1. Downloaded from emj.bmj.com on 26 April 2008
Intra-articular lidocaine versus intravenous
meperidine/diazepam in anterior shoulder
dislocation: a randomised clinical trial
R Shariat Moharari, P Khademhosseini, R Espandar, H Asl Soleymani, M T
Talebian, P Khashayar and A Nejati
Emerg. Med. J. 2008;25;262-264
doi:10.1136/emj.2007.051060
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Original article
Intra-articular lidocaine versus intravenous
meperidine/diazepam in anterior shoulder dislocation:
a randomised clinical trial
R Shariat Moharari,1 P Khademhosseini,1 R Espandar,1 H Asl Soleymani,1 M T Talebian,1
P Khashayar,2 A Nejati1
c Consort flowchart is available ABSTRACT the dislocations are believed to be painful, difficult
online only at http://emj.bmj. Background: Anterior shoulder dislocation is one of the for medical staff, and potentially traumatic (theo-
com/content/vol25/issue5 retically, neurovascular injuries could be caused or
most common complaints of patients referred to
1
Imam Khomeini Hospital, emergency departments. Intravenous opiates and benzo- exacerbated).2 3 Administration of a combination
Medical Sciences/University of diazepines are traditionally prescribed in order to relieve of different sedatives, hypnotics and analgesics has
Tehran, Tehran, Iran; 2 Research
and Development Center, Sina the pain in this group of patients; however, complications brought about successful results, while accompa-
Hospital, Medical Sciences/ always pose a problem. nying complications have always proved challen-
University of Tehran, Tehran, Objective: To compare the pain relief and complications ging.
Iran following intra-articular lidocaine and intravenous meper- Many studies have tried to find out an alter-
idine/diazepam in patients with anterior shoulder dis- native to the above combinations. Intra-articular
Correspondence to:
Dr R Shariat Moharari, Imam location. injection of lidocaine is one such alternative.4
Khomeini Hospital, Keshavarz Methods: 48 patients with non-habitual traumatic Several studies have reported the pain relief
Blvd, Tehran, Iran; naeem. anterior dislocation of the glenohumoral joint admitted to following intra-articular administration of lido-
moharari@gmail.com
Imam Khomeini hospital emergency department were caine as being similar to that achieved with
enrolled in this randomised clinical trial. They were divided intravenous morphine/diazepam or intravenous
Accepted 17 October 2007
into two groups: one group of patients received intra- midazolam/fentanyl. According to these studies,
articular lidocaine 1%, while the other received intrave- the reduction process was easier for both patients
nous meperidine and diazepam. Closed reduction using and physicians using intra-articular injection.5 6
the countertraction–traction method was performed by a In contrast, other studies have reported that this
single person in all the patients. Utilising a 100 mm visual method of administration does not result in the
analogue scale, each patient’s pain was recorded before same degree of pain relief as is achieved using
injection, before reduction, and after reduction. intravenous opiates and benzodiazepines.7
Results: Mean pain (mm) recorded before injection, The objective of our study was to compare the
before reduction, and after reduction in the intra-articular level of pain relief and resulting complications
lidocaine group was 84.3 (95% confidence interval (CI) following intra-articular lidocaine and intravenous
79.8 to 88.8), 52.6 (95% CI 45.2 to 60.1), and 27.3 (95% meperidine/diazepam in patients with anterior
CI 19.9 to 34.7), respectively. The corresponding rates in shoulder dislocation.
