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WITHDRAWN: Posterior dislocation of the shoulder: a case report
JCOT37_proof ■ 25 January 2013 ■ 1/3 j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a u m a x x x ( 2 0 1 3 ) 1 e3
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Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/jcot
Case Report
Posterior dislocation of the shoulder: A case report Q4 Q1
Fayc¸al Dlimi a,*, Mustapha Mahfoud b, Saleh Berrada Mohamed b, Ahmed El Bardouni b, Moradh El Yaacoubi b a b
Department of Orthopaedic Surgery and Traumatology, University Hospital Center, Ibn Sina, Rabat, Morocco Professor, Department of Orthopaedic Surgery and Traumatology, University Hospital Center, Ibn Sina, Rabat, Morocco
article info
abstract
Article history:
Traumatic posterior glenohumeral dislocations are rare and make an accurate diagnosis
Received 1 March 2011
frequently missed because of the absence of characteristic symptoms. These injuries are
Accepted 16 January 2013
exceptional in elderly patients. A systematization of the clinical and radiological approach,
Available online xxx
leads to an early diagnosis and allows a prompt reduction. A 75-year-old woman presented with pain and restriction of movement of her left shoulder as a result of a stair fall. Her left
Keywords:
arm was adducted and internally rotated. Radiographs revealed the posterior shoulder
Axillary view
dislocation. The patient was treated with closed manipulation and her arm immobilized
Closed reduction
for 3 weeks. Results after one-year follow-up were satisfactory with correct range of mo-
Posterior dislocation
tion and no redislocations occurring.
Shoulder dislocation
1.
Introduction
Although the shoulder is the most frequently dislocated joint, posterior dislocation is rare and creates a diagnostic trap for unwary surgeon.1 It represents only 1%e4% of all shoulder dislocations.2 Such dislocations are usually caused by epileptic seizures, electrocution including electroconvulsive therapy and extreme trauma (Triple “E” syndrome)3 due to a fall with axial stress on flexed, internally rotated and adducted shoulders.4e6 However, posterior dislocation in elderly is exceptional and makes difficulties in diagnosis which often lead to delayed treatment, sometimes with consequent sequelae. Some clinical signs can help the examiner to suspect the dislocation. Even the routine antero-posterior roentgenogram may provide a few clues to diagnosis but the axillary view is mandatory to verify diagnosis. We report a 75year-old-woman with traumatic posterior dislocation of the left shoulder.
Copyright ª 2013, Delhi Orthopaedic Association. All rights reserved.
2.
Case report
A 75-year-old woman presented to the emergency department complaining of acute pain and stiffness of her left shoulder following a fall from stairs. Her left arm was carefully held against the chest wall with the shoulder adducted and internally rotated. She had no history of seizure, epilepsy, alcohol intake or previous shoulder dislocation. Physical examination revealed swelling and tenderness in the posterior area of the shoulder, but luckily, the patient did not suffer from any neurological or vascular injuries (Fig. 1). The anteroposterior view revealed a light-bulb sign and an overlap of the glenoid rim and the humeral head (Fig. 2). The axillary view was not obtained due to pain and reduced mobility. Closed reduction was performed by flexion and adduction of the shoulder, traction on the affected extremity and direct pressure applied from behind to push the humeral head into the socket. Reduction was confirmed by radiographs and the shoulder
* Corresponding author. Tel.: þ212 610877533. E-mail address: [email protected] (F. Dlimi). 0976-5662/$ e see front matter Copyright ª 2013, Delhi Orthopaedic Association. All rights reserved. http://dx.doi.org/10.1016/j.jcot.2013.01.004
Please cite this article in press as: Dlimi F, et al., Posterior dislocation of the shoulder: A case report, Journal of Clinical Orthopaedics and Trauma (2013), http://dx.doi.org/10.1016/j.jcot.2013.01.004
Q2
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130
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j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a u m a x x x ( 2 0 1 3 ) 1 e3
Fig. 1 e Clinical appearance of posterior dislocation with swelling of the left shoulder.
was immobilized in adduction and internal rotation for 3 weeks (Fig. 3). The patient received regular physiotherapy and was able to perform her daily activities 2 months later. At one-year follow-up, the outcome was satisfactory and the shoulder was stable and painless with correct range of motion.
