability to reduce the ankle with a lower risk than conscious sedation. METHODS Between September 2005 and January 2007, forty-two patients with an ankle fracture-dislocation presented to our emergency department and were enrolled in a prospective randomized study. The patients were given either conscious sedation or an intra-articular lidocaine block for the reduction and for the application of a plaster splint. After the reduction maneuver, the patients used a visual analog pain scale to rate the level of pain before, during, and after the procedure, from 1 (no pain) to 10 (severe pain). The senior authors reviewed the injury and reduction radiographs to confirm the reduction of the ankle joint. RESULTS Twenty-one patients were randomized to each group. There was no difference in demographic data or fracture patterns between the groups. Both the sedation and the block reduced the pain to a similar degree. The pain reduction (the initial pain level minus the level of pain after medication was given or injected) was an average (and standard deviation) of 4.6 +/- 3.3 for the block group and 4.2 +/- 3.5 for the sedation group (p = 0.64). The average change in the level of pain between the initial presentation and during the reduction was 3.6 +/- 3.8 for the block group and 4.1 +/- 3.3 for the sedation group. Overall, there was no difference in analgesia provided by these two methods (p = 0.71). An acceptable reduction was achieved for forty-one of the forty-two patients with one failure in the sedation group. The average time for ankle reduction and stabilization in a splint was 81.5 minutes for the sedation group and 63.8 minutes for the block group. CONCLUSIONS Compared with conscious sedation, an intra-articular lidocaine block provides a similar degree of analgesia and sufficient analgesia to achieve closed reduction of ankle fracture-dislocations.
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Affiliation(s)
- Brian J White
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 550 First Avenue, NBV 21W-37, New York, NY 10016, USA
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Abstract
BACKGROUND Shoulder pain is a common problem and although there are many accepted standard forms of conservative therapy for shoulder disorders including non-steroidal anti-inflammatory drugs, glucocorticosteroid injections, oral glucocorticosteroid medication, manipulation under anaesthesia, physical therapy, hydrodilatation (distension arthrography) and surgery, evidence of their efficacy is not well established. OBJECTIVES To review the efficacy of common interventions for shoulder pain. SEARCH STRATEGY We searched the Cochrane Musculoskeletal Group trials register, Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, and Science Citation Index) up to May 1998, and hand searched major textbooks, bibliographies of relevant literature, the fugitive literature, and the subject indices of relevant journals including: American College of Rheumatology;British College of Rheumatologists; the Biennial Conference of the Manipulative Physiotherapy Association of Australia;International Federation of Manual Therapists conference proceedings; British Orthopaedic Association;and American Orthopaedic Association. SELECTION CRITERIA Each identified study was assessed for possible inclusion by two independent reviewers based on the blinded methods sections. The determinants for inclusion were that the trial include an intervention of interest (non-steroidal anti-inflammatory drugs, intra-articular or subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anaesthesia, hydrodilatation, or surgery); that treatment allocation was randomized; and that the outcome assessment was blinded. DATA COLLECTION AND ANALYSIS Methodological quality was assessed by two independent, blinded reviewers. Data relating to selection criteria, outcome measurement and treatment effect was extracted from the blinded trials. Range of motion scores were entered as degrees of restriction to movement, and all pain and overall effect scores were transformed to 100 point scales. For continuous outcome measures, where standard deviation was not reported it was either calculated from the raw data or converted from standard error of the mean. If neither of these were reported, authors were contacted in an effort to obtain the missing values. Effect sizes were calculated and combined in a pooled analysis if study population, endpoint and intervention were comparable. MAIN RESULTS Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5 - 22) out of possible score of 40. Selection criteria varied widely even for the same diagnostic label. There was no uniformity in outcome measures used and their measurement properties were rarely reported. Effect sizes for individual trials were small (-1.4 to 3.0). The results of only three studies investigating "rotator cuff tendonitis" could be pooled. Benefit of subacromial steroid injection over placebo for improving range of abduction (weighted difference between means (WMD) 35 degrees , 95% CI 14 to 55) was the only positive finding. AUTHORS' CONCLUSIONS There is little evidence to support or refute the efficacy of common interventions for shoulder pain. As well as, the need for further well designed clinical trials, more research is needed to establish a uniform method of defining shoulder disorders and developing outcome measures which are valid, reliable and responsive in these study populations.
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Affiliation(s)
- S Green
- Monash University, Australasian Cochrane Centre, Monash Medical Centre, Locked Bag 29, Clayton, Victoria, Australia, 3168.
