Diagnostics The orthopedic literature 2011 Daniel L. Lemkin MD a, ⁎ , Michael C. Bond MD a , William J. Brady MD b a Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA b Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA Received 22 February 2012; revised 7 April 2012; accepted 14 April 2012 1. Pain management Wakai A, O'Sullivan R, McCabe A. Intra-articular lignocaine versus intravenous analgesia with or without sedation for manual reduction of acute anterior shoulder dislocation in adults. Cochrane Database Syst Rev. 2011;(4):CD004919. Cheok CY, Mohamad JA, Ahmad TS. Pain relief for reduction of acute anterior shoulder dislocations: a prospective randomized study comparing intravenous seda- tion with intra-articular lidocaine. J Orthop Trauma. 2011;25:5–10. The reduction of dislocations can consume a large amount of time and resources in the emergency department (ED). Many reductions are performed with the aid of procedural sedation, which requires cardiopulmonary monitoring and additional clinicians to assist in the care of the patient. The ability to reduce a shoulder under a local anesthetic reduces the consumption of clinical resources and has the potential to decrease ED length of stay. The review by Wakai and colleagues as well as the study by Cheok and associates compared the use of general sedation and local anesthesia for pain control during shoulder reduction. The Cochrane Review examined published studies that compared the efficacy of intra-articular lignocaine (lido- caine) (IAL) and conventional intravenous analgesia with or without sedation (IVAS). The authors identified 1041 publications through their search strategy and examined that 9 were felt to be clinically relevant, with 5 meeting the inclusion criteria. The 5 studies analyzed for this review encompassed a total of 221 patients. Examined outcomes were procedural success, rate of complications, and proce- dure length. No significant difference was identified for procedural success for IAL vs IVAS (risk ratio, 0.95; 95% confidence interval [CI], 0.83-1.10). Significantly fewer adverse effects were associated with IAL than with IVAS (risk ratio, 0.16; 95% CI, 0.06-0.43). One of the 5 trials documented a decreased procedure length with IAL. This review concedes that individual and overall small sample sizes preclude the ability to draw any definitive conclusions. However, even with this inherent bias, this review helps to heighten awareness that the use of a local anesthetic for reduction of shoulder dislocation appears to have fewer complications, requires fewer clinical resources, and reduces overall length of stay in the ED. Additional studies are needed to definitely prove this point, but IAL appears to be an effective alternative to procedural sedation. Cheok et al assessed the efficacy of IAL compared with that of intravenous sedation (IVS) for uncomplicated anterior shoulder reductions in the ED. Their outcome measures were cost-effectiveness, ED length of stay, procedural success, complications, and patient comfort. The study was performed in Malaysia from September 2000 to March 2002. The agents that were chosen for procedural sedation (meperidine [Demerol, Sanofi Aventis Bridgewater NJ] and diazepam [Valium, Genentech San Francisco, CA]) are no longer commonly used for this application in the United States. This difference may be partly responsible for the variance in outcomes compared with other studies using agents such as etomidate, propofol, and fentanyl. During the 18-month study period, 85 patients with an anterior shoulder dislocation were admitted. Patients who were unstable, had complicated injuries, were allergic to the ⁎ Corresponding author. E-mail address: dan@umem.org (D.L. Lemkin). www.elsevier.com/locate/ajem 0735-6757/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2012.04.020 American Journal of Emergency Medicine (2012) 30, 1296–1305