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Anterior dislocation of the shoulders with bilateral brachial plexus injury
CASE REPORT brachial plexus injury; dislocation, shoulder, bilateral
Anterior Dislocation of the Shoulders With Bilateral Brachial Plexus Injury Mahendra P Mehta, MD, MRCS* Sam R Kottamasu, MDt Detroit, Michigan From the DePartment of Emergency Medicine, Mount Carmel Mercy Hospital;* and Pediatric Radiology, Henry Ford Hospital,t Detroit, Michigan. Received for publication July 18, 1988. Revision received December 27, 1988. Accepted for publication January 27, 1989. Address for reprints: Mahendra P Mehta, MD, MRCS (England), Department of Emergency Medicine, McLaren General Hospital, 401 S Baltenger Highway, Flint, Michigan 48532.
A case of bilateral anterior shoulder dislocation accompanied by bilateral brachial plexus injuries is presented. A 53-year-old man fell and landed on his c h a t and arms flexed at the elbows. The dislocations were satisfactorily reduced using the forward elevation, flexion maneuver. Electro, myography and nerve conduction studies confirmed bilateral brachial plexus lesions. Arthrogram of the right shoulder demonstrated a rotator cuff tear. The patient is undergoing physical therapy and making a slow recovery. [Mehta MP, Kottamasu SR: Anterior dislocation of the shoulders with bilateral brachial plexus injury. Ann Emerg Med May 1989;18: 589-591.] INTRODUCTION Dislocation of the shoulder is nearly always unilateral. Simultaneous bilateral posterior dislocation of the shoulders is uncommon in clinical practice but has been reported after convulsions and severe trauma. Bilateral anterior dislocation of the shoulders, however, is extremely rare. In a computer search of the English literature over the last 20 years, only eight reports of bilateral anterior dislocation of the shoulder were found. 1-8 In the same search, we were unable to find any reported case of anterior dislocation of shoulders with bilateral brachial plexus injuries. We report the first such case.
CASE REPORT A 53-year-old man was brought to the emergency department after he fell 20 ft, landing on his chest and arms flexed at the elbows. He complained of severe pain and paresthesiae in both upper extremities. Physical examination revealed an alert and awake patient in severe distress. His vital signs were blood pressure, 130/80 m m Hg; pulse, 90 and irregular; and respirations, 16; the airway was clear. He was placed on a cardiac monitor that showed ventricular bigeminy. This bigeminy was suppressed by the IV administration of lidocaine in a 75-mg bolus dose and drip at 3 mg/min. A follow-up 12-lead ECG was normal. The patient's cervical spine was immobilized With a Philadelphia collar, and a portable radiograph of the spine was normal. Examination of the Chest revealed bilateral, equal breath sounds, and the heart had no murmurs. He had marked tenderness over the Sternum, and radiographs dem~ onstrated an undisplaced fracture of the body. Palpation of the chest wall and abdomen were normal. Both upper extremities were extended at the elbows and externally rotated and abducted at the shoulders. The contour of the deltoid was lost on both sides, and the acromion appeared the most lateral part of the shoulder, suggesting dislocation of the glenohumeral joints. Shoulder radiographs confirmed bilateral subcoracoid dislocation w i t h o u t fractures (Figure). Neur01ogic examination was significant for diffuse weakness of the right upper extremity involving pr0mimal and distal muscle groups and marked diminution of sensation in Tt dermatome. The left upper extremity also showed diffuse motor weakness and hypoaesthesia in C s through C 7 nerve roots. Complete radiographic evaluation of the cervical spine and chest was unremarkable for any injury. Initial creatine phosphokinase was within normal limits. 148/589
Annals of Emergency Medicine
18:5 May 1989
FIGURE. Radiographs demonstrating
bilateral anterior subcoracoid dislocation of the shoulders. IV access was established with lactated Ringer's, and the patient was given 25 mg meperidine and l0 mg diazepam IV to achieve analgesia and sedation. The dislocations were easily reduced by the forward elevation and flexion method first described by Sir Astley Cooper. 9 Postreduction radiographs showed an anatomic reduction. The shoulders were immobilized with shoulder immobilizers. There was no change in the neurologic status in either extremity after the r e d u c t i o n . D i s t a l p u l s e s remained equal. The patient was admitted to cardiac care unit, and myocardial contusion was ruled out with sequential creatine p h o s p h o k i n a s e , echocardiography, and ECG. He was discharged on third hospital day. On the fourth day, he accidentally dislocated his left shoulder while trying to put on a shirt. Electromyography and nerve conduction studies were performed three weeks after the initial injury and confirmed bilateral brachial plexus injuries. A r t h r o g r a m of the right 18:5 May 1989
shoulder revealed a complete rotator cuff tear. The patient was placed on a transcutaneous electric nerve stimulator, and carbamazepine 300 mg three times daily and amitriptyline 25 mg three times daily for control of pain. Four months after the injury, the patient still had significant weakness and pain and was making a slow recovery. He is presently undergoing physical and occupational therapy.
