versão On-line ISSN 2309-8309
versão impressa ISSN 1681-150X
SA orthop. j. vol.11 no.3 Pretoria Jan. 2012
CASE REPORT AND REVIEW OF THE LITERATURE
MS MolotoI; BE MunguluII; SS GoleleIII
IMBChB(Medunsa) Registrar: Orthopaedics. Dr George Mukhari Hospital (GMH), Medunsa, Ga-Rankuwa, South Africa
IIMD(UNIKIN), High Dip (Ortho)(SA), FC(Ortho)(SA) Consultant: Orthopaedics. Dr George Mukhari Hospital (GMH), Medunsa, Ga-Rankuwa, South Africa
IIIMBChB(Medunsa), MMed(Ortho)Medunsa, FCS(SA)Ortho Senior Consultant: Orthopaedics, Hand & Microsurgery. Dr George Mukhari Hospital (GMH), Medunsa, Ga-Rankuwa, South Africa
Bilateral anterior dislocation of the glenohumeral (shoulder) joint is uncommon. Incidences of bilateral anterior fracture dislocation of the shoulder are relatively rare. About 16 cases are reported in the world literature. We report a case of bilateral anterior dislocation of the shoulder with bilateral avulsion fractures of the greater tuberosities of the humerus following seizure or convulsion due to electric shock.
Key words: Shoulder dislocation, anterior, bilateral, electrocution
Shoulder joint dislocation is the most common type of dislocation1-4 and proximal humeral fractures may accompany this dislocation.5-13 The most common bilateral shoulder dislocation is posterior, due to seizure or convulsion secondary to epilepsy, electric shock, drug overdose, sports injuries, hypoglycaemia, electroconvulsive therapy, neuromuscular disorders or in emotionally disturbed patients due to violent muscle contractions.5,14-16
We report an unusual case of simultaneous bilateral anterior shoulder fracture dislocation in a man who was electrocuted while welding a gate.
On examination he was unable to hold his hands together in front of his body (no internal rotation). There was bilateral loss of the round contour of the shoulders. Both shoulders were held in abduction. A clinical diagnosis of bilateral anterior shoulder dislocation was made. Sensation on the lateral aspect of the proximal arm (army badge area) was intact. Isometric contraction of the deltoid muscle was intact. In addition to the axillary nerve, the rest of the nerves were also intact. Brachial, radial and ulnar arteries' pulses were palpable. Anterior and lateral shoulder X-rays revealed displaced avulsion fractures of the greater tuberosities and bilateral anterior dislocations (Figure 1).
A 50-year-old man was referred to us from a peripheral hospital. He had been electrocuted while welding a gate.
About seven hours after admission the patient was taken to theatre and under general anaesthesia closed reduction of the shoulders was done using the Hippocrates technique. Immobilisation was done with bilateral slings. Control X-rays showed reduced shoulder joints but the tuberosity fractures were still displaced, needing open reduction and internal fixation (ORIF) (Figure 2). Due to logistical problems the patient was taken to theatre only after three weeks for ORIF on both shoulders.
Post-operatively abduction splints were applied. Postoperative X-rays demonstrated well reduced joints and fractures (Figures 3-5). Physiotherapy with muscle strengthening exercises was started four weeks after ORIF. Tables I and II, and Figures 6 to 13, depict the patient's progress at follow-up.
Posterior shoulder dislocations account for 4% of all shoulder dislocations;7,10,17 anterior dislocations account for 95%.4,7,10,15,17-19 Inferior shoulder dislocation (luxatio erecta) occurs in only 0.5% of cases.7,17
Anterior dislocation of the shoulder is caused by a combination of abduction, extension and external rotation forces applied to the arm. It is almost always secondary to trauma.14,15 Axial loading of the adducted, internally rotated arm may cause posterior shoulder dislocation.
The causes of posterior dislocation have been mentioned above. The combined strength of the internal rotators overpowers the external rotators.
Bilateral shoulder dislocation was first described in 1902 in a patient with camphor overdose.5,14,16 Simultaneous bilateral anterior dislocation of the shoulder is rare.5,14,17 The mechanism of injury is usually the same as unilateral shoulder dislocation secondary to trauma. Associated displaced tuberosity fracture occurs in about 15% of all anterior shoulder dislocations.7,8,17
Reported mechanisms of injury resulting in bilateral simultaneous anterior shoulder dislocation include pushups; a heavy object falling on a patients back; domestic assault; fall/seizure; and post-traumatic stress disorder. In other settings the cause is unknown.17,20
Evidence from the literature suggests that bilateral shoulder dislocations due to seizures or electrocution (with violent muscular contractions) are mostly posterior.1,5,9,10,12-15,17,21 Our patient was a victim of electrocution but presented with bilateral anterior shoulder fracture dislocation.
Several methods of closed reduction of anterior shoulder dislocation are used.3,4,19 In our patient we used the Hippocratic method. Shoulder dislocation, like all dislocations, is an emergency. Prompt and urgent treatment of these injuries could have improved the patients recovery.
At six-months' follow-up our patient's ROM on both shoulders was comparable to that of a patient reported by Milind M Porecha et al.5 At one-year follow-up their patient was working without any functional impairment. Our patient, at six-months' follow-up, has not yet returned to his premorbid occupation and activities of daily living (ADL) but already has ROM comparable to their patient at their one-year follow-up.
Bilateral anterior shoulder fracture dislocation following electrocution is rarer than posterior fracture dislocation. Fortunately, clinical diagnosis is straightforward. Urgent closed reduction of the shoulders with ORIF of the displaced avulsion fractures of the greater tuberosities and appropriate physiotherapy intervention will optimise patient outcome.
No benefits of any form have been received from a commercial party related directly or indirectly to the subject of this article. The content of this article is the sole work of the authors.
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Dr MS Moloto
Dept of Orthopaedic Surgery PO Box 224 Medunsa 0204