An Effective Treatment in the Austere Environment? A Critical Appraisal into the Use of Intra-Articular Local Anesthetic to Facilitate Reduction in Acute Shoulder Dislocation.

Acute shoulder dislocation is a common injury in the outdoor environment. The objective of this systematic review of the literature was to determine if intra-articular local anesthetic (IAL) is an effective treatment that could have prehospital application. A methodical search of MEDLINE, PubMed, and EMBASE databases targeted publications from January 1, 1990 until January 1, 2017. Eligible articles compared IAL with other analgesic techniques in patients 16 years or older experiencing acute glenohumeral dislocation. Reduction success, complications, and patient-reported outcome measures underwent comparison. All identified publications originated from the hospital setting. Procedural success rates ranged widely among randomized control trials comparing IAL with intravenous analgesia and sedation (IAL 48-100%, intravenous analgesia and sedation 44-100%). A pooled risk ratio [RR] favored intravenous analgesia and sedation (RR 0.91, 95% confidence interval [CI] 0.84-0.98), but there was significant inconsistency within the analysis (I2 = 75%). IAL provided lower complication rates (4/170, 2%) than intravenous analgesia and sedation (20/150, 13%) (RR 1.11, 95% CI 1.04-1.19, I2 = 63%). One trial found a clinically relevant reduction in visual analogue pain scores when comparing IAL against no additional analgesia in the first minute (IAL 21±13 mm; control 49±15 mm; P<0.001) and fifth minute (IAL 10±10 mm; control 40±14 mm, P<0.001) after reduction. The results suggest that IAL is an effective intervention for acute anterior shoulder dislocation that would have a place in the repertoire of the remote physician. Further research might be beneficial in determining the outcomes of performing IAL in the prehospital setting.

Non-operative management of a patella fracture: environmental considerations in the Subantarctic.

Injuries occurring in the remote environment present particular challenges to healthcare professionals, and decisions need to be carefully made on an individual basis. This report describes the successful management of a patella fracture sustained on the Subantarctic island of South Georgia. A 36-year-old boating officer presented to the island surgery after sustaining an isolated closed injury to his left knee. On physical examination there was a large effusion palpable within the joint, and on subsequent radiography an undisplaced transverse fracture of the patella was apparent. The patient had an intact and competent extensor mechanism, and fulfilled indications for non-operative management. His clinical case was discussed with supervising consultants at the British Antarctic Survey Medical Unit in the United Kingdom, and radiographs forwarded electronically for an orthopaedic review. The decision was made to undertake medical evacuation of the patient. There were additional environmental factors to be considered in this situation. The terrain on South Georgia is rugged and unforgiving, there is a risk of injury posed by the local fauna (Arctocephalus gazella) during summer months, and emergency evacuation from the base would be difficult for any person with restricted mobility. A planned retrieval enabled our patient to continue rehabilitation and physiotherapy in the preferrential setting of his home country, without causing undue delay in time taken returning to work in this remote location.