3.
Discussion
Posterior dislocation of the shoulder was first described by Cooper in 1839 in an epileptic patient.7 It’s an uncommon injury and its incidence in the literature is 2.17%.8 It’s exceptional in elderly patients. The main causes of posterior dislocation are trauma and seizure9 but majority are due to indirect force.8,10,11 Factors such as position of the arm and muscle weakness must also be considered.8,12 Posterior dislocation of the shoulder is the most commonly missed major joint dislocation in the body.8 It is commonly associated with an impaction or “encoche” fracture of the humeral head which causes locking of the humeral head behind the glenoid.13 The diagnosis of posterior dislocation is frequently missed,2,14,15 probably because of the injury’s relative rarity, inadequate physical examination and difficulty in interpreting radiographs.3 Even orthopaedic surgeons initially misdiagnose 60% of posterior shoulder dislocations, and the correct diagnosis is often delayed for months or years.16 At this stage, dislocation becomes chronic and difficult to treat.17 An upper limb with adduction and internal rotation is
Fig. 3 e Check X-ray showing reduced joint.
characteristic of posterior dislocation of the shoulder. The physical characteristic findings described by Mclaughlin1 include an increased palpable prominence of the coracoid, decreased anterior prominence of humeral head, increased palpable posterior prominence of the humeral head below the acromion, marked limitation of abduction and complete absence of external rotation with a fixed internal rotation deformity. Multidirectional radiographs combined with computed tomography (CT) are recommended to make an accurate and early diagnosis.15,18 Radiographs in AP, scapula Y, and axillary views are necessary.19 Signs indicating posterior dislocation of the shoulder on the AP view are the positive rim sign, the absence of the half-moon overlap, the light-bulb sign and the trough line.20,21 Although, the AP X-ray may appear deceptively normal12 and the axillary view is often not obtained routinely. Failure to take adequate radiographs can also constitute a frequent cause of misdiagnosis.22 CT scan is superior to routine radiographs in revealing the posterior dislocation of the shoulder and the osseous abnormalities and may be useful for planning the reduction procedure.15,18 MR imaging is not described as being necessary for mapping soft tissue damage because rotator cuff injury is extremely rare in posterior shoulder dislocations.23 Closed reduction is often obtained
Fig. 2 e Radiographs of the shoulder demonstrate posterior dislocation. Please cite this article in press as: Dlimi F, et al., Posterior dislocation of the shoulder: A case report, Journal of Clinical Orthopaedics and Trauma (2013), http://dx.doi.org/10.1016/j.jcot.2013.01.004
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under general anaesthesia. Patient with locked posterior dislocation should be treated based on the general condition and needs of patient, the duration of dislocation, the size of impression defect and the experience of surgeon.8 Unsuccessful closed reduction are essentially due to a large impression fracture, delayed diagnosis of the dislocation, and anatomical neck fracture.18,24 Surgical intervention is necessary for old unreduced posterior dislocations. The shoulder should be immobilized after reduction and rehabilitation with progressive passive and active physiotherapy is mandatory.
4.
Conclusion
Posterior dislocation of the shoulder can also affect elderly patients. Its diagnosis is easily missed because of the injury’s rarity making therapeutic difficulties and unfavourable prognosis. Multidirectional radiographs and computed tomography are necessary to make an accurate and early diagnosis which requires a high index of suspicion. Prompt reduction and good rehabilitation lead to satisfactory results. Surgery is reserved for old unreduced posterior dislocations.
Funding None.
Conflicts of interest No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Q3
Authorship All authors had access to the data and a role in writing the manuscript.