the intravenous meperidine/diazepam group were 83.2
(95% CI 79.2 to 87.2), 57.9 (95% CI 53.8 to 62.0), and PATIENTS AND METHODS
23.9 (95% CI 18.9 to 28.8), respectively. Both groups This non-blind, randomised clinical trial was
demonstrated a similar significant decline in pain after performed at Imam Khomeini hospital, a univer-
injection (p,0.005). No severe complications were sity affiliated hospital. The human clinical research
reported in either of the groups. ethics committee of Tehran University of Medical
Conclusion: Intra-articular injection of lidocaine before Sciences approved the study. Patients who pre-
closed reduction of anterior shoulder dislocation produces sented to the emergency department with acute
the same pain relief as intravenous meperidine and non-habitual traumatic anterior dislocation of the
diazepam. glenohumoral joint, confirmed at x ray, from May
2005 until 2006 were eligible for inclusion in the
study. The patients selected were aged between 18
The shoulder is the most commonly dislocated and 80 years. Those patients with a simultaneous
joint. Often, little or no trauma is involved and the fracture, multisystem multiple traumas, distal
arm position alone has resulted in dislocation. The neural injury in the upper extremity, dermal
clinical diagnosis of anterior shoulder dislocation is infection of the shoulder, haemorrhagic disorders,
simple. Patients typically present the dislocation and allergies to the drugs administered during this
with one arm slightly abducted and extended with study, as well as those requiring reduction in more
the elbow flexed and the opposite arm supporting than a joint, were excluded. Addicted individuals,
it. Most shoulder dislocations are anterior, and in who used opioids regularly, were also excluded.
most such dislocations, the humeral head assumes The procedures and the objectives of the study
a subcoracoid position. Subglenoid, infraclavicular, were described for all the patients and they all
and intrathoracic dislocations are uncommon signed an informed consent form.
variants of anterior dislocation.1 2 The patients were randomly assigned into two
Different reduction methods are applied in groups using a computer random number gen-
patients with anterior shoulder dislocation. All of erator. In the first group, intravenous meperidine
262 Emerg Med J 2008;25:262–264. doi:10.1136/emj.2007.051060

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Original article
25 mg and diazepam 5 mg was slowly injected over 1–2 min, Table 1 Mean (SD) pain scores and 95% confidence
and the reduction was performed in 5 min. In the second group, intervals, based on 100 mm analogue visual scale, before
an intra-articular injection of lidocaine 1% was administered via injection, before reduction, and after reduction
the anterior method, as it was much easier. Initially, 1 ml of IVMD IAL
lidocaine 1% was used to achieve skin anaesthesia, and then a
needle was inserted in the inferior lateral site of the coracoid in a Before injection 83.2 (9.5) 84.3 (10.8)
79.2 to 87.2 79.8 to 88.8
posterior direction, until it reached the glenoid hole. Then 20 ml Before reduction* 57.9 (9.7) 52.6 (17.7)
of lidocaine 1% was injected into the shoulder joint. At least 53.8 to 62.0 45.2 to 60.1
15 min were allowed to elapse before the reduction attempt. A After reduction 23.9 (11.8) 27.3 (17.5)
traction–countertraction method was applied to reduce the 18.9 to 28.8 19.9 to 34.7
dislocation. In this method, traction is applied along the IAL, intra-articular lidocaine; IVMD, intravenous meperidine/
abducted arm while an assistant applies countertraction using diazepam.
a folded sheet by wrapping it across the chest. It should be *15 min after IAL injection.
noted that the physician and the resident, who were respec-
tively responsible for undertaking the injections and performing group; however, a second attempt was required in five (20.8%)
the reductions, had both gone through the necessary learning and four (16.7%) cases in the IVMD and IAL groups,
curve and participated in this study only when they had reached respectively. It should be noted that six patients (25%) in the
an adequate level of skill in performing the procedures. IAL group required a third attempt at reduction. The Mann–
All the patients were monitored with ECG, pulse oximetry Whitney test did not reveal a significant difference between the
and capnography throughout the reduction period. Closed two groups in the number of attempts required for a successful
reduction was performed via traction–countertraction by a reduction to be achieved (Z = 1.894; p = 0.058). In addition,
single physician in all of the patients. In the event of a reduction reduction was performed more rapidly in the IVMD group
failure, the protocol allowed the crossover into the other group. (t = 3.660, p = 0.001), while patients in the IAL group had to
Complications such as hypotension (systolic blood pressure stay in the emergency department for a shorter period of time
,90 mm Hg), bradycardia, respiratory depression (SPO2 ,92%, (t = 2.454, p = 0.018) (table 3).
