Comparison of Intra-Articular Lidocaine and Intravenous Sedation for Reduction of Shoulder Dislocations A RANDOMIZED, PROSPECTIVE STUDY

2135 COPYRIGHT 2002 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Comparison of Intra-Articular Lidocaine and Intravenous Sedation for Reduction of Shoulder Dislocations A RANDOMIZED, PROSPECTIVE STUDY BY SUZANNE L. MILLER, MD, EDMOND CLEEMAN, MD, JOSHUA AUERBACH, MD, AND EVAN L. FLATOW, MD Investigation performed at the Department of Orthopaedics, The Mount Sinai Hospital, New York, NY 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. Anterior dislocations of the glenohumeral joint are common, and many reduction techniques, including those described by Hippocrates, Kocher, Milch, and Stimson, have been employed 1-5. In the hospital emergency department, acute anterior shoulder dislocations are commonly reduced with intravenous sedation combined with a manual reduction technique. A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). Recently, intra-articular lidocaine has been advocated as a means of providing analgesia and subsequent muscle relaxation to the patient. The method is advantageous because it does not require intravenous access or patient monitoring after the shoulder is reduced. In 1991, Lippitt et al. 6 compared a retrospective series of shoulder dislocations reduced after administration of intravenous sedation with a prospective series of dislocations reduced after administration of intra-articular lidocaine. They reported a lower complication rate in the lidocaine group (one of forty) than in the group treated with intravenous sedation (nineteen of fifty-two). Other investiga-

2136 Fig. 1 Identification of the lateral edge of the acromion allows for intra-articular injection. of the affected shoulder on initial presentation to the emergency room. Once a dislocation was confirmed clinically and radiographically, the emergency room physician notified the orthopaedic resident on call. Of the patients who met the study criteria and agreed to participate in the study, those with an odd medical record number received a local intra-articular injection of lidocaine (Xylocaine) whereas those with an even medical record number received intravenous sedation. For the intra-articular injection, the affected shoulder was prepared with three swabs of povidone-iodine, and 20 ml of 1% lidocaine was injected into the glenohumeral joint, from just off the lateral edge of the acromion, through a 20-gauge, 35- tors have attempted to compare intra-articular lidocaine with intravenous sedation 7-10 but used manual reduction techniques that were physician-dependent and nonstandardized. The purpose of this study was to compare the efficacy of intra-articular lidocaine with that of intravenous sedation for patients treated with a standardized reduction technique that was not physician-dependent and thus minimized treatment bias. Materials and Methods Study Design fter obtaining approval from our institutional review board, A we instituted a prospective, randomized trial to determine whether local intra-articular lidocaine is as effective as intravenous sedation in facilitating reduction of anterior dislocations of the glenohumeral joint. The modified Stimson method was used to reduce the shoulders 5. This method was chosen to minimize bias by treating physicians, since manual manipulation is not used. The study was a multicenter trial performed at The Mount Sinai Hospital, which is a private hospital, and at Elmhurst Hospital Center, which is an urban level-i trauma hospital. All patients gave written informed consent prior to their participation in the study. The inclusion criteria were an age of eighteen to seventy years old and an acute anterior shoulder dislocation. Exclusion criteria included multiple trauma, an associated fracture (except a Hill-Sachs compression defect) of the glenoid or tuberosities, open growth plates, a history of allergic reactions to the medications used in the study, and an inability to be placed in the prone position. Technique All patients with a glenohumeral joint dislocation had a trauma series of radiographs (anteroposterior, axillary, and outlet views) Fig. 2 Modified Stimson method of reduction with use of 10 lb (4.5 kg) of traction.

