Rare disease
CASE REPORT
Simultaneous shoulder and elbow dislocation Mutlu Çobanoğlu,1 Feridun Yumrukcal,2 Cengiz Karataş,3 Fatih Duygun4 1
Department of Orthopaedics and Traumatology, Adnan Menderes University School of Medicine, Aydın, Turkey 2 Department of Orthopaedics and Traumatology, Şişli Memorial Hospital, İstanbul, Turkey 3 Department of Orthopaedics and Traumatology, PrivateTuzla Hospital, Istanbul, Turkey 4 Department of Orthopaedics and Traumatology, Antalya Education and Research Hospital, Antalya, Turkey Correspondence to Dr Fatih Duygun, [email protected] Accepted 3 May 2014
To cite: Çobanoğlu M, Yumrukcal F, Karataş C, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014204686
SUMMARY Ipsilateral shoulder and elbow dislocation is very rare and only six articles are present in the literature mentioning this kind of a complex injury. With this presentation we aim to emphasise the importance of assessing the adjacent joints in patients with trauma in order not to miss any accompanying pathologies. We report a case of a 43-year-old female patient with ipsilateral right shoulder and elbow dislocation treated conservatively. The patient reported elbow pain when first admitted to emergency service but she was diagnosed with simultaneous ipsilateral shoulder and elbow injury and treated conservatively. As a more painful pathology may mask the additional ones, one should hasten to help before performing a complete evaluation. Any harm caused to the patient due to this reason would not be a complication but a malpractice.
BACKGROUND Ipsilateral simultaneous shoulder and elbow dislocation is a rare and complex injury. In total 50% of all dislocations are isolated traumatic shoulder dislocations followed by the elbow.1–3 Fractures around the dislocated joint may accompany. Humeral fracture with shoulder dislocation is much more common than simultaneous ipsilateral shoulder and elbow dislocation.4–6 In literature we found only six articles about ipsilateral shoulder and elbow dislocation.4 7–11 Decisions about the choice of treatment should be made after full evaluation of the patient’s situation including age, occupation, health status, severity of the injury and even whether the affected side is the dominant one or not. Decisions between a surgical intervention and a conservative measure should be made only after considering these factors, but before this a careful evaluation is necessary in order not to complicate the case. We report a case of a 43-year-old
Figure 1 (A) Image before reduction. (B) Anteroposterior X-ray of right elbow. (C) Lateral X-ray of right elbow. (D) Anteroposterior and lateral X-ray of the right elbow after reduction.
Çobanoğlu M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204686
1
Rare disease
Figure 2 (A) Image of the right shoulder. (B) Anteroposterior X-ray of the right shoulder before reduction. (C) Anteroposterior X-ray of the right shoulder after reduction. female patient with ipsilateral right shoulder and elbow dislocation treated conservatively.
CASE PRESENTATION A 43-year-old overweight (body mass index (BMI) 26 kg/m2) female patient was admitted with right elbow pain after falling down from 2 m. After her initial evaluation in the emergency room, deformity of the right elbow, oedema and approximately 2 cm of skin laceration on medial epicondyle were noted. Hypoesthesia of the ulnar nerve trace was also noted without any motor deficit. Radiographic evaluation revealed posterolateral elbow dislocation (figure 1A–D). The patient then was consulted with an orthopaedic surgeon. The following evaluation revealed discomfort and pain in the right shoulder with accompanying limitation of range of motion. Owing to her overweight no epaulette sign was inspected. Before any manipulation, radiographic evaluation of the shoulder was considered and anterior dislocation of the shoulder was diagnosed (figure 2A–C). Axillary nerve was intact. Brachial, radial and ulnar arteries were palpable. Trauma series were also seen in order not to leave a possible pelvic or vertebral injury undiagnosed. Under sedative anaesthesia, first the elbow and then the shoulder dislocations were reduced. Skin laceration was irrigated and sutured with added local anaesthesia. There was no osseous pathology on control radiographic evaluation and ulnar hypoesthesia no longer existed.
