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Bilateral anterior glenohumeral dislocation in a weightlifter
254
Injury: the British Journal of Accident Surgery (1990) Vol. 21/No.
Discussion Dislocations of the lunate, perilunar dislocations and fracture-dislocations are now widely accepted as different stages of the same injury pattern (Green and O’Brien, 198O), but all are uncommon injuries accounting for less than 10 per cent of all carpal injuries. With regard to our case we were only able to find one similar injury occurring during weightlifting, but even that involved a fall in an amateur lifter while lifting only 22.68 kg (501bs) and was not a spontaneous dislocation (Wooton and Jones, 1988). Carpal dislocation is most commonly seen in the 20-35year-old age group (Panting et al., 1984) and is nearly always the result of considerable force, with the most common methods of injury being either a fall from a building or ladder, or involvement in a road traffic accident (Adkinson and Chapman, 1982). Associated severe injuries are rare; median nerve symptoms are common (up to 57 per cent), but long-term deficit is very uncommon (Rawlings, 1981).
Analysis of the pathomechanics of injury indicate that the precise nature of the final injury is determined by the type, magnitude and duration of the force, the position of the hand at the time of impact, and the properties of the bones and ligaments. With regard to lunate dislocation it is now widely accepted that the forces involved are extension (or hyperextension), ulnar deviation and varying degrees of supination (Mayfield, 1980). Watching a weightlifter performing a lift of any type, clearly illustrates how all these forces interact during the lift.
4
The wrist is in extension (large hyperextensive forces during the actual lift) with marked degrees of both ulnar deviation and supination whilst holding and lifting the bar.
References Adkinson J. W. and Chapman M. W. (1982) Treatment of acute lunate and perilunate dislocations. Clin. Orfhop. 164,199. Green D. P. and O’Brien G. T. (1980) Classification and management of carpal dislocations. C/in. orthop. 149,~. Mayfield J. K. (1980) Mechanisms of carpal injury. C/in. Or&p. 149,45. Panting A. L., Lamb D. W., Noble J. et al. (1984) Dislocations of the lunate with and without fractures of the scaphoid. J. Bone Joint surg. 66B, 391. Rawlings I. D. (1981) Management of dislocations of the carpal lunate. Irrjuy 12,319. Wooton J. R. and Jones D. H. (1988) An unusual weightlifting injury. lrzjuy 19, 446.
Paper accepted 30 November
1989.
l$tcesfs for reprints shouMbe dressed to: D. C. Lewis, Department of Surgery, University Hospital of Wales, Heath Park, Cardiff CF4 4xW.
Bilateral anterior glenohumeral weightlifter
dislocation in a
N. Mafhlli* and H. M. T. MUail ‘Institute of Child Health, Sports Medicine Laboratory, London, UK ‘Chase Farm Hospital, Enfield, Middlesex, UK
London and The Hospital for Sick Children, Great Ormond
A case of bilateralanterior dislocation of theshoulderjoinf is described.The patient was a recreationalweightlifferwho sustainedfhe injury while petformingthe @d-over’ bench movewmf usingfree weighfs.Probably, theshouMers dislocatedwhen the force developedby the periarficular muscleswas lessthan the a&al weightfhaf the pafienfwas fryingto lift. The needfor stricter sufefy rulesand bettersupervisionin healthclubs is sfressed.
Introduction In the past few years, there has been an explosion in the popularity of fitness programmes. Weightlifting is a very popular activity. Musculoskeletal injuries due to weightlifting have been reported with increased frequency (Ryan and 0 1990 Butterworth-Heinemann 0020-1383/90/040254-03
Ltd
Street,
Salciccioli, 1976; Brown and Kimball, 1983). Recently, the death of a 9-year-old boy due to an’accident with weightlifting equipment has been reported (George et al., 1989).
Case report A 31-year-old Caucasian male recreational weightlifter came to the accident and emergency department complaining of sudden bilateral shoulder pain. He was training in the ‘pull-over’ bench movement when he felt that his shoulders were going ‘out of place’ and could not continue his session. The patient reasoned that the weight must have been in the most cephalad position when the dislocation occurred. The patient had no past medical history of epilepsy or convulsions and had taken no alcohol for about 24 h before the training session.
255
Case reports
a
a
b Figure I. Anteroposterior
view of both shoulders.