DISCUSSION Dislocation of the shoulder may be the result of a direct or indirect force, the latter being the more common mechanism.2, 3 Excessive abduction, external rotation, and extension of the arm cause disruption of the muscles, ligaments, capsule, and the glenoid labrum, forcing the head from the articulation. The arm position after anterior dislocation is usually one of abduction and slight external rotation. The mechanisms of bilateral anterior dislocation, the extremity position after injury, and the a c c o m p a n y i n g reported complications are summarized (Table). The neurologic injuries associated w i t h a n t e r i o r d i s l o c a t i o n of the shoulder may involve brachial plexus Annals of Emergency Medicine
diffusely or, more commonly, a part of t h e p l e x u s (eg, c i r c u m f l e x nerve). 1°-12 The vascular injuries may be a result of laceration or thrombosis of axillary artery. Associated fractures of the head, neck, and tuberosities of the humerus may complicate a shoulder dislocation. Complications can include recurrent dislocation, rotator cuff tears, persistent pain, and stiffness. The incidence of pain and stiffness is higher in patients more than 40 years old. If the s y m p t o m s persist, an arthrogram should be obtained to rule out a rotator cuff injuryA3 Reduction of anterior dislocation of the shoulder can be achieved after adequate analgesia and sedation by a number of methods, the more commonly performed being the forward elevation maneuver, 9 Stimson's method, 14 and Kocher's maneuver. The incidence of reported neurologic sequelae after anterior dislocation of the shoulder varies from 5% to 75%.1°, 11 Neurologic complications are more c o m m o n than one might expect, and a thorough neurologic examination would likely confirm this. S u p r a c l a v i c u l a r plexus injuries have worse prognoses than injuries 590/149
SHOULDER DISLOCATIONS Mehta & Kottamasu
TABLE. M e c h a n i s m s
Author
of reported bilateral anterior shoulder dislocations
Mechanism
Jones ~ Hartney-Velazco 2 Carew-McColl 3 Tanzman4 Salem 5 Segal 6
Arm Position
Bench press Drug-induced seizure Electric shock, elevation Convulsion Electric shock Seizures (two) Water skiing Mcfie 7 Motorcycle Yadav8 Seizure Present case report Fall from ladder
*Abd-ext rotation, hyperextension Abd-ext rotation, hyperextension Abd-ext rotation Abd-ext rotation, hyperextension Abd-ext rotation, hyperextension Abd-ext rotation, hyperextension Abd-ext rotation, hyperextension Outstretched, internal rotation Abd-ext rotation, elevation Abd-ext rotation, elbow flexion
Sequelae
None None None None None Fracture, greater tuberosity Recurrent None Stiffness Bilateral injury, rotator cuff tears
