Intra Articular Shoulder Block

Other Names

• Intra-articular Block

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Background

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

• This page refers to intra-articular block for Shoulder Dislocation
  • This can be performed by palpation or with ultrasound guidance, US guidance is recommended
  • Approach is similar to Glenohumeral Joint Injection

Anatomy

• Shoulder Joint
  • Articulation of Humeral Head, Glenoid
  • Held in anterior dislocation by pectoralis, biceps

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Indications

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

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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

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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

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Aftercare

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

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Complications

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

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See Also

• Procedures Main
• Ultrasound Main

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