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31
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Leonard M, Kiely P. Reduction of anterior shoulder dislocations: a basic treatment guideline based on clinical practice. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2007. [DOI: 10.1007/s00590-007-0229-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chong M, Karataglis D, Learmonth D. Survey of the management of acute traumatic first-time anterior shoulder dislocation among trauma clinicians in the UK. Ann R Coll Surg Engl 2007; 88:454-8. [PMID: 17002849 PMCID: PMC1964698 DOI: 10.1308/003588406x117115] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The aim of this work was to survey how acute traumatic first-time anterior shoulder dislocation (AFSD) is managed among trauma clinicians in UK using a postal questionnaire. PATIENTS AND METHODS A total of 150 questionnaires were sent out to active consultant members of the British Trauma Society in the UK. Questions were laid out in two 'workgroups'. In Workgroup One, an assortment of questions was included regarding choices and methods of analgesia, methods of monitoring used, methods of reduction, and position of immobilisation. In Workgroup Two, three different case scenarios were analysed to look into the 'post-reduction' management. RESULTS The response rate was 60%. Of respondents, 22% have a local protocol for managing AFSD. Almost all respondents recommended pre- and post-reduction X-rays as standard practice. Most respondents favoured systemic analgesia and sedation with airways' monitoring, as opposed to intra-articular anaesthesia (68 versus 9). Eighty-four respondents advocated immobilisation in internal rotation compared to six in external rotation. Only 19% (16 of 84) of respondents would perform an immediate arthroscopic stabilisation in young, fit patients presenting with this type of injury. CONCLUSIONS This survey revealed variations among trauma clinicians in managing AFSD on the 'front-line'. There is a need to address the issue of intra-articular analgesia, immobilisation technique and management of AFSD in the young patient with regards to immediate surgical intervention. We suggest that these issues be revised and clarified, ideally in a randomised, controlled, clinical trial prior to the introduction of a protocol for managing this problem.
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Affiliation(s)
- Mark Chong
- The Royal Orthopaedic Hospital NHS Trust, Birmingham, UK.
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33
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Abstract
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).
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Affiliation(s)
- John E Kuhn
- Vanderbilt Sports Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-8828, USA.
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34
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Park MC, Blaine TA, Levine WN. Shoulder dislocation in young athletes: current concepts in management. PHYSICIAN SPORTSMED 2002; 30:41-8. [PMID: 20086508 DOI: 10.3810/psm.2002.12.580] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A fall onto an outstretched arm or a collision on the playing field often leads to an acute anterior shoulder dislocation for high school- and college-age athletes. The diagnosis is usually made by history and physical exam. The angle of impact is an important diagnostic clue. If no neurologic contraindications or signs of acute fracture are seen, radiographs are unnecessary, and early reduction before the onset of muscle spasm is essential. Recent advances in arthroscopic techniques have dramatically reduced the high incidence of recurrent instability in young elite athletes, though nonoperative management with immobilization is still an excellent option.
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Affiliation(s)
- Maxwell C Park
- Columbia-Presbyterian Medical Center, Columbia University, New York, NY, 10032, USA.
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35
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Miller SL, Cleeman E, Auerbach J, Flatow EL. Comparison of intra-articular lidocaine and intravenous sedation for reduction of shoulder dislocations: a randomized, prospective study. J Bone Joint Surg Am 2002; 84:2135-9. [PMID: 12473699 DOI: 10.2106/00004623-200212000-00002] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Acute anterior glenohumeral dislocations have been commonly treated with closed reduction and the use of intravenous sedation. Recently, the use of intra-articular lidocaine has been advocated as an alternative to sedation, since intravenous access and patient monitoring are not required. The purpose of this study was to evaluate the value of local anesthesia compared with that of the commonly used intravenous sedation during the performance of a standardized reduction technique. METHODS In a prospective, randomized study, skeletally mature patients with an isolated glenohumeral joint dislocation and no associated fracture were randomized to receive either intravenous sedation or intra-articular lidocaine to facilitate reduction of the dislocation. Reduction was performed with the modified Stimson method. The two groups were compared with regard to the rate of successful reduction, pain as rated on a visual analog scale, time required for the reduction, time from the reduction until discharge from the emergency department, and cost. RESULTS Thirty patients were enrolled in the study. Five (two in the lidocaine group and three in the sedation group) required scapular manipulation in addition to the Stimson technique to reduce the dislocation. The lidocaine group spent significantly less time in the emergency department (average time, seventy-five minutes compared with 185 minutes in the sedation group, p < 0.01). There was no significant difference between the two groups with regard to pain (p = 0.37), success of the Stimson technique (p = 1.00), or time required to reduce the shoulder (p = 0.42). The cost of the intravenous sedation was $97.64 per patient compared with $0.52 for use of the intra-articular lidocaine. CONCLUSIONS Use of intra-articular lidocaine to facilitate reduction with the Stimson technique is a safe and effective method for treating acute shoulder dislocations in an emergency room setting. Intra-articular lidocaine requires less money, time, and nursing resources than does intravenous sedation to facilitate reduction with the Stimson technique.