*Abd, abduction; ext, extension. to t h e i n f r a c l a v i c u l a r p o r t i o n of t h e p l e x u s b e c a u s e t h e n e r v e s are i n j u r e d b y a s t r e t c h i n g force n e a r t h e i r p o i n t s of a n c h o r a g e n e a r t h e s p i n a l cord. lo T h e e x c e p t i o n to t h i s is i n j u r y to t h e axillary (circumflex) nerve, which h a s a p o o r p r o g n o s i s . 15 A l t h o u g h t h e p r o g n o s i s for n e u r o l o g i c r e c o v e r y is good, f u n c t i o n a l r e c o v e r y is i m p a i r e d b y s t i f f n e s s a n d pain. It is, t h e r e f o r e , important to reduce a dislocated j o i n t as s o o n as p o s s i b l e a n d b e g i n early joint motion, especially in the o l d e r p a t i e n t . S u r g i c a l e x p l o r a t i o n of c l o s e d b r a c h i a l p l e x u s i n j u r i e s is n o t recommended because most lesions are s i m p l e n e u r o p r a x i a . 1~
SUMMARY B i l a t e r a l a n t e r i o r d i s l o c a t i o n of t h e s h o u l d e r s is a rare o r t h o p e d i c e n t i t y . W e h a v e d e s c r i b e d a case of b i l a t e r a l a n t e r i o r d i s l o c a t i o n of t h e s h o u l d e r s with bilateral brachial plexus injury i n a 5 3 - y e a r - o l d m a n w h o f e l l forw a r d f r o m a h e i g h t of 20 ft. N e u r o logic injury must be considered in
150/591
e v e r y p a t i e n t w i t h a s h o u l d e r dislocation, and every shoulder dislocat i o n m u s t b e r e d u c e d as s o o n as possible, e s p e c i a l l y w h e n a n e u r o l o g i c or v a s c u l a r c o m p l i c a t i o n exists. I n addit i o n , e a r l y j o i n t e x e r c i s e s s h o u l d be started, particularly in older patients.
The authors wish to t h a n k Billie Crabtree for her assistance in preparing the manuscript.
REFERENCES 1. Jones M: Bilateral anterior dislocation of the shoulders due to the bench press Iletter). Br J Sports Med 1987;3:I39. 2. Harmey-Velazco K, Velazco A, Fleming L: Bilateral anterior dislocation of the shoulder. South Med [ 1984;77:1340-1341. 3. Carew-McColl M: Bilateral anterior dislocation of shoulder caused by electric shock. Br J C]in Pz'act 1980;34:251-254. 4. Tanzrnan M, Segev Z, Kaufman B: Missed bilateral anterior dislocation of the shoulder following convulsions. Harefuah 1983;105~266. 5. Salem M: Bilateral anterior fracture dislocation of the shoulder joints due to severe electric
Annals of Emergency Medicine
shock. Irljury 1983;14:361-363. 6. Segal D, Yablon IG, Lynch JJ, et al: Acute bilateral anterior dislocation of the shoulders. Clin Orthop 1979;140:21-22. 7. Mcfie J: Bilateral anterior dislocation of the shoulders: A case report. Injury 1986;8:67-69. 8. Yadav SS: Bilateral simultaneous fractureDislocation of the shoulder due to muscular violence. [ Postgrad Med 1977;23:137-139. 9. Cooper Sir A: A Treatise on Dislocation and on Fractures of the Joints. Boston, Lilly, Welt and Hendee, 1932, p 9. 10. Barnes R: Traction injuries of the brachial plexus in adults. J Bone Joint Surg 1934;31B:10. 11. Bateman JE: An operative approach to supraclavicular brachial plexus injuries. J Bone Joint Surg 1949;31B:34. 12. Seddon HJ (ed): Peripheral Nerve Injuries by Nerve Injuries. Medical Research Council Report Series Number 282. Her Majesty's Stationery Office. London, I954. 13. Neviaser RJ: Ruptures of the rotator cuff. Orthop Clin North A m I987;18:387-394. 14. Stimson LA: An easy method of reduction of the shoulder and the hip. Med Rec 1900;57: 356-357. 15. Bonney G: Injuries of the brachial plexus. Br [ Hospital Med 1974;April:567-578.