Acknowledgements This study was self-funded.
references
1. McLaughlin HL. Posterior dislocation of the shoulder. J Bone Joint Surg Am. 1952;34:584e590.
3
2. Perron AD, Jones RL. Posterior shoulder dislocation: avoiding a missed diagnosis. Am J Emerg Med. 2000;18:189e191. 3. Brackstone M, Patterson SD, Kertesz A. Triple “E” syndrome: bilateral locked posterior fracture dislocation of the shoulders. Neurology. 2001;56(10):1403e1404. 4. Becker R, Weyand F. Die seltene, doppelseitige hintere Schulterluxation. Unfallschirurg. 1990;93:66e68. 5. Blasier RB, Burkus JK. Management of posterior fracturedislocations of the shoulder. Clin Orthop Relat Res. 1988;232:197e204. 6. Martens C, Hessels G. Bilateral posterior four-part fracturedislocation of the shoulder. Acta Orthop Belg. 1995;61(3):249e254. 7. Cooper Sir A. On the dislocation of the Os Humeri upon the dorsum scapulae, and upon fractures near the shoulder-joint. Guys Hosp Rep. 1839;4:265. 8. Rockwood C, Green C. Fracture in Adults. 2nd ed. Philadelphia etc: J B Lippincott & Co; 1975:806e856. 9. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956;38:957e977. 10. Apley G. In: Solomon L, ed. Apley’s System of Orthopedics and Fracture. 6th ed. Butterworth & Co; 1982:383. 11. McGlone R, Gosnold JK. Posterior dislocation of shoulder and bilateral hip fractures caused by epileptic seizure. Arch Emerg Med. 1987;4:115e116. 12. Kessel L. Clinical Disorders of the Shoulder. 1st ed. Edinburgh etc: Churchill Livingstone; 1982:150e165. 13. Kirtland S, Resnik D, Sartoris DJ. Closed unreduced dislocation of glenohumeral joint. J Trauma. 1998;28:1622e1630. 14. Clough TM, Bale RS. Bilateral posterior dislocation shoulder dislocation: the importance of the axillary radiographic view. Eur J Emerg Med. 2001;2:161e163. 15. Aparicio G, Calvo E, Bonilla L. Neglected traumatic posterior dislocation of the shoulder: controversies on indication for the treatment and new CT scan findings. J Orthop Sci. 2000;5:37e42. 16. Hatzis N, Kaar TK, Wirth MA, Rockwood Jr CA. The often overlooked posterior dislocation of the shoulder. Tex Med. 2001;97:62e67. 17. Rowe CR, Zarins B. Chronic unreduced dislocation of the shoulder. J Bone Joint Surg Am. 1982;64:494e505. 18. Cicak N. Posterior dislocation of the shoulder. J Bone Joint Surg Br. 2004;86:324e332. 19. Bloom MH, Obata WG. Diagnosis of posterior dislocation of the shoulder with use of Velpeau axillary and angle-up roentgenographic views. J Bone Joint Surg Am. 1967;49:943e949. 20. Arndt JH, Sears AD. Posterior dislocation of the shoulder. Am J Roentgenol Radium Ther Nucl Med. 1965;94:639e645. 21. Cisternino SJ, Rogers LF, Stufflebam BC, Kruglik GD. The trough line: a radiographic sign of the posterior shoulder dislocation. AJR Am J Roentgenol. 1978;130:951e954. 22. Kaar TK, Worth M, Rockwood C. Missed dislocation of the humeral head. J Bone Joint Surg. 1999;81-A:708e710. 23. Steinmann SP. Posterior shoulder instability. Arthroscopy. 2003;19(10):102e105. 24. Richards RH, Clarke NM. Locked posterior fracturedislocation of the shoulder. Injury. 1989;20:297e300.