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Affiliation(s)
- Suzanne L Miller
- Department of Orthopaedics, The Mount Sinai Hospital, New York, NY 10029, USA
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36
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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 2002; 22:241-5. [PMID: 11932085 DOI: 10.1016/s0736-4679(01)00475-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The purpose of this study was to compare the analgesic effectiveness of intra-articular lidocaine versus intravenous meperidine and diazepam during the reduction of anterior shoulder dislocations. Patients were randomized to one of the two methods before the reduction of shoulder dislocations. Patients marked a visual analog pain scale at baseline, after anesthesia just before reduction, and at the time of discharge. Interference with the procedure caused by pain or lack of muscle relaxation, perception of adequacy of analgesia by the patient, adverse effects, and time to discharge from the Emergency Department (ED) were measured. Differences of outcomes, relative risks (RR), and 95% confidence intervals (CIs) were derived. Fifty-four patients with anterior shoulder dislocations presenting from May 21, 1998 through January 21, 1999 were included in this study; 29 were randomly assigned to receive intra-articular lidocaine (IAL) and 25 to receive intravenous meperidine/diazepam (IVMD). IAL was less effective than IVMD in relieving pre-reduction pain (p = 0.045) but equally effective in overall pain relief (p = 0.98). IAL was more effective than IVMD in shortening recovery time (p = 0.025). There was an indication favoring IVMD in terms of physician-perceived muscle relaxation and patient's perception of analgesia adequacy. In conclusion, although the IVMD method appears to have some clinically and statistically significant advantages, IAL possesses some favorable features that render it to be an analgesia alternative in shoulder dislocation reduction.
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Affiliation(s)
- Michael Orlinsky
- Department of Emergency Medicine, LAC+USC Medical Center, University of Southern California, Keck School of Medicine, Los Angeles, California 90033, USA
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37
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Arthroscopic Repair of Primary Anterior Dislocations of the Shoulder. TECHNIQUES IN SHOULDER AND ELBOW SURGERY 2001. [DOI: 10.1097/00132589-200103000-00002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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38
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Abstract
OBJECTIVES To review the efficacy of common interventions for shoulder pain. SEARCH STRATEGY We searched the Cochrane Musculoskeletal Group trials register, Cochrane Controlled Trials Register, Medline, Embase, Cinahl, and Science Citation Index) up to May 1998, and hand searched major textbooks, bibliographies of relevant literature, the fugitive literature, and the subject indices of relevant journals including: American College of Rheumatology;British College of Rheumatologists; the Biennial Conference of the Manipulative Physiotherapy Association of Australia;International Federation of Manual Therapists conference proceedings; British Orthopaedic Association;and American Orthopaedic Association. SELECTION CRITERIA Each identified study was assessed for possible inclusion by two independent reviewers based on the blinded methods sections. The determinants for inclusion were that the trial include an intervention of interest (non-steroidal anti-inflammatory drugs, intra-articular or subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anaesthesia, hydrodilatation, or surgery); that treatment allocation was randomized; and that the outcome assessment was blinded. DATA COLLECTION AND ANALYSIS Methodological quality was assessed by two independent, blinded reviewers. Data relating to selection criteria, outcome measurement and treatment effect was extracted from the blinded trials. Range of motion scores were entered as degrees of restriction to movement, and all pain and overall effect scores were transformed to 100 point scales. For continuous outcome measures, where standard deviation was not reported it was either calculated from the raw data or converted from standard error of the mean. If neither of these were reported, authors were contacted in an effort to obtain the missing values. Effect sizes were calculated and combined in a pooled analysis if study population, endpoint and intervention were comparable. MAIN RESULTS Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5 - 22) out of possible score of 40. Selection criteria varied widely even for the same diagnostic label. There was no uniformity in outcome measures used and their measurement properties were rarely reported. Effect sizes for individual trials were small (-1.4 to 3. 0). The results of only three studies investigating rotator cuff tendonitis could be pooled. Benefit of subacromial steroid injection over placebo for improving range of abduction (weighted difference between means (WMD) 35 degrees, 95% CI 14 to 55) was the only positive finding. REVIEWER'S CONCLUSIONS There is little evidence to support or refute the efficacy of common interventions for shoulder pain. As well as, the need for further well designed clinical trials, more research is needed to establish a uniform method of defining shoulder disorders and developing outcome measures which are valid, reliable and responsive in these study populations.
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Affiliation(s)
- S Green
- Institute of Public Health and Health Services Research, Monash University, Australasian Cochrane Center, Melbourne, Australia, 3181.