18:5 May 1989
Anterior Dislocation of the Shoulders With Bilateral Brachial Plexus Injury Mahendra P Mehta, MD, MRCS* Sam R Kottamasu, MDt Detroit, Michigan From the DePartment of Emergency Medicine, Mount Carmel Mercy Hospital;* and Pediatric Radiology, Henry Ford Hospital,t Detroit, Michigan. Received for publication July 18, 1988. Revision received December 27, 1988. Accepted for publication January 27, 1989. Address for reprints: Mahendra P Mehta, MD, MRCS (England), Department of Emergency Medicine, McLaren General Hospital, 401 S Baltenger Highway, Flint, Michigan 48532.
A case of bilateral anterior shoulder dislocation accompanied by bilateral brachial plexus injuries is presented. A 53-year-old man fell and landed on his c h a t and arms flexed at the elbows. The dislocations were satisfactorily reduced using the forward elevation, flexion maneuver. Electro, myography and nerve conduction studies confirmed bilateral brachial plexus lesions. Arthrogram of the right shoulder demonstrated a rotator cuff tear. The patient is undergoing physical therapy and making a slow recovery. [Mehta MP, Kottamasu SR: Anterior dislocation of the shoulders with bilateral brachial plexus injury. Ann Emerg Med May 1989;18: 589-591.] INTRODUCTION Dislocation of the shoulder is nearly always unilateral. Simultaneous bilateral posterior dislocation of the shoulders is uncommon in clinical practice but has been reported after convulsions and severe trauma. Bilateral anterior dislocation of the shoulders, however, is extremely rare. In a computer search of the English literature over the last 20 years, only eight reports of bilateral anterior dislocation of the shoulder were found. 1-8 In the same search, we were unable to find any reported case of anterior dislocation of shoulders with bilateral brachial plexus injuries. We report the first such case.
CASE REPORT A 53-year-old man was brought to the emergency department after he fell 20 ft, landing on his chest and arms flexed at the elbows. He complained of severe pain and paresthesiae in both upper extremities. Physical examination revealed an alert and awake patient in severe distress. His vital signs were blood pressure, 130/80 m m Hg; pulse, 90 and irregular; and respirations, 16; the airway was clear. He was placed on a cardiac monitor that showed ventricular bigeminy. This bigeminy was suppressed by the IV administration of lidocaine in a 75-mg bolus dose and drip at 3 mg/min. A follow-up 12-lead ECG was normal. The patient's cervical spine was immobilized With a Philadelphia collar, and a portable radiograph of the spine was normal. Examination of the Chest revealed bilateral, equal breath sounds, and the heart had no murmurs. He had marked tenderness over the Sternum, and radiographs dem~ onstrated an undisplaced fracture of the body. Palpation of the chest wall and abdomen were normal. Both upper extremities were extended at the elbows and externally rotated and abducted at the shoulders. The contour of the deltoid was lost on both sides, and the acromion appeared the most lateral part of the shoulder, suggesting dislocation of the glenohumeral joints. Shoulder radiographs confirmed bilateral subcoracoid dislocation w i t h o u t fractures (Figure). Neur01ogic examination was significant for diffuse weakness of the right upper extremity involving pr0mimal and distal muscle groups and marked diminution of sensation in Tt dermatome. The left upper extremity also showed diffuse motor weakness and hypoaesthesia in C s through C 7 nerve roots. Complete radiographic evaluation of the cervical spine and chest was unremarkable for any injury. Initial creatine phosphokinase was within normal limits. 148/589
Annals of Emergency Medicine
18:5 May 1989
FIGURE. Radiographs demonstrating
bilateral anterior subcoracoid dislocation of the shoulders. IV access was established with lactated Ringer's, and the patient was given 25 mg meperidine and l0 mg diazepam IV to achieve analgesia and sedation. The dislocations were easily reduced by the forward elevation and flexion method first described by Sir Astley Cooper. 9 Postreduction radiographs showed an anatomic reduction. The shoulders were immobilized with shoulder immobilizers. There was no change in the neurologic status in either extremity after the r e d u c t i o n . D i s t a l p u l s e s remained equal. The patient was admitted to cardiac care unit, and myocardial contusion was ruled out with sequential creatine p h o s p h o k i n a s e , echocardiography, and ECG. He was discharged on third hospital day. On the fourth day, he accidentally dislocated his left shoulder while trying to put on a shirt. Electromyography and nerve conduction studies were performed three weeks after the initial injury and confirmed bilateral brachial plexus injuries. A r t h r o g r a m of the right 18:5 May 1989
shoulder revealed a complete rotator cuff tear. The patient was placed on a transcutaneous electric nerve stimulator, and carbamazepine 300 mg three times daily and amitriptyline 25 mg three times daily for control of pain. Four months after the injury, the patient still had significant weakness and pain and was making a slow recovery. He is presently undergoing physical and occupational therapy.