2137 Statistical Analysis Statistical analysis included paired t tests for continuous data and Mann-Whitney U tests for nonparametric data. With the alpha level set at 0.05, it was determined prospectively that fourteen patients per group would give 90% power to identify a thirty-minute difference in emergency room stay. Fig. 3 Scapular manipulation involves rotating the inferior border of the scapula medially while the patient s arm is hanging. mm needle (Fig. 1). When intravenous sedation was used, the emergency room nurse placed an intravenous line, and 2 mg of Versed (midazolam) and 100 µg of fentanyl (Sublimaze) was administered intravenously. All patients were then placed prone on the stretcher with the affected arm hanging down, and 10 lb (4.5 kg) of traction was applied with a weight and strap (the modified Stimson technique) (Fig. 2). While the patient was in the prone position, he or she was asked to rate the pain on a scale of 1 to 10 (with 1 being very mild pain and 10 being the worst pain one could ever have). When reduction occurred, the patient tended to become more comfortable and often could tell exactly when the shoulder relocated. Reduction was confirmed by palpation of the reduced humeral head. If the shoulder was not relocated within twenty-five minutes, scapular manipulation 11 was performed with the patient in the same prone position. To achieve reduction with scapular manipulation, the physician pushes the tip of the scapula medially while simultaneously rotating the superior aspect of the scapula laterally (Fig. 3). After the shoulder was reduced, a sling was applied and the patient was sent for confirmatory postreduction radiographs. The emergency room physician determined when it was appropriate to discharge the patient after treatment, and the nurse in attendance recorded this information in the chart. The orthopaedic resident on call recorded the time that the patient was placed in the prone position, the time that the shoulder relocated, and the time that the patient left the emergency room. Additional data collected by the orthopaedic resident included the name and age of the patient, the date of the procedure, the medical record number, any history of dislocations, the success of the reduction with the Stimson method, the scores on the visual analog pain scale, and any acute drug reaction. The costs of supplies, equipment, and personnel for the two methods were calculated on the basis of information supplied by the hospital pharmacy and distribution center. Results orty-two consecutive patients presented to the emergency Froom with an acute anterior glenohumeral dislocation between November 2000 and May 2001. Eight patients who had a fracture of the greater tuberosity were excluded. Two patients who were intubated in the trauma bay and therefore could not be placed prone were also excluded, and two patients refused to participate in the study. Both patients who refused to participate had a history of multiple dislocations and stated that they preferred sedation and use of a manual manipulation technique. Of the remaining thirty patients, sixteen received an intra-articular lidocaine injection and fourteen received intravenous sedation (Table I). The average age was thirty-four years (range, seventeen to sixty-nine years) for the entire series, thirty-three years (range, seventeen to fifty-four years) for the lidocaine group, and thirty-five years (range, seventeen to sixty-nine years) for the intravenous sedation group. Four patients in the lidocaine group and five in the intravenous sedation group had had previous dislocation of the shoulder. All reported having had one or two prior dislocations except for one patient in the intravenous sedation group, who reported thirty prior dislocations. No patients reported that they had had previous surgery on the dislocated shoulder. There were no systemic (cardiovascular or respiratory) or local side effects associated with either the intra-articular lidocaine or the intravenous sedation. The dislocation was successfully reduced with the Stimson technique in fourteen of the sixteen patients who received lidocaine and in eleven of the fourteen who received intravenous sedation (p = 1.00, Fisher exact test). All five shoulders that could not be reduced with the modified Stimson technique were reduced with scapular manipulation. No additional medication was given. The average time for the reduction to occur with the modified Stimson technique was 11.4 minutes (range, three to twenty-two minutes) in the lidocaine group and 8.5 minutes (range, one to twenty minutes) in the sedation group (p = 0.42, t test). The lidocaine group left the emergency department at an average (and standard deviation) of 75 ± 48 minutes after the shoulder was reduced, whereas the intravenous sedation group left in an average of 185 ± 26 minutes (p < 0.01, t test). The average pain score was 7.0 ± 2.6 for the lidocaine group and 7.4 ± 2.5 for the intravenous sedation group (p = 0.37, Mann-Whitney U test). The data were also analyzed after exclusion of patients with a history of dislocation. There was still no significant difference between the treatment groups with regard to the success of the reduction (p = 1.00, Fisher exact test) or the time for the reduction to occur (10.1 minutes in the lidocaine group and 12.1 minutes in the intravenous sedation; p = 0.71, t test).

