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• W4308342878 abstract "Posterior shoulder dislocations are a rare and often missed cause of shoulder disability. They comprise approximately 2%-4% of all shoulder dislocations and are associated with concomitant injuries in about 65% of patients.1Basal O. Dincer R. Turk B. Locked posterior dislocation of the shoulder: a systematic review.EFORT Open Rev. 2018; 3: 15-23https://doi.org/10.1302/2058-5241.3.160089Crossref PubMed Scopus (17) Google Scholar,2Betz M.E. Traub S.J. Bilateral posterior shoulder dislocations following seizure.Intern Emerg Med. 2007; 2: 63-65https://doi.org/10.1007/s11739-007-0017-yCrossref PubMed Scopus (14) Google Scholar,7Rouleau D.M. Herbert-Davies J. Incidence of associated injury in posterior shoulder dislocation.J Orthop Trauma. 2012; 26: 246-251https://doi.org/10.1097/BOT.0b013e3182243909Crossref PubMed Scopus (89) Google Scholar On presentation, posterior shoulder dislocations are associated with severe pain and muscle spasms. The arm is usually adducted and in slight internal rotation, with resistance to external rotation and abduction due to pain.5Ketenci I.E. Duymus T.M. Ulusoy A. Yanik H.S. Mutlu S. Durakbasa M.O. Bilateral posterior shoulder dislocation after electrical shock: a case report.Ann Med Surg. 2015; 4: 417-421https://doi.org/10.1016/j.amsu.2015.10.010Crossref PubMed Scopus (9) Google Scholar The most common mechanism of posterior shoulder dislocations is from seizures, usually tonic clonic, and occur in approximately 34%-38% of cases.4Kelly M.J. Holton A.E. Cassar-Gheiti A.J. Hanna S.A. Quinlan J.F. Molony D.C. The aetiology of posterior glenohumeral dislocations and occurrence of associated injuries: a systematic review.Bone Joint J. 2019; 101-B: 15-21https://doi.org/10.1302/0301-620X.101B1.BJJ-2018-0984.R1Crossref PubMed Scopus (12) Google Scholar,7Rouleau D.M. Herbert-Davies J. Incidence of associated injury in posterior shoulder dislocation.J Orthop Trauma. 2012; 26: 246-251https://doi.org/10.1097/BOT.0b013e3182243909Crossref PubMed Scopus (89) Google Scholar Other classic mechanisms include electric shock or electrocution, falls, and anterior-directed shoulder trauma such as a fall on an outstretched hand or motor vehicle accident.1Basal O. Dincer R. Turk B. Locked posterior dislocation of the shoulder: a systematic review.EFORT Open Rev. 2018; 3: 15-23https://doi.org/10.1302/2058-5241.3.160089Crossref PubMed Scopus (17) Google Scholar,2Betz M.E. Traub S.J. Bilateral posterior shoulder dislocations following seizure.Intern Emerg Med. 2007; 2: 63-65https://doi.org/10.1007/s11739-007-0017-yCrossref PubMed Scopus (14) Google Scholar,4Kelly M.J. Holton A.E. Cassar-Gheiti A.J. Hanna S.A. Quinlan J.F. Molony D.C. The aetiology of posterior glenohumeral dislocations and occurrence of associated injuries: a systematic review.Bone Joint J. 2019; 101-B: 15-21https://doi.org/10.1302/0301-620X.101B1.BJJ-2018-0984.R1Crossref PubMed Scopus (12) Google Scholar,5Ketenci I.E. Duymus T.M. Ulusoy A. Yanik H.S. Mutlu S. Durakbasa M.O. Bilateral posterior shoulder dislocation after electrical shock: a case report.Ann Med Surg. 2015; 4: 417-421https://doi.org/10.1016/j.amsu.2015.10.010Crossref PubMed Scopus (9) Google Scholar Associated injuries include fractures, with posterior fracture dislocations making up less than 1% of all fracture dislocations, rotator cuff tears, and reverse Hill-Sachs injury.1Basal O. Dincer R. Turk B. Locked posterior dislocation of the shoulder: a systematic review.EFORT Open Rev. 2018; 3: 15-23https://doi.org/10.1302/2058-5241.3.160089Crossref PubMed Scopus (17) Google Scholar,7Rouleau D.M. Herbert-Davies J. Incidence of associated injury in posterior shoulder dislocation.J Orthop Trauma. 