DISCUSSION Dislocation of the shoulder may be the result of a direct or indirect force, the latter being the more common mechanism.2, 3 Excessive abduction, external rotation, and extension of the arm cause disruption of the muscles, ligaments, capsule, and the glenoid labrum, forcing the head from the articulation. The arm position after anterior dislocation is usually one of abduction and slight external rotation. The mechanisms of bilateral anterior dislocation, the extremity position after injury, and the a c c o m p a n y i n g reported complications are summarized (Table). The neurologic injuries associated w i t h a n t e r i o r d i s l o c a t i o n of the shoulder may involve brachial plexus Annals of Emergency Medicine
diffusely or, more commonly, a part of t h e p l e x u s (eg, c i r c u m f l e x nerve). 1°-12 The vascular injuries may be a result of laceration or thrombosis of axillary artery. Associated fractures of the head, neck, and tuberosities of the humerus may complicate a shoulder dislocation. Complications can include recurrent dislocation, rotator cuff tears, persistent pain, and stiffness. The incidence of pain and stiffness is higher in patients more than 40 years old. If the s y m p t o m s persist, an arthrogram should be obtained to rule out a rotator cuff injuryA3 Reduction of anterior dislocation of the shoulder can be achieved after adequate analgesia and sedation by a number of methods, the more commonly performed being the forward elevation maneuver, 9 Stimson's method, 14 and Kocher's maneuver. The incidence of reported neurologic sequelae after anterior dislocation of the shoulder varies from 5% to 75%.1°, 11 Neurologic complications are more c o m m o n than one might expect, and a thorough neurologic examination would likely confirm this. S u p r a c l a v i c u l a r plexus injuries have worse prognoses than injuries 590/149
SHOULDER DISLOCATIONS Mehta & Kottamasu
TABLE. M e c h a n i s m s
Author
of reported bilateral anterior shoulder dislocations
Mechanism
Jones ~ Hartney-Velazco 2 Carew-McColl 3 Tanzman4 Salem 5 Segal 6
Arm Position
Bench press Drug-induced seizure Electric shock, elevation Convulsion Electric shock Seizures (two) Water skiing Mcfie 7 Motorcycle Yadav8 Seizure Present case report Fall from ladder
*Abd-ext rotation, hyperextension Abd-ext rotation, hyperextension Abd-ext rotation Abd-ext rotation, hyperextension Abd-ext rotation, hyperextension Abd-ext rotation, hyperextension Abd-ext rotation, hyperextension Outstretched, internal rotation Abd-ext rotation, elevation Abd-ext rotation, elbow flexion
Sequelae
None None None None None Fracture, greater tuberosity Recurrent None Stiffness Bilateral injury, rotator cuff tears