Please cite this article in press as: Dlimi F, et al., Posterior dislocation of the shoulder: A case report, Journal of Clinical Orthopaedics and Trauma (2013), http://dx.doi.org/10.1016/j.jcot.2013.01.004
320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378
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Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/jcot
Case Report
Posterior dislocation of the shoulder: A case report Q4 Q1
Fayc¸al Dlimi a,*, Mustapha Mahfoud b, Saleh Berrada Mohamed b, Ahmed El Bardouni b, Moradh El Yaacoubi b a b
Department of Orthopaedic Surgery and Traumatology, University Hospital Center, Ibn Sina, Rabat, Morocco Professor, Department of Orthopaedic Surgery and Traumatology, University Hospital Center, Ibn Sina, Rabat, Morocco
article info
abstract
Article history:
Traumatic posterior glenohumeral dislocations are rare and make an accurate diagnosis
Received 1 March 2011
frequently missed because of the absence of characteristic symptoms. These injuries are
Accepted 16 January 2013
exceptional in elderly patients. A systematization of the clinical and radiological approach,
Available online xxx
leads to an early diagnosis and allows a prompt reduction. A 75-year-old woman presented with pain and restriction of movement of her left shoulder as a result of a stair fall. Her left
Keywords:
arm was adducted and internally rotated. Radiographs revealed the posterior shoulder
Axillary view
dislocation. The patient was treated with closed manipulation and her arm immobilized
Closed reduction
for 3 weeks. Results after one-year follow-up were satisfactory with correct range of mo-
Posterior dislocation
tion and no redislocations occurring.
Shoulder dislocation
1.
Introduction
Although the shoulder is the most frequently dislocated joint, posterior dislocation is rare and creates a diagnostic trap for unwary surgeon.1 It represents only 1%e4% of all shoulder dislocations.2 Such dislocations are usually caused by epileptic seizures, electrocution including electroconvulsive therapy and extreme trauma (Triple “E” syndrome)3 due to a fall with axial stress on flexed, internally rotated and adducted shoulders.4e6 However, posterior dislocation in elderly is exceptional and makes difficulties in diagnosis which often lead to delayed treatment, sometimes with consequent sequelae. Some clinical signs can help the examiner to suspect the dislocation. Even the routine antero-posterior roentgenogram may provide a few clues to diagnosis but the axillary view is mandatory to verify diagnosis. We report a 75year-old-woman with traumatic posterior dislocation of the left shoulder.
Copyright ª 2013, Delhi Orthopaedic Association. All rights reserved.
2.
Case report
A 75-year-old woman presented to the emergency department complaining of acute pain and stiffness of her left shoulder following a fall from stairs. Her left arm was carefully held against the chest wall with the shoulder adducted and internally rotated. She had no history of seizure, epilepsy, alcohol intake or previous shoulder dislocation. Physical examination revealed swelling and tenderness in the posterior area of the shoulder, but luckily, the patient did not suffer from any neurological or vascular injuries (Fig. 1). The anteroposterior view revealed a light-bulb sign and an overlap of the glenoid rim and the humeral head (Fig. 2). The axillary view was not obtained due to pain and reduced mobility. Closed reduction was performed by flexion and adduction of the shoulder, traction on the affected extremity and direct pressure applied from behind to push the humeral head into the socket. Reduction was confirmed by radiographs and the shoulder
* Corresponding author. Tel.: þ212 610877533. E-mail address: [email protected] (F. Dlimi). 0976-5662/$ e see front matter Copyright ª 2013, Delhi Orthopaedic Association. All rights reserved. http://dx.doi.org/10.1016/j.jcot.2013.01.004
Please cite this article in press as: Dlimi F, et al., Posterior dislocation of the shoulder: A case report, Journal of Clinical Orthopaedics and Trauma (2013), http://dx.doi.org/10.1016/j.jcot.2013.01.004
Q2
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130
JCOT37_proof ■ 25 January 2013 ■ 2/3
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j o u r n a l o f c l i n i c a l o r t h o p a e d i c s a n d t r a u m a x x x ( 2 0 1 3 ) 1 e3
Fig. 1 e Clinical appearance of posterior dislocation with swelling of the left shoulder.
was immobilized in adduction and internal rotation for 3 weeks (Fig. 3). The patient received regular physiotherapy and was able to perform her daily activities 2 months later. At one-year follow-up, the outcome was satisfactory and the shoulder was stable and painless with correct range of motion.