2138 TABLE I Comparison of Results of Reduction with Lidocaine and Reduction with Intravenous Sedation Lidocaine Sedation P Value Average age (range) (yr) 33 (17-54) 35 (17-69) No. of previous dislocations 4 5 Average pain score (points) 7.0 7.41 0.37 (Mann-Whitney U test) No. with successful Stimson reduction 14/16 11/14 1.00 (Fisher exact test) Average time in emergency room (min) 75 185 <0.01 (t test) The cost of using intravenous sedation for the closed reduction was $97.64, and the cost of using lidocaine was $0.52 (Table II). TABLE II Cost Comparison of Lidocaine and Intravenous Sedation Lidocaine Sedation Syringe (20 ml) $0.17 Syringe (5 ml) $0.14 Needle $0.03 $0.03 Lidocaine $0.32 Fentanyl $0.31 Midazolam $5.90 Intravenous setup $2.86 1 bag of 1/2 normal $0.83 saline solution Nursing (3 hr) $87.57 Total $0.52 $97.64 Discussion n 1995, Suder et al. 8 prospectively randomized fifty-two Ipatients with recurrent shoulder dislocations to receive either intra-articular lidocaine or intravenous narcotics to facilitate reduction. The choice of the manipulative reduction method was left up to the treating physician. No significant difference was found between the two analgesic methods with regard to the success of the reduction (p = 1.00). Three patients who received intravenous sedation had respiratory side effects that required medical management, and two of the three had to stay in the hospital for one day. None of the patients who received intra-articular lidocaine had a local or systemic side effect. In 1995, Matthews and Roberts 7 prospectively randomized thirty patients with anterior shoulder dislocation to receive either intra-articular lidocaine or intravenous sedation for pain control. Within each group, patients were assigned to receive traction/countertraction 12 or scapular rotation to reduce the dislocation. If either of these methods failed, the treating physician could use any other method that he or she thought appropriate. Physicians subjectively rated the difficulty of performing the maneuver. Although Matthews and Roberts reported that intra-articular lidocaine provided adequate muscle relaxation for all fifteen patients in whom it was used, different methods of manual reduction were employed by different physicians, making comparisons between the two pain-control methods difficult. In another prospective consecutive series, Kosnik et al. 10 randomized forty-nine patients to receive either intravenous sedation or intra-articular lidocaine. The traction/countertraction method described by Rockwood and Wirth 12 was used to reduce the dislocation in all patients. There was no significant difference (p = 0.37) between the two groups with regard to the pain reported by the patient or the ease of reduction according to the physician. Twenty-four of twenty-nine patients who received lidocaine had a successful reduction whereas all twenty patients who received intravenous sedation had a successful reduction. This difference was not significant. In addition, half of the patients who had had intravenous sedation previously did not prefer the intra-articular lidocaine injection. In our series, there was no difference in the success rate of the Stimson technique or the time required to reduce the shoulder between the two groups. Like Matthews and Roberts 7, we found that patients left the emergency room significantly sooner when they had received intra-articular lidocaine. This is important, as it meant that additional staff was not required to monitor the patient for as long as three hours after the reduction. Furthermore, the pain perceived by the patients was not significantly different between the two groups. Intra-articular lidocaine injection has a number of benefits compared with intravenous sedation. Patient monitoring, including monitoring of oxygen saturation and performing electrocardiography, by professional personnel is not required during or after the reduction. In addition, complications including respiratory depression and cardiac compromise have not been reported with intra-articular lidocaine. Furthermore, it costs less. The one potential devastating drawback of intra-articular lidocaine injection would be the development of an infection in the shoulder. Fortunately, to date this has not been reported as a complication of this technique. In our

2139 experience, the use of intra-articular lidocaine in conjunction with the Stimson technique to reduce acute anterior dislocations of the shoulder requires less manpower, money, and time than does intravenous sedation. Suzanne L. Miller, MD Edmond Cleeman, MD Joshua Auerbach, MD Evan L. Flatow, MD Department of Orthopaedics, The Mount Sinai Hospital, 5 East 98th Street, Box 1188, New York, NY 10029. E-mail address for E.L. Flatow: evan.flatow@msnyuhealth.org The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. References 1. Kocher MS, Feagin JA Jr. Shoulder injuries during alpine skiing. Am J Sports Med. 1996;24:665-69. 2. Adams F. The genuine works of Hippocrates: translated from the Greek with a preliminary discourse and annotations. Vol 1 and 2. New York: Wood; 1890. 3. Kocher T. Eine neue Reductionsmethode fur Schuiterverrenkung. Berliner Klin Wehnschr. 1870;7:101-5. 4. Milch H. Treatment of dislocation of the shoulder. Surgery. 1938;3:732-40. 5. Stimson LA. An easy method of reduction dislocation of the shoulder and hip. Med Record. 1900;57:356. 6. Lippitt SB, Kennedy JP, Thompson TR. Intraarticular lidocaine versus intravenous analgesia in the reduction of dislocated shoulders. Orthop Trans. 1991;15:804. 7. Matthews DE, Roberts T. Intraarticular lidocaine versus intravenous analgesic for reduction of acute anterior shoulder dislocations. A prospective randomized study. Am J Sports Med. 1995;23:54-8. 8. Suder PA, Mikkelsen JB, Hougaard K, Jensen PE. Reduction of traumatic secondary shoulder dislocations with lidocaine. Arch Orthop Trauma Surg. 1995;114:233-6. 9. Suder PA, Mikkelsen JB, Hougaard K, Jensen PE. Reduction of traumatic, primary anterior shoulder dislocations with local anesthesia. J Shoulder Elbow Surg. 1994;3:288-94. 10. 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. 11. Anderson D, Zvirbulis R, Ciullo J. Scapular manipulation for reduction of anterior shoulder dislocations. Clin Orthop. 1982;164:181-3. 12. Rockwood CA Jr, Wirth MA. Subluxations and dislocations about the glenohumeral joint. In: Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, editors. Rockwood and Green s fractures in adults. 4th ed, vol 2. Philadelphia: Lippincott-Raven; 1996. p 1193-339.