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39
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Blake R, Hoffman J. Emergency department evaluation and treatment of the shoulder and humerus. Emerg Med Clin North Am 1999; 17:859-76, vi. [PMID: 10584106 DOI: 10.1016/s0733-8627(05)70101-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The shoulder girdle is a versatile anatomic structure with a wide range of mobility and function. Its soft tissue and skeletal components are subject to a variety of injuries spanning from overuse syndromes to acute trauma. This article reviews the key historical and physical examination techniques of the shoulder, and special attention is paid to proper imaging in the emergency department, which aids in the diagnosis of specific disorders. This article also reviews the various therapeutic options, including surgery.
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Affiliation(s)
- R Blake
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, Washington, USA
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40
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Kosnik J, Shamsa F, Raphael E, Huang R, Malachias Z, Georgiadis GM. Anesthetic methods for reduction of acute shoulder dislocations: a prospective randomized study comparing intraarticular lidocaine with intravenous analgesia and sedation. Am J Emerg Med 1999; 17:566-70. [PMID: 10530535 DOI: 10.1016/s0735-6757(99)90197-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A prospective, randomized, nonblinded clinical trial was undertaken to evaluate whether local intraarticular lidocaine injection (IAL) is equally effective in facilitating reduction of acute anterior shoulder dislocations (AASD) as intravenous analgesia/sedation (IVAS). The setting was an urban, Level 1, trauma center. Patients enrolled presented to the emergency department (ED) with radiographically confirmed AASD and were randomized either to the IVAS group or the IAL group. Ease of reduction and pain associated with reduction were measured subjectively using a 10-point scale. There were 49 patients entered into the study, 20 in the IVAS group and 29 in the IAL group. There was no statistically significant difference between mean +/- SD pain scores of 3.32+/-2.39 in the IVAS group and 4.90+/-2.34 in the IAL group (P = .18), or mean +/- SD ease of reduction scores of 3.32+/-2.36 in the IVAS group and 4.45+/-2.46 in the IAL group (P = .12). Although IVAS tended to have a higher success rate (20 of 20) than IAL (25 of 29) in this study, Kaplan-Meier estimates for delayed time-events curves applying the log-rank test showed that this difference was not statistically significant overall (P = .16). However, with reduction rate evaluated as a function of time delay in seeking treatment, patients presenting 5.5 hours after dislocation were more likely to fail treatment with IAL (P = .00001). Additionally, half of the patients in the IAL group who had experience with IVAS did not favor IAL. Emergency physicians should be aware of IAL as an alternative technique that may be considered in patients when there are reasons to avoid systemic analgesia or sedation.
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Affiliation(s)
- J Kosnik
- Department of Emergency Medicine, Wayne State University, Detroit, MI 48201, USA
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41
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Gleeson AP, Graham CA, Meyer AD. Intra-articular lignocaine versus Entonox for reduction of acute anterior shoulder dislocation. Injury 1999; 30:403-5. [PMID: 10645353 DOI: 10.1016/s0020-1383(99)00105-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- A P Gleeson
- Accident and Emergency Department, Royal Infirmary of Edinburgh, UK
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42
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Abstract
Anterior shoulder dislocations are commonly seen in emergency departments. With the recent proliferation of shoulder arthroscopy, the pathoanatomy has been better delineated. Arthroscopic series have confirmed the very high percentage of Bankart lesions (avulsions of the inferior glenohumeral ligament-labral complex), especially in younger patients. A high rate of recurrent dislocation in young patients has been noted in the literature with standard conservative treatment, consisting of immobilization with or without rehabilitation. This high recurrence rate is thought to be due to the Bankart lesion. Recently, investigations with the use of arthroscopic Bankart repairs have shown high success rates in preventing recurrences, with low surgical morbidity. A young, first-time, traumatic anterior dislocation patient should be referred for consideration of possible early arthroscopic Bankart repair, rather than automatically being treated conservatively with immobilization.
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Affiliation(s)
- D Y Wen
- Department of Family and Community Medicine, University of Missouri, Columbia 65212, USA
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43
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44
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Affiliation(s)
- A P Gleeson
- Accident and Emergency Department, St George's Healthcare NHS Trust, London, UK
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45
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Gleeson AP, Graham CA, Jones I, Beggs I, Nutton RW. Comparison of intra-articular lignocaine and a suprascapular nerve block for acute anterior shoulder dislocation. Injury 1997; 28:141-2. [PMID: 9205582 DOI: 10.1016/s0020-1383(96)00167-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We compared the analgesic effects of a suprascapular nerve block with intra-articular local anaesthetic in 20 patients presenting with acute anterior glenohumeral dislocations. The intra-articular local anaesthetic technique was a simpler procedure which provided significantly more analgesia for patients.
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46
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Geraci MC, Alleva JT, Prather H. Manipulation under Anesthesia. Phys Med Rehabil Clin N Am 1996. [DOI: 10.1016/s1047-9651(18)30372-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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