Et CO2 .40), pain and drowsiness were recorded by a technician Complications were reported in 14 (58.3%) and three (12.5%)
blind to the study objectives and the patient’s group. Pain was patients in the IVMD and IAL groups, respectively (x2 = 11.021,
measured subjectively using a 100 mm visual analogue scale p = 0.001). These complications are listed in table 4. Respiratory
(VAS). Each patient was interviewed by the technician and was depression requiring intervention occurred in five of the patients
asked to rate their pain before injection, before reduction, and in the IVMD group, whose situation improved following bag
after reduction. Drowsiness was calculated based on the mask ventilation. Intubation was performed in none of these
Ramsay Sedation Scale (RSS). An RSS level of 3 was the goal cases.
sedation level in the group who received intravenous diazepam/ All the patients were reported to have an RSS level of 1
meperidine. In this group, drowsiness was considered as a (anxious, agitated or restless) at the time of admission. Three of
complication when the patient presented with an RSS level of the patients in the IAL group had an RSS level of 3 and were
>4. In the intra-articular lidocaine group, as no sedation was considered to be drowsy. On the other hand, this complication
expected, drowsiness was considered as a complication in those was more frequent in the IVMD group; five patients were
patients with an RSS level of 3 (responds to commands only). reported to have an RSS level of 4.
During the pilot study, the difference between the pain score Joint infection, discomfort or any other complications
(VAS) of the two groups were calculated (mean difference 7.5); secondary to injury to the joint surface was not reported during
according to this finding, and with a = 0.05 and a power of 80%, the study period. No further medication was prescribed in any
a sample size of 48 (24 patients in each group) was required. The of the cases.
statistical analyses were performed using SPSS10 software. We
used repeated measurements analysis of variance (ANOVA) and
Student’s t test, if indicated, to compare pain scores between DISCUSSION
and within the groups. If the data series were not normally The results of the present study revealed that the administra-
distributed, non-parametrical tests were used. Fisher’s exact test tion of intra-articular lidocaine has the same pain relieving
was also used to compare the complications between the two effects as intravenous meperidine and diazepam; in addition, it
groups. A value of p,0.05 was considered significant. resulted in fewer complications. In other words, intra-articular
lidocaine did not have any significant sedative, musculo-
relaxant or anxiolytic effects compared to diazepam; moreover,
RESULTS
according to the present study, it provided pain relief before
Forty-eight patients were enrolled in the study and were divided
into two groups, each compromising 24 patients, including 22
males (91.7%). Mean (SD) age in the intravenous meperidine/ Table 2 Changes in pain scores (mean difference between two times
diazepam (IVMD) and intra-articular lidocaine (IAL) groups and 95% confidence intervals) from before injection to after reduction
were 38.9 (15.6) and 31.7 (9.2) years, respectively (t = 1.941, t test
p = 0.058). The mean weight of the patients was 73 (4.)6 kg IVMD IAL t p
(range 58–93 kg).
Before injection to before 29.4 36.3 1.257 0.219
Pain assessment based on the 100 mm VAS is outlined in reduction 23.3 to 35.5 26.7 to 46.0
table 1. As shown in table 2, significant pain relief was achieved Before injection to after 70.2 66.2 0.728 0.470
in both groups (F = 207.493, p,0.001), and the duration of pain reduction 63.5 to 77.0 57.0 to 75.4
relief was similar (F = 3.077, p = 0.056). Before reduction to after 58.4 49.8 1.305 0.199
The first attempt at reduction was successful in 19 cases reduction 49.8 to 66.9 39.3 to 60.3
(79.2%) in the IVMD group and in 14 cases (58.3%) in the IAL IAL, intra-articular lidocaine; IVMD, intravenous meperidine/diazepam.