On examination he had clinical anterior glenohumeral dislocation with a small area of hypoaesthesia on the lateral aspect of the left detoid. The dislocations were confirmed radiologically (F&res 7 and2). A bilateral Kocher’s manoeuvre was successfully performed under SO mg of intramuscular pethidine and 10 mg of intravenous diazepam (Figure 3). Recovery was uneventful.
Discussion The glenohumeral joint is prone to dislocations, as its stability relies on the integrity of the surrounding soft structures. Bilateral synchronous dislocation of the shoulder is a rare injury (McFie, 1976, Segal et al., 1977; Brown, 1984). It is
b Figure 2. Lateral view of both shoulders. An anterior disloc :al:ion is evident bilaterally.
256
Injury: the British Journal of Accident Surgery (1990) Vol. 21/No.4
glenohumeral instability (Codman, 1934). In the patient reported, the shoulders were abducted, and connected by the weightlifting bar. The movement he was trying to perform was to bring the loaded bar from a cephalad position to the knees without flexing the elbows while lying on a bench. The shoulder joints were thus kept in fixed rotation. When the bar was parallel to the ground, muscles and joint capsule were probably the only stabilizing structures available. If the load on the bar is greater than muscular strength at that angle, a dislocation may occur, as the capsule is not strong enough to withstand forces of this magnitude, A number of articles have expressed serious concern about the safety of weightlifting apparatus, especially when they are in the form of ‘free weights’ (Brown and Kimball, 1983; George et al., 1989). The accident reported emphasizes the risk of serious injuries, especially in the usually poorly supervised and informal environment of a health gymnasium where non-competitive weightlifters train.
a
References
b Figure 3. Anteroposterior
view after reduction. Repositioning is
shown.
generally associated with epileptic seizures, electrocution and diabetic hypoglycaemia (Carew-McCall, 1980; Brown, 1984; Litchfield et al., 1988), and may be produced voluntarily (Reiser and Wilson, 1961). Only one case was connected with a sporting activity, namely water-skiing (Segal et al., 1977). Forces acting on both shoulders simultaneously may produce a bilateral dislocation from several mechanisms (Brown, 1984). Traction accounted for some of the lesions described (McFie, 1976; Segal et al., 1977). The humeral heads can be displaced by forces directed along the longitudinal axis of the arm when a simultaneous deceleration force is applied, as in a fall on outstretched hands. Other possible mechanisms are a fall with the shoulders in fixed extension, abduction and internal rotation, or forced hyperabduction when the acromion acts as a pivot to lever the humeral head outside the joint. In the latter case, an erect bilateral dislocation is produced (Peiro et al., 1975). Full abduction is the pivotal position of maximum
Brown R. J. (1984) Bilateral dislocation of the shoulders. Irzjuq 15, 267. Brown E. W. and Kimball R. G. (1983) Medical history associated with adolescent powerlifting. Pediatrics 72,636. Carew-McCall M. (1980) Bilateral shoulder dislocation caused by electric shock. Br. ]. Ck Pmt. 34,251. Codman E. A. (1934) The Shoulder.Boston: Thomas Todd Co. George D. H., Stakiw K. and Wright C. J. (1989) Fatal accident with weight-lifting equipment: implications for safety standards. Can. Med. Assoc. 1. 140,925. Litchfield J. C., Subhedar V. Y., Beevers D. G. et al. (1988) Bilateral dislocation of the shoulders due to nocturnal hypoglycaemia. Postgrad. Med. ]. 64,450. McFie J. (1976) Bilateral anterior dislocation of the shoulders: a case report. Injliry 8,67. Peiro A., Ferrandis R. and Correa F. (1975) Bilateral erect dislocation of the shoulders. Injury 6,294. Reiser R. P. and Wilson C. L. (1961) Bilateral recurrent dislocation of the shoulder (atraumatic) in a thirteen-year-old girl. Report of an unusual case. 1. Bone]oint Surg. 43A, 553. Ryan J. R. and Salciccioli G. G. (1976) Fractures of the distal radial epiphysis in adolescent weight lifters. Am. ]. Sports Med. 4,26. Segal D., Yablon I. G., Lynch J. J. et al. (1977) Acute bilateral anterior dislocation of the shoulders. Clin. Orthop. 140,21.
Paper accepted 30 November
1989.
Requesfsfor repi& shmM be aaYressed to: N. Maffulli MD, Institute of Health, Sports Medicine Laboratory, 30 Guilford Street, London WCl, UK.