2012; 26: 246-251https://doi.org/10.1097/BOT.0b013e3182243909Crossref PubMed Scopus (89) Google Scholar Treatment includes closed or open reduction, with additional soft tissue or bony procedures, and patients with delayed treatment for persistent instability may require arthroplasty.8Rouleau D.M. Hebert-Davies J. Robinson C.M. Acute traumatic posterior shoulder dislocation.J Am Acad Orthop Surg. 2014; 22: 145-152https://doi.org/10.5435/JAAOS-22-03-145Crossref PubMed Scopus (51) Google Scholar Reported here is a case of bilateral posterior shoulder fracture dislocations resulting from a seizure due to hyponatremia in a patient with psychogenic polydipsia. The patient was fully informed and gave written consent to submit the details of this case for publication in a peer-reviewed journal. The patient is a 50-year-old male who presented to the emergency department for bilateral shoulder pain after sustaining a seizure due to hyponatremia, as his sodium level was 112 mmol/L (normal range for this institution is 136-145 mmol/L). The patient had a medical history significant for psychogenic polydipsia and bipolar 1 disorder. Initial examination demonstrated mild deformity of both shoulders, mild swelling, absence of ecchymosis, and intact skin. The patient was unable to raise his arms, and his range of motion (ROM) was very limited due to pain. He was able to actively flex and extend his bilateral elbows, wrists, and hands, and he was neurovascularly intact. Imaging demonstrated bilateral posterior shoulder 2-part fracture dislocations extending through the head and neck junctions bilaterally, with greater displacement on the left compared to the right (Fig. 1). Computed tomography (CT) Scans obtained that day demonstrated comminuted fractures of the left proximal humerus extending from the medial proximal metaphysis to the articular surface superiorly with moderate override, with the majority of the articular surface rotated and dislocated posteriorly (Fig. 2 A-C) and posterior dislocation of the right shoulder with comminuted fractures of the anatomic and surgical neck extending to the articular surface (Fig. 2 D-F). The patient underwent closed reduction of his bilateral shoulder dislocations one day after the injury, and surgery was delayed due to severe hyponatremia.Figure 2Representative computed tomography scans at the time of injury: (A) sagittal, (B) coronal, and (C) axial views of the left humerus, (D) sagittal, (E) coronal, and (F) axial views of the right humerus.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Approximately 1.5 months post-initial injury and presentation, the patient was able to undergo initial surgical intervention with open reduction and internal fixation (ORIF) of the left humerus. Plain-film radiographs were repeated for accurate operative planning and demonstrated a fracture pattern consistent with the initial CT scans (Fig. 3). The left proximal humerus fracture was treated first in order to preserve the native glenohumeral joint (Fig. 4). Due to the fracture pattern on the right side, we did not believe that the native glenohumeral joint could be preserved, so arthroplasty was delayed until recovery from the ORIF.Figure 4Intraoperative radiographs of open reduction and internal fixation, left proximal humerus.View Large Image Figure ViewerDownload Hi-res image Download (PPT) At the patient’s 3-month follow-up appointment, partial collapse of the left humeral head was noted on x-ray, indicating possible avascular necrosis (AVN) (Fig. 5). The patient continued to struggle to maintain his sodium within normal limits due to his psychogenic polydipsia, and thus, he was unable to undergo surgery on his right proximal humerus until exactly one year after initial injury and presentation. During his preoperative evaluation, his ROM in flexion was 110° and in external rotation was 20° (Table I). Due to the patient’s accompanying rotator cuff tear and post-traumatic arthritis (Figs. 6 and 7), he underwent a right reverse total shoulder arthroplasty (rTSA) (Fig. 8). At his follow-up visit 2.5 months after his right rTSA, his ROM in flexion was 150°, his external rotation was 15°, his American Shoulder and Elbow Surgeons score was 85, and his visual analog scale score was 0 (Table I).Table IPatient-reported outcomes and functional range of motion measurements pre- and post-reverse total shoulder arthroplasty.Preoperative measurementsPostoperative measurementsLeft ROM – flexion110°160° ROM – external rotation20°25° ASES85 VAS1Right ROM – flexion100°150° ROM – external rotation20°15° ASES85 VAS0ROM, range of motion; ASES, American Shoulder and Elbow Surgeons; VAS, visual analog scale. Open table in a new tab Figure 6Plain-film radiographs of the right shoulder 8 months after the initial injury demonstrating post-traumatic arthritis and dislocation: (A) anterior-posterior (AP) external rotation, (B) AP internal rotation, (C) 45-45 oblique view.