TREATMENT A long arm split and shoulder arm strap were used. After 3 weeks of immobilisation, shoulder and elbow rehabilitation programmes were begun simultaneously.
dislocation and so radiological evaluation of the proximal and distal bones of the involved joint is a must. When simultaneous dislocation of two neighbouring joints is diagnosed alcohol misuse must also be questioned as this might be the predisposing factor causing muscular relaxation.11 There is a consensus about the mechanism of injury and it is thought to be falling on the flexed elbow while the shoulder is in abduction.8 12 With this kind of trauma one must be very careful about a probable neurovascular injury. Re-examination must be carried out following reduction. In our case, skin laceration on the medial side of the elbow and ulnar nerve hypoesthesia were reasons to suspect ulnar nerve injury but it fully recovered after reduction and motor deficit never existed. When ipsilateral shoulder and elbow dislocation exists, the elbow must be reduced first in order to have a stable distal part. Shoulder reduction after the elbow is much easier and safer as the distal extremity is stable while reducing the shoulder.7–9 An orthopaedic surgeon is a consultant of a patient who is first seen in emergency service. Sometimes a consultant may evaluate the patient on the basis of the knowledge given by the doctor of emergency service. This may cause additional pathologies being overlooked. Hurried interventions without a thorough history taking and examination may cause potential harm to the patient, and this is unsuitable to the Hippocratic mandate —primum non-nocere— that is, ‘first do no harm’. As a more painful pathology may mask the additional ones, one should hasten to help before performing a complete evaluation. Any harm caused to the patient due to this reason would not be a complication but a malpractice. Although simultaneous ipsilateral shoulder and elbow dislocation is rare, every possibility should be kept in mind before any intervention is made and a detailed examination should be carried out to not overlook an accompanying pathology.
OUTCOME AND FOLLOW-UP In the third month after injury, full painless shoulder range of motion was reached. Elbow extension was limited to 5° without any sign of instability.
DISCUSSION Although isolated shoulder or elbow dislocations are frequently seen, simultaneous ipsilateral shoulder and elbow dislocation is rare. Six articles about simultaneous ipsilateral shoulder and elbow dislocation4 7–11 in literature mention the possibility of overlooking shoulder dislocation because of the elbow dislocation being more painful.7–9 Four of these articles also mention humeral fracture accompanying shoulder and elbow dislocation.4 7 8 10 Fractures may be seen neighbouring the joint 2
Learning points ▸ Ipsilateral simultaneous shoulder and elbow dislocation is a rare and complex injury. ▸ Decision about the choice of treatment should be made after full evaluation of the patient’s situation including age, occupation, health status, severity of the injury and even whether the affected side is the dominant one or not. ▸ As a more painful pathology may mask the additional ones, one should hasten to help before performing a complete evaluation. Çobanoğlu M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204686
Rare disease Competing interests None. Patient consent Obtained.
5 6
Provenance and peer review Not commissioned; externally peer reviewed. 7
REFERENCES 1
2 3 4
Taşkoparan H, Kılınçoğlu V, Tunay S, et al. Immobilization of the shoulder in external rotation for prevention of recurrence in acute anterior dislocation. Acta Orthop Traumatol Turc 2010;44:278–84. Kesmezacar H, Sarıkaya IA. The results of conservatively treated simple elbow dislocations. Acta Orthop Traumatol Turc 2010;44:199–205. Lasanianos N, Garnavos C. An unusual case of elbow dislocation. Orthopedics 2008;31:806. Inan U, Çevik AA, Ömeroglu H. Open humerus shaft fracture with ipsilateral anterior shoulder fracture-dislocation and posterior elbow dislocation: a case report. J Trauma 2008;64:1383–6.
8 9 10
11 12
Pradhan I, Banskota AK. Anterior dislocation of the shoulder with ipsilateral humerus shaft fracture. Kathmandu Univ Med J (KUMJ) 2008;24:502–4. Kazakos K, Paraschou S, Lasanianos NG, et al. A humeral shaft fracture complicated with anterior shoulder dislocation in a young male treated with modified Intramedullary nailing prior to reduction: a case report. Cases J 2009;2:9075. Ali FM, Krishnan S, Farhan MJ. A case of ipsilateral shoulder and elbow dislocation: an easily missed injury. J Accid Emerg Med 1998;15:198. Khan MR, Mirdad TM. Ipsilateral dislocation of the shoulder and elbow. Saudi Med J 2001;11:1019–21. Suman RK. Simultaneous dislocations of the shoulder and the elbow. Injury 1981;12:438. Kerimoglu S, Turgutoglu O, Aynaci O, et al. Ipsilateral dislocation of the shoulder and elbow joints with contralateral comminuted humeral fracture. Saudi Med J 2006;12:1908–2011. Essoh JB, Kodo M, Traoré A, et al. Ipsilateral dislocation of the shoulder and elbow: a case report. Niger J Surg Res 2005;7:319–20. Sankaran-Kutty M, Sadat-Ali M. Dislocation of the shoulder with ipsilateral humeral shaft fracture. Arch Orthop Trauma Surg 1989;108:60–2.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