Emerg Med J 2008;25:262–264. doi:10.1136/emj.2007.051060 263

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Original article
Table 3 Reduction time and the period of stay in the Table 4 Reported complications
emergency department (mean and 95% confidence Complication IVMD (%) IAL (%)
intervals)
Drowsiness 5 (20.8) 3 (12.5)
IVMD IAL
Respiratory depression 5 (20.8) –
Reduction time (s) 105.0 284.6 Hypotension 5 (20.8) –
84.0 to 126.1 185.3 to 383.9 Headache 2 (8.3) –
Stay in emergency 216.5 140.6 Nausea 2 (8.3) –
department (min) 164.0 to 269.0 104.2 to 177.1
Localised paraesthesia 1 (4) –
IAL, intra-articular lidocaine; IVMD, intravenous meperidine/
diazepam. IAL, intra-articular lidocaine; IVMD, intravenous meperidine/
diazepam.
reduction similar to that obtained with intravenous meperidine/
was a limitation of the study. The weight of our patients ranged
diazepam.
from 58–93 kg; as a result, lidocaine toxicity following the
In a study conducted by Orlinsky et al, it was shown that,
administration of 210 mg lidocaine was not troublesome in
compared with intra-articular lidocaine, intravenous meperidine
these patients.
and diazepam was more effective in reducing pain score (before
Complications secondary to intra-articular injection of
reduction). The difference between the pain scores following
lidocaine was not seen in any of the studies by Kosnik et al,5
the injection (before reduction) and at the time of discharge,
Suder et al,4 Lippitt et al9 and Matthews and Roberts.10
and also between the time of admission and discharge, was
Complications following intravenous injection in the aforemen-
shown to be the same in the two groups. It also stated that
tioned studies were 5%, 11%, 12%, and 30%, respectively; it
sufficient pain relief was not achieved in 24% and 4% of the
should be noted that, except for the Suder study, none of the
patients who had received intra-articular lidocaine and intra-
complications were reported to be severe.4 5 9 10 Cunningham
venous meperidine/diazepam, respectively. As a result, the
has stated the possibility of joint infection following an intra-
success rate in the two groups was stated to be 44% and 55%,
articular injection of lidocaine, which is not reported in any
respectively.8 In the study by Kosnik et al, failure was reported
other study.11
in five of the patients who had received IAL; four of them were
cured by changing the treatment protocol. As a result, they
documented the success rate to be higher in the group who had CONCLUSION
received intravenous diazepam and morphine (IV: 100%; IA According to our study’s findings, intra-articular lidocaine
83%).5 Conversely, Lippitt et al showed a 100% success rate in appears to be a suitable analgesia alternative to intravenous
the group who had received intra-articular lidocaine, and a 75% opiates and benzodiazepines for the reduction of spontaneous
success rate in the group who received the intravenous drugs.9 anterior shoulder dislocation. Further studies addressing the
Likewise, Suder et al stated a nearly similar success rate in the issues surrounding the associated complications are required
two groups (IV: 94%; IA: 97%).4 Mathews and Roberts did not before definite conclusions regarding safety can be made.
state any failure using either of the above mentioned medica-
Competing interests: None declared.
tions.10
In the current study, an acceptable result was achieved Ethics approval: This study has been approved by the Human Clinical Research
Ethics Committee of Tehran University of Medical Sciences.
despite the number of attempts performed. The first attempt at
reduction was successful in 79% of the cases in the IVMD group Patient consent: Informed consent was obtained from all patients participating in
this study.
and 58% in the IAL group. However, reduction was accom-
plished following a second attempt in the remaining patients in
the IVMD group; a third attempt was required for some REFERENCES
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264 Emerg Med J 2008;25:262–264. doi:10.1136/emj.2007.051060