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 7Preoperative computed tomography scans of the right shoulder, 10 months after initial presentation: (A) sagittal, (B) coronal, and (C) axial view.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Intraoperative radiographs of right reverse total shoulder replacement.View Large Image Figure ViewerDownload Hi-res image Download (PPT) ROM, range of motion; ASES, American Shoulder and Elbow Surgeons; VAS, visual analog scale. At a subsequent follow-up appointment for the left shoulder, 16 months post injury, the patient presented with worsening left-shoulder pain. On plain radiographs, AVN of the humeral head was once again noted with further collapse on x-ray, and the patient was recommended to undergo arthroplasty of the left shoulder (Fig. 9). At that time, his ROM in flexion was 100° and in external rotation was 20° (Table I). Six weeks later, (18 months post-initial injury and presentation) the patient underwent removal of hardware and conversion to rTSA, due to advancing AVN of the humeral head, torn rotator cuff, scar tissue, and adhesions (Fig. 10).Figure 10Intraoperative radiographs of left hardware removal and left reverse total shoulder replacement.View Large Image Figure ViewerDownload Hi-res image Download (PPT) At his subsequent follow-up appointments, he reported adequate pain control and denied numbness or tingling in his distal extremities. As of his most recent follow-up visit, 10 months after his left rTSA, he had 4 of 5 strength in both flexion and external rotation, his ROM in flexion was 160° and his external rotation was 25°, his American Shoulder and Elbow Surgeons score was 85, and his visual analog scale score was 1 (Table I). This case of bilateral posterior shoulder fracture dislocations is unique to other case reports in the current literature because it is the result of severe hyponatremia leading to seizure activity in a patient with psychogenic polydipsia. Cases of unilateral or bilateral posterior shoulder dislocations documented in the literature due to seizure activity, have been attributed to causes such as epilepsy, seizure disorders, hypoglycemia, and alcohol withdrawal.2Betz M.E. Traub S.J. Bilateral posterior shoulder dislocations following seizure.Intern Emerg Med. 2007; 2: 63-65https://doi.org/10.1007/s11739-007-0017-yCrossref PubMed Scopus (14) Google Scholar,3Gosens T. Poels P.J. Rondhuis J.J. Posterior dislocation fractures of the shoulder in seizure disorders--two case reports and a review of literature.Seizure. 2000; 9: 446-448Abstract Full Text PDF PubMed Scopus (30) Google Scholar The majority of bilateral shoulder dislocations are posterior, but a rare case of bilateral anterior shoulder dislocation due to hyponatremic seizures was reported.9Sivananda P. Sudheer T. Varun Kumar P. Mani Kumar P. Bilateral anterior dislocation of shoulder with greater tuberosity fracture due to hyponatremia: a rare presentation.J Evid Based Med Healthc. 2015; 2: 283-286https://doi.org/10.18410/jebmh/2015/39Crossref Google Scholar The hyponatremic seizures leading to bilateral anterior shoulder dislocation; however, were due to electrolyte deficiency from a diarrheal illness and not a psychologic condition of excess water intake as in this case.9Sivananda P. Sudheer T. Varun Kumar P. Mani Kumar P. Bilateral anterior dislocation of shoulder with greater tuberosity fracture due to hyponatremia: a rare presentation.J Evid Based Med Healthc. 2015; 2: 283-286https://doi.org/10.18410/jebmh/2015/39Crossref Google Scholar Due to the rare incidence of posterior shoulder dislocation, it is often missed on examination and on anterior-posterior and lateral x-ray imaging.3Gosens T. Poels P.J. Rondhuis J.J. Posterior dislocation fractures of the shoulder in seizure disorders--two case reports and a review of literature.Seizure. 2000; 9: 446-448Abstract Full Text PDF PubMed Scopus (30) Google Scholar Posterior shoulder dislocations can be identified on axillary x-rays, but this view can be difficult to obtain in patients due to pain with abduction.3Gosens T. Poels P.J. Rondhuis J.J. Posterior dislocation fractures of the shoulder in seizure disorders--two case reports and a review of literature.Seizure. 