Bilateral anterior shoulder dislocation in epilepsy: A case report and review of literature

Kathir Azhagan Stalin

Consultant Orthopaedic Surgeon, Kauvery Hospital, Chennai, India

Abstract

Bilateral anterior shoulder dislocation is an uncommon condition. The majority of incidents are posterior dislocations, which typically happen as a result of exposure to a powerful electric shock or during diffuse tonic-clonic contractions of epileptic convulsions. We describe a 23-year-old epileptic patient in this study who experienced acute bilateral anterior shoulder dislocation. Shoulder X-rays and MRI were used to diagnose and manage the patient. One shoulder underwent arthroscopic Bankart repair. The other shoulder, however, received conservative management. The patient got successful results for both shoulders. The key is early diagnosis and prompt management, which calls for high clinical suspicion and meticulous assessment.

Keywords: Epileptic seizure; Shoulder dislocation

Background

The most frequent type of shoulder dislocation is anterior glenohumeral dislocation. However bilateral anterior dislocation of the shoulders is uncommon, and there aren’t many cases that have been documented in the literature. Although symmetrical and asymmetrical dislocation (anterior-posterior and anterior-inferior) have been documented, the symmetrical posterior variant is more common in bilateral dislocations following epilepsy [1,2]. Bilateral anterior dislocation of the shoulder is a less common occurrence [2-6]. We present a case of bilateral anterior glenohumeral dislocation caused by an epileptic seizure in a 23-year-old gentleman.

Case Presentation

At our emergency department, a 23-year-old male office assistant complained of bilateral shoulder pain after an episode of seizure and a fall from the bed. The patient awoke on the ground in the middle of the night, a few minutes after falling out of bed, but had no recollection of the fall. He was previously diagnosed to have recurrent generalized epilepsy and was non-complaint with the medications.

He arrived at the hospital with his shoulders flattened and squared, his arms slightly externally rotated, extended, and abducted, and he was unable to internally rotate or adduct his arms. (Fig. 1). Both shoulders had normal neurovascular status. AP view of the shoulders revealed a bilateral subcoracoid anterior glenohumeral dislocation with no associated fracture (Fig. 2).

Then, while he was sedated and relaxed with IV Propofol and fentanyl, Kocher’s approach of closed reduction was carried out on him, and X-ray studies confirmed the reduction (Fig. 3). His arms were placed in a bilateral sling for 1 week and gradually mobilized from the first week.

While he was recovering from the initial incident, he suffered another episode of generalized seizure and dislocated his right shoulder. Under IV sedation, closed reduction was carried out, and X-ray examinations confirmed the reduction.

Bilateral-anterior-shoulder-dislocation-in-epilepsy

After two weeks, a bilateral MRI revealed labral tears in both shoulders. Clinically, no instability was noticed in the left shoulder, however, but was noted to be present in the right shoulder.

If the patient was able to go a year without having any seizures, we planned to move forward with the surgical option for the right shoulder given the instability, anxiety and apprehension, and radiological indications.

The patient received physiotherapy and neurological care. After 18 months, the right shoulder had undergone soft tissue stabilization. The patient was then reviewed periodically by the physio team and the surgeon, and the range of motion and functioning of both shoulders were assessed. The patient’s left shoulder was completely mobile and there was no instability. He had a little diminished ER (45o) in his right shoulder, but it had no functional impact.

Discussion

Bilateral glenohumeral joint dislocations in all planes, with or without fractures, are uncommon because the forces required to produce a dislocation must act synchronously and simultaneously at both joints [7]. Since Cooper [8] and Myenter [9] reported the first cases in 1839 and 1902, posterior shoulder dislocations have been the most common type of bilateral shoulder dislocations. This can happens during epileptic convulsions when a violent muscle contraction dislocates the humeral head posteriorly [1,2]. Bilateral anterior shoulder dislocation is a rare occurrence [2-6]. Trauma(fall) [10], nocturnal hypoglycaemia [6,11], electrocution [12,13], diving [14] and bench pressing [15] are some of the other reported causes of these bilateral injuries.

A 19-year-old man with a similar history was described in 2020 by Ghannam et al [15]. With conservative treatment, the patient improved without the need for surgery. Timothy et al described a unique case of bench pressing-related bilateral anterior dislocation. With a full range of motion and instability recorded, the patient had an uneventful recovery [7].

In their analysis, Malick et al. found that 43% of bilateral anterior shoulder dislocations were associated with complications, frequently on both sides [16]. Two-thirds of these complicated injuries were associated with fractures. Three-quarters of fractures are isolated greater tuberosity (GT) fractures. One-fifth of fractures were comminuted 3- and 4-part proximal humerus fractures [16]. There are fewer associated neurovascular injuries reported (28.5%) [16]. None of the complications listed was experienced by our patient.

The main treatment for acute BSASD is closed reduction. Malick et al [16]. concluded that of the 133 acute bilateral anterior dislocations they evaluated, only a few surgeons [17] have used arthroscopic stabilization. However, arthroscopic treatment of recurrent acute bilateral anterior dislocation has a great success rate, according to Kalkan et al study [18]. To address the anterior instability and enhance the patient’s rehabilitation, we used arthroscopic Bankart repair.

Conclusion

The great importance of clinical and radiologic diagnosis must be emphasized. Bilateral anterior dislocation of the shoulder may not be as uncommon as previously believed and must be taken into consideration in EDs, especially in non-traumatic cases. To avoid chronic shoulder neglect and its associated complication, patients with epilepsy must be screened with the utmost vigilance to quickly diagnose and manage the shoulders.

References

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  8. Cooper, A., A Treatise on Dislocations and Fractures of the Joints. 1851: Blanchard and Lea.
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  13. Carew-McColl, M., Bilateral shoulder dislocations caused by electric shock. The British journal of clinical practice, 1980. 34(8-9): p. 251-254.
  14. Mathis, R.D., Bilateral shoulder dislocation: an unusual occurrence. The Journal of emergency medicine, 1990. 8(1): p. 41-43.
  15. Abdelaziz, G., Acute Bilateral Anterior Shoulder Dislocation after an Epileptic Seizure: A Case Report. EC Ortho-paedics, 2020. 11: p. 59-61.
  16. Diallo, M., et al., Bilateral anterior shoulder dislocations: A review of two cases and the relevant literature. Clinical Case Reports, 2020. 8(12): p. 3378-3387.
  17. Åžanel, S., et al., Bilateral, locked, recurrent anterior shoulder dislocation: case report. Joint Diseases and Related Surgery, 2015. 26(1): p. 052-055.
  18. Kalkan, T., et al., Bilateral anterior shoulder dislocation in two cases due to housework accidents. Acta Orthopaedica et Traumatologica Turcica, 2009. 43(3): p. 260-263.
Dr.-Kathir-Azhagan-Stalin

Dr. Kathir Azhagan Stalin

Consultant Orthopaedic Surgeon

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