*Abd, abduction; ext, extension. to t h e i n f r a c l a v i c u l a r p o r t i o n of t h e p l e x u s b e c a u s e t h e n e r v e s are i n j u r e d b y a s t r e t c h i n g force n e a r t h e i r p o i n t s of a n c h o r a g e n e a r t h e s p i n a l cord. lo T h e e x c e p t i o n to t h i s is i n j u r y to t h e axillary (circumflex) nerve, which h a s a p o o r p r o g n o s i s . 15 A l t h o u g h t h e p r o g n o s i s for n e u r o l o g i c r e c o v e r y is good, f u n c t i o n a l r e c o v e r y is i m p a i r e d b y s t i f f n e s s a n d pain. It is, t h e r e f o r e , important to reduce a dislocated j o i n t as s o o n as p o s s i b l e a n d b e g i n early joint motion, especially in the o l d e r p a t i e n t . S u r g i c a l e x p l o r a t i o n of c l o s e d b r a c h i a l p l e x u s i n j u r i e s is n o t recommended because most lesions are s i m p l e n e u r o p r a x i a . 1~
SUMMARY B i l a t e r a l a n t e r i o r d i s l o c a t i o n of t h e s h o u l d e r s is a rare o r t h o p e d i c e n t i t y . W e h a v e d e s c r i b e d a case of b i l a t e r a l a n t e r i o r d i s l o c a t i o n of t h e s h o u l d e r s with bilateral brachial plexus injury i n a 5 3 - y e a r - o l d m a n w h o f e l l forw a r d f r o m a h e i g h t of 20 ft. N e u r o logic injury must be considered in
150/591
e v e r y p a t i e n t w i t h a s h o u l d e r dislocation, and every shoulder dislocat i o n m u s t b e r e d u c e d as s o o n as possible, e s p e c i a l l y w h e n a n e u r o l o g i c or v a s c u l a r c o m p l i c a t i o n exists. I n addit i o n , e a r l y j o i n t e x e r c i s e s s h o u l d be started, particularly in older patients.
The authors wish to t h a n k Billie Crabtree for her assistance in preparing the manuscript.
REFERENCES 1. Jones M: Bilateral anterior dislocation of the shoulders due to the bench press Iletter). Br J Sports Med 1987;3:I39. 2. Harmey-Velazco K, Velazco A, Fleming L: Bilateral anterior dislocation of the shoulder. South Med [ 1984;77:1340-1341. 3. Carew-McColl M: Bilateral anterior dislocation of shoulder caused by electric shock. Br J C]in Pz'act 1980;34:251-254. 4. Tanzrnan M, Segev Z, Kaufman B: Missed bilateral anterior dislocation of the shoulder following convulsions. Harefuah 1983;105~266. 5. Salem M: Bilateral anterior fracture dislocation of the shoulder joints due to severe electric
Annals of Emergency Medicine
shock. Irljury 1983;14:361-363. 6. Segal D, Yablon IG, Lynch JJ, et al: Acute bilateral anterior dislocation of the shoulders. Clin Orthop 1979;140:21-22. 7. Mcfie J: Bilateral anterior dislocation of the shoulders: A case report. Injury 1986;8:67-69. 8. Yadav SS: Bilateral simultaneous fractureDislocation of the shoulder due to muscular violence. [ Postgrad Med 1977;23:137-139. 9. Cooper Sir A: A Treatise on Dislocation and on Fractures of the Joints. Boston, Lilly, Welt and Hendee, 1932, p 9. 10. Barnes R: Traction injuries of the brachial plexus in adults. J Bone Joint Surg 1934;31B:10. 11. Bateman JE: An operative approach to supraclavicular brachial plexus injuries. J Bone Joint Surg 1949;31B:34. 12. Seddon HJ (ed): Peripheral Nerve Injuries by Nerve Injuries. Medical Research Council Report Series Number 282. Her Majesty's Stationery Office. London, I954. 13. Neviaser RJ: Ruptures of the rotator cuff. Orthop Clin North A m I987;18:387-394. 14. Stimson LA: An easy method of reduction of the shoulder and the hip. Med Rec 1900;57: 356-357. 15. Bonney G: Injuries of the brachial plexus. Br [ Hospital Med 1974;April:567-578.
18:5 May 1989