2000; 9: 446-448Abstract Full Text PDF PubMed Scopus (30) Google Scholar Therefore, CT scans are a helpful tool in diagnosis and management of posterior shoulder dislocations, and were obtained in the patient presented in this case during his initial work-up.3Gosens T. Poels P.J. Rondhuis J.J. Posterior dislocation fractures of the shoulder in seizure disorders--two case reports and a review of literature.Seizure. 2000; 9: 446-448Abstract Full Text PDF PubMed Scopus (30) Google Scholar A missed diagnosis of posterior shoulder dislocation can lead to delay in treatment and impaired shoulder function.8Rouleau D.M. Hebert-Davies J. Robinson C.M. Acute traumatic posterior shoulder dislocation.J Am Acad Orthop Surg. 2014; 22: 145-152https://doi.org/10.5435/JAAOS-22-03-145Crossref PubMed Scopus (51) Google Scholar While in this case the diagnosis was determined upon initial presentation, definitive operative treatment of the fracture dislocations after closed reduction was delayed due to risks of undergoing surgery with the patient’s severe hyponatremia; surgical management of the left shoulder was delayed 1.5 months from his injury, and surgery on his right shoulder was delayed 1 year from the date of injury. Consistent with the majority of cases of posterior shoulder dislocation, this patient sustained associated injuries, including bilateral fractures and rotator cuff tears.7Rouleau D.M. Herbert-Davies J. Incidence of associated injury in posterior shoulder dislocation.J Orthop Trauma. 2012; 26: 246-251https://doi.org/10.1097/BOT.0b013e3182243909Crossref PubMed Scopus (89) Google Scholar ORIF is usually necessary after closed reduction for displaced fractures with minimal articular surface involvement.10Tellisi N.K. Abusitta G.R. Fernandes R.J. Bilateral posterior fracture dislocation of the shoulders following seizure.Saudi Med J. 2004; 25: 1727-1729PubMed Google Scholar Displaced fractures, fractures involving greater than 40% of the articular surface, and 4-part fractures of the proximal humerus are less likely to be successfully treated with ORIF due to the greater likelihood of AVN with these fracture types.6Ogawa K. Yoshida A. Inokuchi W. Posterior shoulder dislocation associated with fracture of the humeral anatomic neck: treatment guidelines and long-term outcome.J Trauma. 1999; 46: 318-323Crossref PubMed Scopus (31) Google Scholar,10Tellisi N.K. Abusitta G.R. Fernandes R.J. Bilateral posterior fracture dislocation of the shoulders following seizure.Saudi Med J. 2004; 25: 1727-1729PubMed Google Scholar Due to the increased displacement of the left proximal humerus fracture, signs of AVN and humeral head collapse were evident approximately 3 months following ORIF. Arthroplasty is recommended in cases of AVN, along with in cases of fractures involving greater than 50% of the articular surface and fractures associated with rotator cuff tears.10Tellisi N.K. Abusitta G.R. Fernandes R.J. Bilateral posterior fracture dislocation of the shoulders following seizure.Saudi Med J. 2004; 25: 1727-1729PubMed Google Scholar Therefore, this patient originally underwent reverse total shoulder replacement on the right side due to the fracture and associated rotator cuff tear, and subsequently underwent hardware removal and reverse total shoulder replacement on the left due to the patient’s fracture, rotator cuff tear, and development of AVN. This rare case of bilateral shoulder fracture dislocations is unique to the current literature due to its causative mechanism of seizure activity due to hyponatremia from psychogenic polydipsia. The management and treatment course of this patient’s fracture dislocations were also unusual due to the need to delay surgical intervention because of severe, unmanaged hyponatremia caused by the patient’s excessive water intake. ORIF of the left shoulder was complicated by AVN, and the patient was treated with bilateral reverse total shoulder replacements." @default.
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• W4308342878 title "Bilateral posterior shoulder fracture dislocations from seizures due to hyponatremia: a case report" @default.
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