Çobanoğlu M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204686
3
CASE REPORT
Simultaneous shoulder and elbow dislocation Mutlu Çobanoğlu,1 Feridun Yumrukcal,2 Cengiz Karataş,3 Fatih Duygun4 1
Department of Orthopaedics and Traumatology, Adnan Menderes University School of Medicine, Aydın, Turkey 2 Department of Orthopaedics and Traumatology, Şişli Memorial Hospital, İstanbul, Turkey 3 Department of Orthopaedics and Traumatology, PrivateTuzla Hospital, Istanbul, Turkey 4 Department of Orthopaedics and Traumatology, Antalya Education and Research Hospital, Antalya, Turkey Correspondence to Dr Fatih Duygun, [email protected] Accepted 3 May 2014
To cite: Çobanoğlu M, Yumrukcal F, Karataş C, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014204686
SUMMARY Ipsilateral shoulder and elbow dislocation is very rare and only six articles are present in the literature mentioning this kind of a complex injury. With this presentation we aim to emphasise the importance of assessing the adjacent joints in patients with trauma in order not to miss any accompanying pathologies. We report a case of a 43-year-old female patient with ipsilateral right shoulder and elbow dislocation treated conservatively. The patient reported elbow pain when first admitted to emergency service but she was diagnosed with simultaneous ipsilateral shoulder and elbow injury and treated conservatively. As a more painful pathology may mask the additional ones, one should hasten to help before performing a complete evaluation. Any harm caused to the patient due to this reason would not be a complication but a malpractice.
BACKGROUND Ipsilateral simultaneous shoulder and elbow dislocation is a rare and complex injury. In total 50% of all dislocations are isolated traumatic shoulder dislocations followed by the elbow.1–3 Fractures around the dislocated joint may accompany. Humeral fracture with shoulder dislocation is much more common than simultaneous ipsilateral shoulder and elbow dislocation.4–6 In literature we found only six articles about ipsilateral shoulder and elbow dislocation.4 7–11 Decisions about the choice of treatment should be made after full evaluation of the patient’s situation including age, occupation, health status, severity of the injury and even whether the affected side is the dominant one or not. Decisions between a surgical intervention and a conservative measure should be made only after considering these factors, but before this a careful evaluation is necessary in order not to complicate the case. We report a case of a 43-year-old
Figure 1 (A) Image before reduction. (B) Anteroposterior X-ray of right elbow. (C) Lateral X-ray of right elbow. (D) Anteroposterior and lateral X-ray of the right elbow after reduction.
Çobanoğlu M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204686
1
Rare disease
Figure 2 (A) Image of the right shoulder. (B) Anteroposterior X-ray of the right shoulder before reduction. (C) Anteroposterior X-ray of the right shoulder after reduction. female patient with ipsilateral right shoulder and elbow dislocation treated conservatively.
CASE PRESENTATION A 43-year-old overweight (body mass index (BMI) 26 kg/m2) female patient was admitted with right elbow pain after falling down from 2 m. After her initial evaluation in the emergency room, deformity of the right elbow, oedema and approximately 2 cm of skin laceration on medial epicondyle were noted. Hypoesthesia of the ulnar nerve trace was also noted without any motor deficit. Radiographic evaluation revealed posterolateral elbow dislocation (figure 1A–D). The patient then was consulted with an orthopaedic surgeon. The following evaluation revealed discomfort and pain in the right shoulder with accompanying limitation of range of motion. Owing to her overweight no epaulette sign was inspected. Before any manipulation, radiographic evaluation of the shoulder was considered and anterior dislocation of the shoulder was diagnosed (figure 2A–C). Axillary nerve was intact. Brachial, radial and ulnar arteries were palpable. Trauma series were also seen in order not to leave a possible pelvic or vertebral injury undiagnosed. Under sedative anaesthesia, first the elbow and then the shoulder dislocations were reduced. Skin laceration was irrigated and sutured with added local anaesthesia. There was no osseous pathology on control radiographic evaluation and ulnar hypoesthesia no longer existed.
