Management of Acute Anterior Shoulder Dislocation
Appropriate relaxation of the musculature is the key to successful reduction. This can be achieved safely in several ways (Table 5). The method used depends on the patient, the clinician's preference and the equipment available at the time of reduction.
Some surgeons prefer not to use any analgesia at all, thereby avoiding the potential side effects caused by analgesic agents. This is only possible in specific circumstances, for instance in atraumatic, early (within 6 hours) and recurrent dislocations. However, only a reduction technique with minimal traction should be employed (such as Milch's or scapular technique) by an experienced clinician in these circumstances. O'Connor et al reported successful reduction of 76 consecutive acute anterior shoulder dislocations without any analgesia using Milch's traction technique (see below).
A survey of UK trauma clinicians found that the most popular methods were intravenous analgesia (primarily opiates) with sedation (primarily benzodiazepines). This combination is highly effective, but side effects include respiratory depression and continued reduced consciousness following reduction, which necessitates continuous monitoring, both during the procedure and until the patient is fully alert. This can be time-consuming and requires an assistant to manage the patient's airway.
Advantages include rapid onset of pain relief, ease of use and non-invasive administration. There are minimal side effects. A recent prospective study comparing nitrous oxide/oxygen with the common intravenous agents showed significantly reduced time in the emergency department (77 vs 177 min). A prospective randomised trial demonstrated adequate analgesia for 80.9% of successful relocations.
This has recently grown in popularity. Local anaesthetic (10 ml of 1% lidocaine) is infiltrated into the glenohumeral joint through a lateral approach. This is a safe, effective, has few side effects and avoids the need for monitoring the airway. It also provides the opportunity to drain a haemoarthrosis; however, there is a risk of introducing infection. Studies looking at the efficacy of intra-articular analgesia generally exclude fracture dislocations in their studies and there is currently insufficient evidence for its use with fractures. Experienced clinicians can use this method outside the hospital, for instance on a sports field, where monitoring facilities are not available. However, caution is warranted given the potential risk of infection. A recent meta-analysis and a Cochrane review have shown that intra-articular analgesia permits the same pain control and reduction success as intravenous agents, while markedly reducing time in the emergency department and treatment cost. There were fewer adverse effects and no cases of infection. Recent in vitro research has demonstrated that local anaesthetic agents can lead to chondrotoxicity in the joint. There is a greater risk of chondrolysis with longer exposure to a higher concentration of anaesthetic, for instance, with a post-operative pain pump, than with a single injection.
Analgesia and Sedation
Appropriate relaxation of the musculature is the key to successful reduction. This can be achieved safely in several ways (Table 5). The method used depends on the patient, the clinician's preference and the equipment available at the time of reduction.
No Analgesia
Some surgeons prefer not to use any analgesia at all, thereby avoiding the potential side effects caused by analgesic agents. This is only possible in specific circumstances, for instance in atraumatic, early (within 6 hours) and recurrent dislocations. However, only a reduction technique with minimal traction should be employed (such as Milch's or scapular technique) by an experienced clinician in these circumstances. O'Connor et al reported successful reduction of 76 consecutive acute anterior shoulder dislocations without any analgesia using Milch's traction technique (see below).
Intravenous Analgesia and Sedation
A survey of UK trauma clinicians found that the most popular methods were intravenous analgesia (primarily opiates) with sedation (primarily benzodiazepines). This combination is highly effective, but side effects include respiratory depression and continued reduced consciousness following reduction, which necessitates continuous monitoring, both during the procedure and until the patient is fully alert. This can be time-consuming and requires an assistant to manage the patient's airway.
Nitrous Oxide and Oxygen (Entonox)
Advantages include rapid onset of pain relief, ease of use and non-invasive administration. There are minimal side effects. A recent prospective study comparing nitrous oxide/oxygen with the common intravenous agents showed significantly reduced time in the emergency department (77 vs 177 min). A prospective randomised trial demonstrated adequate analgesia for 80.9% of successful relocations.
Intra-articular Analgesia
This has recently grown in popularity. Local anaesthetic (10 ml of 1% lidocaine) is infiltrated into the glenohumeral joint through a lateral approach. This is a safe, effective, has few side effects and avoids the need for monitoring the airway. It also provides the opportunity to drain a haemoarthrosis; however, there is a risk of introducing infection. Studies looking at the efficacy of intra-articular analgesia generally exclude fracture dislocations in their studies and there is currently insufficient evidence for its use with fractures. Experienced clinicians can use this method outside the hospital, for instance on a sports field, where monitoring facilities are not available. However, caution is warranted given the potential risk of infection. A recent meta-analysis and a Cochrane review have shown that intra-articular analgesia permits the same pain control and reduction success as intravenous agents, while markedly reducing time in the emergency department and treatment cost. There were fewer adverse effects and no cases of infection. Recent in vitro research has demonstrated that local anaesthetic agents can lead to chondrotoxicity in the joint. There is a greater risk of chondrolysis with longer exposure to a higher concentration of anaesthetic, for instance, with a post-operative pain pump, than with a single injection.
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