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|Year : 1977 | Volume
| Issue : 3 | Page : 137-139
Bilateral simultaneous fracture-dislocation of the shoulder due to muscular violence
Department of Orthopaedic Surgery, Jawaharlal, Institute of Post Graduate Medical Education and Research, Pondicherry, India
S S Yadav
Department of Orthopaedic Surgery, Jawaharlal, Institute of Post Graduate Medical Education and Research, Pondicherry
A convulsive seizure may be fraught with hazard. A case of bilateral anterior fracture-dislocation of the shoulder as a result of convulsions is reported. The need of an awareness of such a possibility during fits is emphasized and a conservative therapeutic approach is recommended.
|How to cite this article:|
Yadav S S. Bilateral simultaneous fracture-dislocation of the shoulder due to muscular violence. J Postgrad Med 1977;23:137-9
| :: Introduction|| |
Although shoulder is most commonly dislocated in the body, occurrence of bilateral fracture-dislocation during convulsive episodes is rare. Only a few cases have been reported in the literature. ,, We are presenting below one such case of bilateral fracture-dislocation occurring during a convulsive episode.
| :: Case report|| |
A fifty six year old South Indian male suddenly had convulsions and became unconscious after seeing the dead body of a close relation. His son immediately caught him and prevented him from falling back on the ground. He was attended by a local doctor who sedated him. On regaining consciousness (after four hours) he complained of pain and inability to lift both the shoulders. The patient had been a known hypertensive and mild diabetic and had been having irregular treatment. In the past he had never sustained any injury over the shoulders.
The family doctor treated him for ten days with analgesics and local heat. In absence of relief the patient went to a nearby hospital where a diagnosis of periarthritis of shoulders was entertained and was treated with phenylbutazone and local application or a counter-irritent ointment over the shoulders. Since the symptoms did not subside, roentgenograms were taken and a diagnosis of bilateral fracture-dislocation of shoulder was made. The patient was then referred to us about six weeks after the injury.
On examination, the shoulders were adducted with a flat contour. An attempt to move the shoulders was painful and there was complete loss of abduction, flexion and extension on either side. The elbows and hands on both sides were not affected. Roentgenograms revealed bilateral anterior fracture-dislocation of the shoulder with gross communication at the fracture site along with evidence of new bone formation See [Figure 1] on page 136b. His B.P. was 170/105 mm of Hg., blood sugar, 140 mg% blood urea 48 mg%. Urine showed green colour on benedict's test. The haemogram and other relevant investigations were within normal limits.
Considering the delay and the discouraging results usually obtained after surgery in such cases, he was put on assisted shoulder exercises, electrical stimulations and infra-red therapy. Repeat roentgenograms after 6 months revealed no evidence of union at the fracture site on either side. Since the gravity of the situation was explained to the patient, he co-operated with the therapists in achieving the goal of a successful outcome. He could get 70° abduction on either side and could carry out his usual activities without much difficulty See [Figure 2] on page 136b. The patient was happy to see the encouraging results of the therapy.
| :: Discussion|| |
Although shoulder is the most commonly dislocated in the body, occurrence of bilateral fracture-dislocation during convulsive episode is rare and only a few cases have been described. , Absence of obvious trauma often leads to initial diagnostic errors and are accepted as minor shoulder ailment like periarthritis. Since the original damage is of a serious nature, delay in diagnosis further aggravates the problem.
In most of the reported cases the victim has been prevented from falling. Violent uncoordinated muscular contractions especially in abduction and external rotation against resistance has been described as a possible cause. During the initial phase of convulsion the scapulae are brought forward violently against the humeral head and results in locking in `Pivotal Position'. , When the rescuer holds the patient by arm, a dislocation or a fracture-dislocation results.
It has been observed that the result obtained in an average fracture-dislocation of the shoulder is seldom satisfactory if by a good result, one means the restoration of the part to normal function. The restoration of normal anatomy is rare as it makes closed reduction hard to achieve and open reduction difficult. Both in operated and unoperated cases avascular necrosis of the humeral head and degenerative changes are quite common. , The result in addition to being influenced primarily by the severity of the bone injury is also affected by other factors like soft tissue injury particularly the rotator-cuff. Excision of the humeral head, a prosthetic replacement and arthrodesis are the recommended surgical procedures. , Removal of the head of the humerus with or without transposition of the rotator-cuff has been well tried but it leads to an unstable joint and the mobility and power of abduction are greately reduced.
In our case, taking into account the delay in diagnosis and considering the poor result usually obtained after surgery, it was decided to put the patient on conservative regime. The functional result was reasonable and to the patient's satisfaction. The other factors like patient's age, health and willingness to work and to regain good strength and motion in the injured joint do play a definite role in the out-come of the overall results. A, patient may be well satisfied with a reasonable function of the joint. The surgeon at the same tine may well be dissatisfied with the same result because of serious limitation of extremes of movements and because of the X-ray results which is disturbingly poor.
| :: Acknowledgement|| |
I am thankful to Dr. D. B. Bisht, Principal.; Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry-6 for his kind permission to publish this case report.
| :: References|| |
|1.||Kelly, J. P.: Fractures complicating electro convulsive therapy and chronic epilepsy. J. Bone and Joint Surg., 36-B: 70-79. 1954. |
|2.||Knight, R. A. and Mayne, J. A.: Communited fracture and fracture dislocations involving articular surface of the humeral head. J. Bone and Joint Surg.. 39-A: 1343-1355, 1957. |
|3.||Neer, C. S., Brow, T. H. (Jr.) and McLaughlin, H.L.: Fracture of the neck of the humerus with dislocation of the head fragment. Ann. Surg., 85: 252-258, 1953 |
|4.||Neer, C. S.: Prosthetic replacement of the humeral head. Surg. Clin. N. Amer., 43: 1581-1597, 1963. |
|5.||Neviaser, J. S.: Complicated fractures and dislocations about the shoulder joint. J. Bone & Joint Surg., 44-A: 984-998, 1962. |
|6.||Pear, B. L.: Bilateral posterior fracture dislocation of the shoulder an unusual complication of a convulsive seizure. The New Eng. J. of Med., 283: 135-136, 1970. |
[Figure 1], [Figure 2]