What are the recommendations for acute pain management in shoulder dislocation?

Acute Pain Management for Shoulder Dislocation

For acute shoulder dislocation, use intra-articular lidocaine injection (20 mL) as first-line analgesia, which provides adequate pain relief with fewer complications and shorter hospital stays compared to intravenous sedation, or consider ultrasound-guided interfascial plane block with ropivacaine for superior analgesia without motor blockade. 1, 2

Analgesic Options

First-Line: Regional Anesthesia

Intra-articular lidocaine (IAL) is the preferred initial approach for acute anterior shoulder dislocation reduction, offering several advantages over systemic sedation 1:

• Administer 20 mL of lidocaine directly into the glenohumeral joint under ultrasound guidance 3, 1
• Provides adequate pain relief comparable to intravenous sedation (no significant difference in pain scores, p=0.23) 1
• Success rate of 81% for reduction (26 of 32 patients) 1
• Zero complications compared to 29% complication rate with IV sedation 1
• 32% cost reduction compared to intravenous methods 1
• Shorter hospital stay duration 1
• Allows immediate diagnosis and treatment in urgent care settings using point-of-care ultrasound 3

Emerging Alternative: Interfascial Plane Block (IPB)

The ultrasound-guided interfascial plane block is a superior emerging technique for proximal humerus fractures and fracture-dislocations 2:

• Inject 20 mL of 7.5 mg/mL ropivacaine between the deltoid and subscapularis muscles 2
• Pain relief achieved within 15 minutes 2
• Facilitates closed reduction without additional sedation 2
• Lower risk of hemidiaphragmatic paresis compared to interscalene blocks 2
• Minimal motor blockade 2
• Relatively easy to learn for clinicians familiar with ultrasound-guided techniques 2

Second-Line: Intravenous Sedation

If regional anesthesia fails or is contraindicated, use intravenous sedation 1:

• Demerol and Diazepam combination achieves 100% reduction success rate 1
• Target Ramsay sedation scale score of 1-2 4
• Major drawback: 29% complication rate and longer hospitalization 1
• Reserve for failed regional attempts (approximately 19% of IAL cases) 1

Reduction Technique Selection

Choose reduction methods that minimize pain and avoid additional trauma 5, 4:

Preferred: Scapular Manipulation

• Significantly less painful than Kocher's technique (p<0.01) 4
• 96.7% success rate when combined with procedural sedation 4
• Single-operator technique with patient sitting 5

Alternative: Cunningham Technique

• Effective when combined with ultrasound-guided intra-articular analgesia 3
• Gentle, non-traumatic approach 3

Clinical Pitfalls to Avoid

Do not rely solely on systemic opioids as they increase complications without improving pain control compared to regional techniques 1, 2:

• Avoid Kocher's method as first-line due to higher pain intensity 4
• Never skip axillary or scapula-Y radiographic views before reduction, as AP views alone miss dislocations 6, 7
• Perform radiographs upright, not supine, to avoid underestimating malalignment 6, 7
• Do not delay reduction - immediate reduction after diagnosis minimizes complications 5

Post-Reduction Management

After successful reduction 6:

• Acetaminophen or ibuprofen for ongoing pain if no contraindications 6
• Consider subacromial corticosteroid injection if rotator cuff or bursal inflammation is present 6
• Initiate gentle range of motion exercises to prevent stiffness 6