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Intra Articular Shoulder Block

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Other Names

  • Intra-articular Block

Background

Anterior shoulder dislocation with internal rotation and adduction. Note squared off shoulder, prominent acromion and loss of deltopectoral groove

Anatomy


Indications

  • Shoulder Dislocation
    • Safe, effective when compared to procedural sedation. May reduce time in ED.[1]
    • Ultrasound likely increases accuracy[2]
    • Posterior approach is easier, more effective (compared to lateral or anterior)[3]

Contraindications

  • Relative
    • Able to control symptoms, achieve reduction with less invasive means
  • Absolute
    • Allergy to local anesthetic
    • Altered or unconscious patient
    • Infection overlying the area
    • Neurologic deficit in the affected extremity

Procedure

Palpation guided hematoma block
Ultrasound and needle position (simulated by finger) for ultrasound guided intra-articular block

Equipment

  • Sterile gloves
  • Sterile gauze
  • Antiseptic (e.g. chlorhexidine or alcohol)
  • Syringe (10 - 30 mL depending on preference)
  • Needles (large bore for drawing up local, small gauge for injection)
  • Anesthetic (e.g. 2% lidocaine or 0.5% bupivacaine)
    • Typical volume of injection is 10-20 mL
  • Ultrasound machine (optional, but recommended)
    • High frequency linear probe

Preparation

  • The patient is typically seated
  • They should be in a position where you can access the glenoid fossa
  • Ultrasound positioning
    • If ultrasound is being used, it should be placed on the contralateral side
    • Patient is often facing away so that you can access posterolateral shoulder
  • Pre-procedural ultrasound evaluation
    • Place the probe posteriorly in the transverse plane
    • Along the axis of the spine of the scapula and just caudal to the acromion
    • Identify the humeral head, glenoid fossa and joint capsule

Palpation Guided Technique

  • Identify landmark by palpating the Glenoid Fossa
    • The defect left by the dislocated humeral head is usually obvious
    • This may be more difficult to palpate in an obese patient
    • Mark skin after identifying optimal entry
  • Disinfect skin
    • Optional: place a skin wheel at entry site
  • Insert the needle into the skin advancing towards the glenoid fossa
    • As you advance, aspirate
    • The appearance of blood suggests you have entered the joint capsule
    • It's possible you hit the glenoid fossa without aspirating any blood
  • Inject anesthetic

Ultrasound Guided Technique

Ultrasound guided intra-articular shoulder block
  • Ultrasound
    • Perform pre-procedure scan (see above)
  • Disinfect skin
    • Sterile Gloves, sterile probe cover
    • Consider marking estimated entry point prior to prepping skin
  • Re-apply probe, orient to anatomy
    • Enter the skin in-plane just lateral to the lateral edge of the probe
    • Follow the needle lateral to medial into the glenoid fossa
    • Once inside the joint capsule, aspirate and then inject
    • Needle visualization should be maintained

Aftercare

  • Anticipate improvement in pain and symptoms within 15-20 minutes

Complications

  • Inadequate pain relief
  • Extra-articular injection
    • This could happen in suprascapular artery, circumflex scapular artery
  • Nerve injury
  • Infection

See Also


References

  1. Fitch RW, Kuhn JE. Intraarticular lidocaine versus intravenous procedural sedation with narcotics and benzodiazepines for reduction of the dislocated shoulder: a systematic review. Acad Emerg Med. 2008 Aug;15(8):703-8. doi: 10.1111/j.1553-2712.2008.00164.x. PMID: 18783486.
  2. Sage W, Pickup L, Smith TO, Denton ER, Toms AP. The clinical and functional outcomes of ultrasound-guided vs landmark-guided injections for adults with shoulder pathology--a systematic review and meta-analysis. Rheumatology (Oxford). 2013 Apr;52(4):743-51. doi: 10.1093/rheumatology/kes302. Epub 2012 Dec 28. PMID: 23275390.
  3. Ogul H, Bayraktutan U, Ozgokce M, Tuncer K, Yuce I, Yalcin A, Pirimoglu B, Sagsoz E, Kantarci M. Ultrasound-guided shoulder MR arthrography: comparison of rotator interval and posterior approach. Clin Imaging. 2014 Jan-Feb;38(1):11-7. doi: 10.1016/j.clinimag.2013.07.006. Epub 2013 Oct 9. PMID: 24119385.
Created by:
John Kiel on 11 November 2022 09:10:24
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Last edited:
11 November 2022 10:10:50
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