TREATMENT A long arm split and shoulder arm strap were used. After 3 weeks of immobilisation, shoulder and elbow rehabilitation programmes were begun simultaneously.
dislocation and so radiological evaluation of the proximal and distal bones of the involved joint is a must. When simultaneous dislocation of two neighbouring joints is diagnosed alcohol misuse must also be questioned as this might be the predisposing factor causing muscular relaxation.11 There is a consensus about the mechanism of injury and it is thought to be falling on the flexed elbow while the shoulder is in abduction.8 12 With this kind of trauma one must be very careful about a probable neurovascular injury. Re-examination must be carried out following reduction. In our case, skin laceration on the medial side of the elbow and ulnar nerve hypoesthesia were reasons to suspect ulnar nerve injury but it fully recovered after reduction and motor deficit never existed. When ipsilateral shoulder and elbow dislocation exists, the elbow must be reduced first in order to have a stable distal part. Shoulder reduction after the elbow is much easier and safer as the distal extremity is stable while reducing the shoulder.7–9 An orthopaedic surgeon is a consultant of a patient who is first seen in emergency service. Sometimes a consultant may evaluate the patient on the basis of the knowledge given by the doctor of emergency service. This may cause additional pathologies being overlooked. Hurried interventions without a thorough history taking and examination may cause potential harm to the patient, and this is unsuitable to the Hippocratic mandate —primum non-nocere— that is, ‘first do no harm’. As a more painful pathology may mask the additional ones, one should hasten to help before performing a complete evaluation. Any harm caused to the patient due to this reason would not be a complication but a malpractice. Although simultaneous ipsilateral shoulder and elbow dislocation is rare, every possibility should be kept in mind before any intervention is made and a detailed examination should be carried out to not overlook an accompanying pathology.
OUTCOME AND FOLLOW-UP In the third month after injury, full painless shoulder range of motion was reached. Elbow extension was limited to 5° without any sign of instability.
DISCUSSION Although isolated shoulder or elbow dislocations are frequently seen, simultaneous ipsilateral shoulder and elbow dislocation is rare. Six articles about simultaneous ipsilateral shoulder and elbow dislocation4 7–11 in literature mention the possibility of overlooking shoulder dislocation because of the elbow dislocation being more painful.7–9 Four of these articles also mention humeral fracture accompanying shoulder and elbow dislocation.4 7 8 10 Fractures may be seen neighbouring the joint 2
Learning points ▸ Ipsilateral simultaneous shoulder and elbow dislocation is a rare and complex injury. ▸ Decision about the choice of treatment should be made after full evaluation of the patient’s situation including age, occupation, health status, severity of the injury and even whether the affected side is the dominant one or not. ▸ As a more painful pathology may mask the additional ones, one should hasten to help before performing a complete evaluation. Çobanoğlu M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204686
Rare disease Competing interests None. Patient consent Obtained.
5 6
Provenance and peer review Not commissioned; externally peer reviewed. 7
REFERENCES 1
2 3 4
Taşkoparan H, Kılınçoğlu V, Tunay S, et al. Immobilization of the shoulder in external rotation for prevention of recurrence in acute anterior dislocation. Acta Orthop Traumatol Turc 2010;44:278–84. Kesmezacar H, Sarıkaya IA. The results of conservatively treated simple elbow dislocations. Acta Orthop Traumatol Turc 2010;44:199–205. Lasanianos N, Garnavos C. An unusual case of elbow dislocation. Orthopedics 2008;31:806. Inan U, Çevik AA, Ömeroglu H. Open humerus shaft fracture with ipsilateral anterior shoulder fracture-dislocation and posterior elbow dislocation: a case report. J Trauma 2008;64:1383–6.
8 9 10
11 12
Pradhan I, Banskota AK. Anterior dislocation of the shoulder with ipsilateral humerus shaft fracture. Kathmandu Univ Med J (KUMJ) 2008;24:502–4. Kazakos K, Paraschou S, Lasanianos NG, et al. A humeral shaft fracture complicated with anterior shoulder dislocation in a young male treated with modified Intramedullary nailing prior to reduction: a case report. Cases J 2009;2:9075. Ali FM, Krishnan S, Farhan MJ. A case of ipsilateral shoulder and elbow dislocation: an easily missed injury. J Accid Emerg Med 1998;15:198. Khan MR, Mirdad TM. Ipsilateral dislocation of the shoulder and elbow. Saudi Med J 2001;11:1019–21. Suman RK. Simultaneous dislocations of the shoulder and the elbow. Injury 1981;12:438. Kerimoglu S, Turgutoglu O, Aynaci O, et al. Ipsilateral dislocation of the shoulder and elbow joints with contralateral comminuted humeral fracture. Saudi Med J 2006;12:1908–2011. Essoh JB, Kodo M, Traoré A, et al. Ipsilateral dislocation of the shoulder and elbow: a case report. Niger J Surg Res 2005;7:319–20. Sankaran-Kutty M, Sadat-Ali M. Dislocation of the shoulder with ipsilateral humeral shaft fracture. Arch Orthop Trauma Surg 1989;108:60–2.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
Çobanoğlu M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204686
3