3.
Discussion
Posterior dislocation of the shoulder was first described by Cooper in 1839 in an epileptic patient.7 It’s an uncommon injury and its incidence in the literature is 2.17%.8 It’s exceptional in elderly patients. The main causes of posterior dislocation are trauma and seizure9 but majority are due to indirect force.8,10,11 Factors such as position of the arm and muscle weakness must also be considered.8,12 Posterior dislocation of the shoulder is the most commonly missed major joint dislocation in the body.8 It is commonly associated with an impaction or “encoche” fracture of the humeral head which causes locking of the humeral head behind the glenoid.13 The diagnosis of posterior dislocation is frequently missed,2,14,15 probably because of the injury’s relative rarity, inadequate physical examination and difficulty in interpreting radiographs.3 Even orthopaedic surgeons initially misdiagnose 60% of posterior shoulder dislocations, and the correct diagnosis is often delayed for months or years.16 At this stage, dislocation becomes chronic and difficult to treat.17 An upper limb with adduction and internal rotation is
Fig. 3 e Check X-ray showing reduced joint.
characteristic of posterior dislocation of the shoulder. The physical characteristic findings described by Mclaughlin1 include an increased palpable prominence of the coracoid, decreased anterior prominence of humeral head, increased palpable posterior prominence of the humeral head below the acromion, marked limitation of abduction and complete absence of external rotation with a fixed internal rotation deformity. Multidirectional radiographs combined with computed tomography (CT) are recommended to make an accurate and early diagnosis.15,18 Radiographs in AP, scapula Y, and axillary views are necessary.19 Signs indicating posterior dislocation of the shoulder on the AP view are the positive rim sign, the absence of the half-moon overlap, the light-bulb sign and the trough line.20,21 Although, the AP X-ray may appear deceptively normal12 and the axillary view is often not obtained routinely. Failure to take adequate radiographs can also constitute a frequent cause of misdiagnosis.22 CT scan is superior to routine radiographs in revealing the posterior dislocation of the shoulder and the osseous abnormalities and may be useful for planning the reduction procedure.15,18 MR imaging is not described as being necessary for mapping soft tissue damage because rotator cuff injury is extremely rare in posterior shoulder dislocations.23 Closed reduction is often obtained
Fig. 2 e Radiographs of the shoulder demonstrate posterior dislocation. Please cite this article in press as: Dlimi F, et al., Posterior dislocation of the shoulder: A case report, Journal of Clinical Orthopaedics and Trauma (2013), http://dx.doi.org/10.1016/j.jcot.2013.01.004
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under general anaesthesia. Patient with locked posterior dislocation should be treated based on the general condition and needs of patient, the duration of dislocation, the size of impression defect and the experience of surgeon.8 Unsuccessful closed reduction are essentially due to a large impression fracture, delayed diagnosis of the dislocation, and anatomical neck fracture.18,24 Surgical intervention is necessary for old unreduced posterior dislocations. The shoulder should be immobilized after reduction and rehabilitation with progressive passive and active physiotherapy is mandatory.
4.
Conclusion
Posterior dislocation of the shoulder can also affect elderly patients. Its diagnosis is easily missed because of the injury’s rarity making therapeutic difficulties and unfavourable prognosis. Multidirectional radiographs and computed tomography are necessary to make an accurate and early diagnosis which requires a high index of suspicion. Prompt reduction and good rehabilitation lead to satisfactory results. Surgery is reserved for old unreduced posterior dislocations.
Funding None.
Conflicts of interest No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Q3
Authorship All authors had access to the data and a role in writing the manuscript.