Injury: the British Journal of Accident Surgery (1990) Vol. 21/No.
Discussion Dislocations of the lunate, perilunar dislocations and fracture-dislocations are now widely accepted as different stages of the same injury pattern (Green and O’Brien, 198O), but all are uncommon injuries accounting for less than 10 per cent of all carpal injuries. With regard to our case we were only able to find one similar injury occurring during weightlifting, but even that involved a fall in an amateur lifter while lifting only 22.68 kg (501bs) and was not a spontaneous dislocation (Wooton and Jones, 1988). Carpal dislocation is most commonly seen in the 20-35year-old age group (Panting et al., 1984) and is nearly always the result of considerable force, with the most common methods of injury being either a fall from a building or ladder, or involvement in a road traffic accident (Adkinson and Chapman, 1982). Associated severe injuries are rare; median nerve symptoms are common (up to 57 per cent), but long-term deficit is very uncommon (Rawlings, 1981).
Analysis of the pathomechanics of injury indicate that the precise nature of the final injury is determined by the type, magnitude and duration of the force, the position of the hand at the time of impact, and the properties of the bones and ligaments. With regard to lunate dislocation it is now widely accepted that the forces involved are extension (or hyperextension), ulnar deviation and varying degrees of supination (Mayfield, 1980). Watching a weightlifter performing a lift of any type, clearly illustrates how all these forces interact during the lift.
4
The wrist is in extension (large hyperextensive forces during the actual lift) with marked degrees of both ulnar deviation and supination whilst holding and lifting the bar.
References Adkinson J. W. and Chapman M. W. (1982) Treatment of acute lunate and perilunate dislocations. Clin. Orfhop. 164,199. Green D. P. and O’Brien G. T. (1980) Classification and management of carpal dislocations. C/in. orthop. 149,~. Mayfield J. K. (1980) Mechanisms of carpal injury. C/in. Or&p. 149,45. Panting A. L., Lamb D. W., Noble J. et al. (1984) Dislocations of the lunate with and without fractures of the scaphoid. J. Bone Joint surg. 66B, 391. Rawlings I. D. (1981) Management of dislocations of the carpal lunate. Irrjuy 12,319. Wooton J. R. and Jones D. H. (1988) An unusual weightlifting injury. lrzjuy 19, 446.
Paper accepted 30 November
1989.
l$tcesfs for reprints shouMbe dressed to: D. C. Lewis, Department of Surgery, University Hospital of Wales, Heath Park, Cardiff CF4 4xW.
Bilateral anterior glenohumeral weightlifter
dislocation in a
N. Mafhlli* and H. M. T. MUail ‘Institute of Child Health, Sports Medicine Laboratory, London, UK ‘Chase Farm Hospital, Enfield, Middlesex, UK
London and The Hospital for Sick Children, Great Ormond
A case of bilateralanterior dislocation of theshoulderjoinf is described.The patient was a recreationalweightlifferwho sustainedfhe injury while petformingthe @d-over’ bench movewmf usingfree weighfs.Probably, theshouMers dislocatedwhen the force developedby the periarficular muscleswas lessthan the a&al weightfhaf the pafienfwas fryingto lift. The needfor stricter sufefy rulesand bettersupervisionin healthclubs is sfressed.
Introduction In the past few years, there has been an explosion in the popularity of fitness programmes. Weightlifting is a very popular activity. Musculoskeletal injuries due to weightlifting have been reported with increased frequency (Ryan and 0 1990 Butterworth-Heinemann 0020-1383/90/040254-03
Ltd
Street,
Salciccioli, 1976; Brown and Kimball, 1983). Recently, the death of a 9-year-old boy due to an’accident with weightlifting equipment has been reported (George et al., 1989).
Case report A 31-year-old Caucasian male recreational weightlifter came to the accident and emergency department complaining of sudden bilateral shoulder pain. He was training in the ‘pull-over’ bench movement when he felt that his shoulders were going ‘out of place’ and could not continue his session. The patient reasoned that the weight must have been in the most cephalad position when the dislocation occurred. The patient had no past medical history of epilepsy or convulsions and had taken no alcohol for about 24 h before the training session.
255
Case reports
a
a
b Figure I. Anteroposterior
view of both shoulders.
