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Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults

  • Review
  • Intervention

Authors

  • Abel Wakai,

    Corresponding author
    1. Division of Population Health Sciences (PHS), Royal College of Surgeons in Ireland, Emergency Care Research Unit (ECRU), HRB Centre For Primary Care Research, Dublin 2, Ireland
    • Abel Wakai, Emergency Care Research Unit (ECRU), HRB Centre For Primary Care Research, Division of Population Health Sciences (PHS), Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland. awakai@rcsi.ie. abelwakai@gmail.com.

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  • Ronan O'Sullivan,

    1. Our Lady's Children's Hospital Crumlin, National Children's Research Centre, Dublin, Ireland
    2. Cork University Hospital, Cork, Ireland
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  • Aileen McCabe

    1. HRB Centre For Primary Care Research, Division of Population Health Sciences (PHS), Royal College of Surgeons in Ireland, Emergency Care Research Unit (ECRU), Dublin 2, Ireland
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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 methods

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.

Plain language summary

Injection of lignocaine into a dislocated shoulder joint versus injection of a pain-relieving drug with or without injection of a sedative drug into a vein for the purpose of manual manipulation of acute (less than 48 hours old) anterior (towards the front) displacement of a shoulder joint from its normal position.

Joint dislocation refers to displacement of the bones which form a joint away from their anatomical position. The shoulder is the most commonly dislocated joint managed in the emergency department (ED). When the dislocation occurs towards the front of the body, this is known as an anterior shoulder dislocation. It is called an acute anterior shoulder dislocation if the dislocation occurred with the previous 48 hours. Manually manipulating the displaced bones back to their normal position (manual reduction) is very painful. To allow for manual reduction, pain relief can be achieved either by injecting a local anaesthetic drug (for example, lignocaine) into the dislocated shoulder joint (intra-articular lignocaine injection); or by injecting a pain killer with or without a sedative directly into the bloodstream through a vein (intravenous analgesia). The review authors searched the medical literature and identified five studies comparing these two methods. The studies included 211 patients with acute anterior shoulder dislocation; 113 patients underwent intra-articular lignocaine injection and 98 underwent intravenous analgesia with sedation. The review found that there may be no difference in the immediate success of manual reduction of the dislocated shoulder between patients receiving intra-articular lignocaine injection and those who received intravenous analgesia and sedation. However, intra-articular lignocaine injection may be associated with fewer side effects and a shorter stay in the emergency department before discharge from hospital. Compared with intravenous analgesia and sedation, intra-articular lignocaine may also be cheaper. However, the relatively small number of studies included in the review and the relatively small number of patients in each study means that the results of the review preclude definitive conclusions regarding the superiority of either method..