Acknowledgements This study was self-funded.
references
1. McLaughlin HL. Posterior dislocation of the shoulder. J Bone Joint Surg Am. 1952;34:584e590.
3
2. Perron AD, Jones RL. Posterior shoulder dislocation: avoiding a missed diagnosis. Am J Emerg Med. 2000;18:189e191. 3. Brackstone M, Patterson SD, Kertesz A. Triple “E” syndrome: bilateral locked posterior fracture dislocation of the shoulders. Neurology. 2001;56(10):1403e1404. 4. Becker R, Weyand F. Die seltene, doppelseitige hintere Schulterluxation. Unfallschirurg. 1990;93:66e68. 5. Blasier RB, Burkus JK. Management of posterior fracturedislocations of the shoulder. Clin Orthop Relat Res. 1988;232:197e204. 6. Martens C, Hessels G. Bilateral posterior four-part fracturedislocation of the shoulder. Acta Orthop Belg. 1995;61(3):249e254. 7. Cooper Sir A. On the dislocation of the Os Humeri upon the dorsum scapulae, and upon fractures near the shoulder-joint. Guys Hosp Rep. 1839;4:265. 8. Rockwood C, Green C. Fracture in Adults. 2nd ed. Philadelphia etc: J B Lippincott & Co; 1975:806e856. 9. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956;38:957e977. 10. Apley G. In: Solomon L, ed. Apley’s System of Orthopedics and Fracture. 6th ed. Butterworth & Co; 1982:383. 11. McGlone R, Gosnold JK. Posterior dislocation of shoulder and bilateral hip fractures caused by epileptic seizure. Arch Emerg Med. 1987;4:115e116. 12. Kessel L. Clinical Disorders of the Shoulder. 1st ed. Edinburgh etc: Churchill Livingstone; 1982:150e165. 13. Kirtland S, Resnik D, Sartoris DJ. Closed unreduced dislocation of glenohumeral joint. J Trauma. 1998;28:1622e1630. 14. Clough TM, Bale RS. Bilateral posterior dislocation shoulder dislocation: the importance of the axillary radiographic view. Eur J Emerg Med. 2001;2:161e163. 15. Aparicio G, Calvo E, Bonilla L. Neglected traumatic posterior dislocation of the shoulder: controversies on indication for the treatment and new CT scan findings. J Orthop Sci. 2000;5:37e42. 16. Hatzis N, Kaar TK, Wirth MA, Rockwood Jr CA. The often overlooked posterior dislocation of the shoulder. Tex Med. 2001;97:62e67. 17. Rowe CR, Zarins B. Chronic unreduced dislocation of the shoulder. J Bone Joint Surg Am. 1982;64:494e505. 18. Cicak N. Posterior dislocation of the shoulder. J Bone Joint Surg Br. 2004;86:324e332. 19. Bloom MH, Obata WG. Diagnosis of posterior dislocation of the shoulder with use of Velpeau axillary and angle-up roentgenographic views. J Bone Joint Surg Am. 1967;49:943e949. 20. Arndt JH, Sears AD. Posterior dislocation of the shoulder. Am J Roentgenol Radium Ther Nucl Med. 1965;94:639e645. 21. Cisternino SJ, Rogers LF, Stufflebam BC, Kruglik GD. The trough line: a radiographic sign of the posterior shoulder dislocation. AJR Am J Roentgenol. 1978;130:951e954. 22. Kaar TK, Worth M, Rockwood C. Missed dislocation of the humeral head. J Bone Joint Surg. 1999;81-A:708e710. 23. Steinmann SP. Posterior shoulder instability. Arthroscopy. 2003;19(10):102e105. 24. Richards RH, Clarke NM. Locked posterior fracturedislocation of the shoulder. Injury. 1989;20:297e300.
Please cite this article in press as: Dlimi F, et al., Posterior dislocation of the shoulder: A case report, Journal of Clinical Orthopaedics and Trauma (2013), http://dx.doi.org/10.1016/j.jcot.2013.01.004
320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378