On examination he had clinical anterior glenohumeral dislocation with a small area of hypoaesthesia on the lateral aspect of the left detoid. The dislocations were confirmed radiologically (F&res 7 and2). A bilateral Kocher’s manoeuvre was successfully performed under SO mg of intramuscular pethidine and 10 mg of intravenous diazepam (Figure 3). Recovery was uneventful.
Discussion The glenohumeral joint is prone to dislocations, as its stability relies on the integrity of the surrounding soft structures. Bilateral synchronous dislocation of the shoulder is a rare injury (McFie, 1976, Segal et al., 1977; Brown, 1984). It is
b Figure 2. Lateral view of both shoulders. An anterior disloc :al:ion is evident bilaterally.
256
Injury: the British Journal of Accident Surgery (1990) Vol. 21/No.4
glenohumeral instability (Codman, 1934). In the patient reported, the shoulders were abducted, and connected by the weightlifting bar. The movement he was trying to perform was to bring the loaded bar from a cephalad position to the knees without flexing the elbows while lying on a bench. The shoulder joints were thus kept in fixed rotation. When the bar was parallel to the ground, muscles and joint capsule were probably the only stabilizing structures available. If the load on the bar is greater than muscular strength at that angle, a dislocation may occur, as the capsule is not strong enough to withstand forces of this magnitude, A number of articles have expressed serious concern about the safety of weightlifting apparatus, especially when they are in the form of ‘free weights’ (Brown and Kimball, 1983; George et al., 1989). The accident reported emphasizes the risk of serious injuries, especially in the usually poorly supervised and informal environment of a health gymnasium where non-competitive weightlifters train.
a
References
b Figure 3. Anteroposterior
view after reduction. Repositioning is
shown.
generally associated with epileptic seizures, electrocution and diabetic hypoglycaemia (Carew-McCall, 1980; Brown, 1984; Litchfield et al., 1988), and may be produced voluntarily (Reiser and Wilson, 1961). Only one case was connected with a sporting activity, namely water-skiing (Segal et al., 1977). Forces acting on both shoulders simultaneously may produce a bilateral dislocation from several mechanisms (Brown, 1984). Traction accounted for some of the lesions described (McFie, 1976; Segal et al., 1977). The humeral heads can be displaced by forces directed along the longitudinal axis of the arm when a simultaneous deceleration force is applied, as in a fall on outstretched hands. Other possible mechanisms are a fall with the shoulders in fixed extension, abduction and internal rotation, or forced hyperabduction when the acromion acts as a pivot to lever the humeral head outside the joint. In the latter case, an erect bilateral dislocation is produced (Peiro et al., 1975). Full abduction is the pivotal position of maximum
Brown R. J. (1984) Bilateral dislocation of the shoulders. Irzjuq 15, 267. Brown E. W. and Kimball R. G. (1983) Medical history associated with adolescent powerlifting. Pediatrics 72,636. Carew-McCall M. (1980) Bilateral shoulder dislocation caused by electric shock. Br. ]. Ck Pmt. 34,251. Codman E. A. (1934) The Shoulder.Boston: Thomas Todd Co. George D. H., Stakiw K. and Wright C. J. (1989) Fatal accident with weight-lifting equipment: implications for safety standards. Can. Med. Assoc. 1. 140,925. Litchfield J. C., Subhedar V. Y., Beevers D. G. et al. (1988) Bilateral dislocation of the shoulders due to nocturnal hypoglycaemia. Postgrad. Med. ]. 64,450. McFie J. (1976) Bilateral anterior dislocation of the shoulders: a case report. Injliry 8,67. Peiro A., Ferrandis R. and Correa F. (1975) Bilateral erect dislocation of the shoulders. Injury 6,294. Reiser R. P. and Wilson C. L. (1961) Bilateral recurrent dislocation of the shoulder (atraumatic) in a thirteen-year-old girl. Report of an unusual case. 1. Bone]oint Surg. 43A, 553. Ryan J. R. and Salciccioli G. G. (1976) Fractures of the distal radial epiphysis in adolescent weight lifters. Am. ]. Sports Med. 4,26. Segal D., Yablon I. G., Lynch J. J. et al. (1977) Acute bilateral anterior dislocation of the shoulders. Clin. Orthop. 140,21.
Paper accepted 30 November
1989.
Requesfsfor repi& shmM be aaYressed to: N. Maffulli MD, Institute of Health, Sports Medicine Laboratory, 30 Guilford Street, London WCl, UK.