Journal of Orthopaedic Surgery 2005:13(3):303-306

Bilateral anterior dislocation of the shoulders with proximal humeral fractures: a case report
L Sharma, A Pankaj, V Kumar, R Malhotra, S Bhan
Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

ABSTRACT Bilateral simultaneous anterior dislocation of the shoulders with bilateral 3-part fracture of the proximal humeri is unusual. A 42-year-old man presented with pain and restriction of movement on both shoulders. He was injured by a heavy object falling over his back while he was leaning forward holding an overhead bar. His arms were abducted and externally rotated. The injury was not correctly diagnosed, and the patient was treated with repeated manipulations and splintage for 2 weeks. Radiological examination revealed bilateral anterior dislocation of the shoulders with displaced 3-part fractures of the proximal humeri involving the shaft, greater tuberosity, and head. The patient was treated with open reduction and internal fixation through a deltopectoral approach

using multiple Kirschner wires. The shoulders were kept immobilised for 3 weeks until the removal of the wires. The patient was able to resume work 3 months after surgery. He had an excellent and comfortable range of motion in both shoulders at oneyear follow-up.
Key words: shoulder fracture; shoulder dislocation

INTRODUCTION Although anterior shoulder dislocation is the most common major joint dislocation encountered in the emergency department, bilateral glenohumeral dislocations are rare and almost always posterior.1 Such dislocations are usually caused by violent muscle contraction in patients with seizure disorders,

Address correspondence and reprint requests to: Dr Rajesh Malhotra, Professor, Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India. E-mail: rmalhotra62@hotmail.com

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Figure 1 Preoperative radiograph showing bilateral anterior dislocation of the shoulders with bilateral 3-part fracture of the humeri.

or who experience electric shock or undergo electroconvulsive therapy.13 Simultaneous dislocation in different direction is sometimes seen in emotionally disturbed patients. However, simultaneous bilateral anterior shoulder dislocation is rare: only about 30 cases have been described in the literature. Bilateral fracture-dislocation is even rarer, with only few case reports available. In almost all cases, the associated fracture was a 2-part fracture. 1,4 We report a rare case of bilateral traumatic dislocation of the shoulders with bilateral 3-part fracture of the proximal humeri. To the best of our knowledge, this is the first case report of such condition.

(b) Figure 2 Computed tomographic images showing 3dimensional reconstruction and axial section of (a) the right shoulder and (b) the left shoulder.

CASE REPORT A 42-year-old man presented to All India Institute of Medical Sciences, New Delhi, India in October 2003 with pain and restriction of movement on both shoulders. The patient was a manual labourer and was injured by a heavy object falling over his back while he was leaning forward holding an overhead bar. His arms were abducted and externally rotated. He had no history of seizure, epilepsy, alcohol intake, or previous shoulder dislocation. The injury was not correctly diagnosed, and the patient was treated with repeated manipulations and splintage for 2 weeks. Physical examination revealed squared off shoulders with fullness over the anterior aspect. Radiological examination revealed bilateral anterior dislocation of the shoulders with displaced 3-part fractures of the proximal humeri involving the shaft, greater tuberosity, and head, according to the classification described by Neer5 (Figs. 1 and 2).

The patient was treated with open reduction and internal fixation through a deltopectoral approach using multiple Kirschner wires (Fig. 3). An associated tear of the right rotator cuff was repaired. The shoulders were kept immobilised for 3 weeks until the removal of the wires. The patient was able to resume work 3 months after surgery. At one-year follow-up, the patient had an excellent and comfortable range of motion in both shoulders. The active range of motion of the right shoulder was 0 to 110 flexion, 0 to 100 abduction, 0 to 20 extension, 0 to 20 external rotation, and 0 to 35 internal rotation, whereas of the left shoulder was 0 to 100 flexion, 0 to 95 abduction, 0 to 20 extension, 0 to 20 external rotation, and 0 to 30 internal rotation. Shoulder movement did not elicit pain; however, the patient occasionally needed analgesics. Radiographs showed good fracture union with concentric joint (Fig. 4).

DISCUSSION Bilateral shoulder dislocation was first described in 1902 in a patient with muscular contraction caused by a camphor overdose.6 A review of the literature revealed about 30 reports of bilateral anterior shoulder

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Bilateral anterior dislocation of the shoulders 305

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(b)

Figure 3 Immediate postoperative radiographs of the (a) right and (b) left shoulders showing reduced joints and fixation with Kirschner wires.

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Figure 4

Radiographs of the (a) right and (b) left shoulders showing healed fractures at 12-month follow-up.

dislocations, 15 of which were of fracture-dislocation, mostly 2-part fractures. Most were due to violent trauma or electrocution; the remaining few were attributed to epileptic or hypoglycaemic seizures.7 The injury mechanism of anterior dislocation of the shoulder is forced extension, abduction, and

external rotation. A direct blow to the posterior aspect of the shoulder, or a sudden and violent contraction of muscles around the shoulder can result in anterior dislocation. Unilateral anterior dislocation of the shoulder is common because of the position naturally adopted by the upper extremity during a fall.

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However, bilateral occurrence is rare because in almost all instances one extremity takes the brunt of the impact. Associated fracture of the greater tuberosity occurs in 15% of the anterior dislocation cases and indicates an associated rotator cuff tear.8 Three clinical factors are significantly associated with occurrence of fractures in such dislocations: age 40 years or older, the first episode of dislocation, and mechanism of injury.9 Age is associated with decreased bone mass. The first episode of dislocation signifies an intact ligamentous anatomy around the shoulder joint. Mechanisms of injury, such as a fall greater than one flight of stairs, a fight/assault, or a motor vehicle accident, are associated with high-energy trauma. Two of the 3 factors were present in this case (i.e. first episode of dislocation and age 40 years or older). Although the mechanism of injury was novel, it was a high-energy injury similar to the other mechanisms described. Bilateral simultaneous traumatic anterior dislocation of the shoulder associated with a bilateral 3- or 4-part fracture of the proximal humeri is very rare, with only 2 case reports available. Nagi and Dhillon 10 reported a 49-year-old patient who had bilateral anterior dislocation of the shoulders with associated bilateral fractures of the proximal humeri, but the injury mechanism was not clearly described.

The fracture pattern was described as a Neer type-2 fracture on the right side and type-4 fracture on the left side. The right side was treated with open reduction and internal fixation, whereas the left side with Neers hemi replacement. Dinopoulos et al.11 reported a 76-year-old woman with osteoporotic bones who fell on outstretched arms. She had anterior dislocation of both shoulders with a 3-part fracture of the right proximal humerus. The fracture through the surgical neck of the humerus was impacted. She was treated with closed reduction followed by immobilisation, and the outcome was satisfactory. Our patient was a middle-aged man with no preexisting osteoporosis. Both humeral fractures were displaced suggestive of a high-energy injury. The patient kept both shoulders in abduction and external rotation by holding the overhead bar while he was leaning forward. A heavy object falling on his upper back caused sudden hyperextension and external rotation of the abducted shoulders, thus leading to bilateral anterior dislocation of the shoulders with associated humeral fractures. Closed reduction was not successful because of skeletal discontinuity between the head and shaft fragments. Open reduction and internal fixation were performed with excellent outcome.

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