Dane Swinehart MD, Jordan Meiss MD, and Charles Cox MD Vanderbilt University Medical Center, Vanderbilt Orthopaedic Institute, Nashville, TN, USA An athlete with a primary dislocation of the glenohumeral joint will be in obvious discomfort and resistant of closed reduction attempts secondary to pain. In the current medical care setting, there are several options for premedicating patients that range from IV sedation to intra‐articular anesthetic to regional nerve block. The treating clinician must decide on the best method of anesthesia delivery (IV sedation vs intra‐articular injection) to maximize patient safety while achieving successful reduction and minimizing complications. Premedication is an important aspect of reduction as it can allow for a better outcome in regards to patient safety and satisfaction, in addition to aiding the clinician in a more facile reduction. The included trials compared various outcome measures among techniques for premedication that included IV sedation, intra‐articular lidocaine injection, and suprascapular nerve block. Outcomes that were compared included reduction success, complications, pain level, time to reduction, and overall time spent in the Emergency Department. In the included studies, no difference was seen in rates of reduction among the different techniques used for sedation. Furthermore, patient pain and satisfaction between the various techniques showed no significant differences. There were differences found in complication rates between intra‐articular lidocaine injection and IV sedation. The most common complication involved respiratory depression in the setting of IV sedation. One meta‐analysis found statistically significant increases in rates of respiratory depression, vomiting, and thrombophlebitis in the IV sedation group when compared to the intra‐articular lidocaine group. There were no significant differences found in regards to nausea, hypotension, drowsiness, or headache.4 Time to reduction and overall time spent in the Emergency Department has also been evaluated by the included studies. In general, studies comparing time to reduction favor IV sedation as the quicker method, while intra‐articular lidocaine results in the least overall time spent in the Emergency Department. One systematic review found that mean time spent in the Emergency Department was 109.46 minutes less with intra‐articular lidocaine as compared to IV sedation (95% confidence interval [CI]: 84.60–134.32). In terms of time to reduction, IV sedation was favorable with a time of 105 seconds to reduction (95% CI: 84.0–126.1), while intra‐articular lidocaine had an average time of 284.6 seconds to reduction (95% CI: 185.3–383.9).3 The standard of care for the athlete with a dislocated glenohumeral joint is expeditious reduction and immobilization. It is important to select a technique to best achieve reduction and then to place the arm in a position of relative stability. There are numerus techniques for achieving reduction and immobilization of the glenohumeral joint. Each technique utilizes different strategies to overcome muscular forces and allow the humeral head to reduce back into congruent anatomic alignment with the glenoid. Furthermore, immobilization methods are aimed at maximal stability and preventing recurrent dislocation. It is important to achieve safe, expeditious reduction in a manner that avoids iatrogenic injury to the anatomic structures of the shoulder. Furthermore, choice of immobilization may be important for postreduction stability and prevention of recurrent dislocations.
121 First Time Shoulder Dislocation
Clinical scenario
Top three questions
Question 1: In patients undergoing reduction of primary glenohumeral dislocations, does intravenous (IV) sedation for closed reduction present a greater chance for successful reduction and fewer complications than other methods of premedication for reduction?
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Available literature and quality of the evidence
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Question 2: In a patient undergoing a primary glenohumeral dislocation reduction, is there an ideal reduction and immobilization method that results in fewer complications and reduced recurrence rates?
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