Bilateral posterior fracture-dislocation of the shoulders: management by bilateral shoulder hemiarthroplasties

Management of Bone Loss in Posterior Glenohumeral Shoulder Instability: Current Concepts

» Posterior glenohumeral instability is relatively uncommon compared with anterior instability, but is becoming an increasingly recognized and surgically managed shoulder pathology.» Soft-tissue stabilization alone may not be sufficient in patients who present with substantial bone loss to the posterior glenoid and/or the anterior humeral head.» For posterior glenoid defects, posterior glenoid osteoarticular augmentation can be used, and posterior glenoid opening wedge osteotomy can be considered in cases of posterior instability with pathologic retroversion.» For humeral head lesions, several surgical treatment options are available including subscapularis transposition into the humeral head defect, autograft or allograft reconstruction, humeral rotation osteotomy, and shoulder arthroplasty.

Simultaneous Bilateral Proximal Humerus Fractures Treated with Single-Stage Bilateral Reverse Shoulder Arthroplasty

Introduction

Simultaneous bilateral fractures of the proximal humerus are infrequent, and simultaneous bilateral three- or four-part fractures are even rarer. Reverse shoulder arthroplasty (RSA) is being used increasingly for the treatment of three- and four-part fractures of the proximal humerus. However, treatment of simultaneous bilateral fractures of the proximal humerus is difficult because of concern about postoperative immobilization and rehabilitation. Case Presentation. A 75-year-old woman presented with bilateral shoulder pain subsequent to a fall on the street. Physical examination and radiographs showed simultaneous bilateral fractures of the proximal humerus. The right side fracture was classified as a four-part fracture and the left side fracture as a three-part fracture, according to Neer's classification. The right shoulder had a risk of avascular necrosis of the humeral head. For the left shoulder, the fracture type had caused ischemia of the humeral head. Single-stage bilateral RSA was performed 9 days after the injury. An abduction pillow was applied for 5 weeks postoperatively. Passive motion exercises were permitted starting at 4 weeks postoperatively, and active range of motion exercises were permitted at 6 weeks postoperatively. At the patient's most recent follow-up 30 months after surgery, the patient reported no restriction of the activities of daily living. Radiographs revealed no lucent line on the humerus and glenoid components, although bone resorption and superior retraction of the tuberosities on both sides were observed.

Conclusions

Single-stage bilateral RSA improved shoulder function, but healing of the greater tuberosity can affect the improvement in external rotation after the operation. Although a long-term follow-up is needed, single-stage bilateral RSA appears to be a viable treatment option.

Bilateral posterior fracture-dislocation of the shoulders: Two rare case reports and literature review

RATIONALE

Bilateral posterior fracture-dislocation of the shoulders occurs rarely and the diagnosis is often challenging. This injury is often missed or delayed on initial presentation, leading to continuous pain, disability, and rising medical costs. Timely diagnosis and proper treatment are very important to restore shoulder function.

PATIENT CONCERNS

Here we report 2 rare cases. Case 1 was a 53-year-old physical worker with severe pain and limited shoulder movement after an unexpected fall. Case 2 was a 55-year-old man with pain in upper limbs and shoulders after an electric shock.

DIAGNOSIS

Both of them were diagnosed as bilateral posterior fracture-dislocation of the shoulders by computed tomography (CT) scan.

INTERVENTION

After systematic preoperative evaluation, both of them were treated with open reduction and internal fixation.

OUTCOMES

After 16 months follow-up, case 1 was pain-free in both shoulders. He had returned to full activity and was satisfied with his level of function. At 24 months follow-up, both shoulders of case 2 were painless and stable with acceptable range of motion and he was able to carry out daily activities.

LESSONS

Our case reports highlight that bilateral posterior fracture-dislocation of the shoulders is easy to be missed; one way to prevent missing diagnosis is to suspect cases with pain and limited external rotation, especially those with a history of seizures, electric shock, or severe trauma; appropriate history inquiry, physical examination, proper shoulder images are the key to correct diagnosis.

Simultaneous Bilateral Anterior Glenohumeral Joint Dislocation: A Case Report

The unilateral glenohumeral dislocation is the most commonly encountered dislocation in our practices but the simultaneous bilateral dislocation is very rarely seen entity. It almost always occurs posteriorly. While simultaneous bilateral anterior dislocations present even very rare. We report a case of 70-years-old male who visited to our emergency complex due to trauma after he fell into the bathroom in a drunk state. Patient complains of pain and deformity of both glenohumeral joints. Clinical and radiological findings revealed bilateral anterior glenohumeral joint dislocation. Close reduction under general anaesthesia was done and both shoulders were immobilized using shoulder immobilizer.

Simultaneous bilateral reverse shoulder arthroplasty for bilateral four-part fracture of the proximal humerus in an elderly patient: A case report

BACKGROUND

Proximal humeral fracture is the third most common fracture in elderly people after fractures of proximal femur and distal radius. They typically occur after low-energy trauma in women affected by osteoporosis, bilateral involvement is rare and usually with a simple pattern of fracture. Bilateral four-part proximal humerus fractures are even less frequent, with only a few reports published previously, with all of them caused by a seizure or electrocution in patients < 65 years old.

CASE PRESENTATION

We present a 77-year-old right-handed female that sustained a bilateral simultaneous four-part humeral fracture secondary to accidental slip-and-fall occurred at home. Patient was treated with simultaneous bilateral Reverse Shoulder Arthroplasty (RSA) in our structure. Functional assessment was undertaken at 6- and 12-months follow-up (FU) after surgery, using the Constant-Murley score (CMS) and the Disabilities of the Arm, Shoulder and Hand (DASH) score.

OUTCOME

The simultaneous RSA procedure was well tolerated by the patient. Post-operative course was optimal with relatively low blood loss, rapid functional recovery, and fast pain relief. The CMS and DASH score were reasonably good at 6-months FU (right-left: 39-57 and 50.8-30.5, respectively) and they further improved at 1-year FU (right-left: 66-82 and 35.8-19.2, respectively). X-rays showed good position of the implants with no evidence of scapular notching at 1 year. Patient rated the overall satisfaction as good.

DISCUSSION

Bilateral four-part proximal humeral fractures are complex injuries difficult to manage. Optimal treatment is controversial, and it can be conservative or surgical, varying from open reduction and internal fixation (ORIF) to arthroplasty. However, this last option is still directed to only one side, preferring ORIF or conservative treatment for the contralateral. In case of comminute and displaced fractures, low bone quality, rotator cuff deficiencies and eccentric osteoarthritis, RSA is to prefer as a surgical option. For these reason, in selected cases of bilateral four parts proximal humerus fracture, especially when occurs in elderly patients, the simultaneous RSA implantation can represent a valid option to achieve an adequate functional result and a fast recovery. This is the first description, to our knowledge, in English literature of a simultaneous bilateral RSA.

Treatment options for locked posterior shoulder dislocations and clinical outcomes

Posterior dislocations are rare and diagnostically difficult injuries. Diagnosis is often delayed and this leads to a locked posteriorly dislocated humeral head.

Treatment options include conservative methods and surgical anatomic reconstruction options as well as non-anatomic surgical procedures such as subscapularis tendon transfer, hemiarthroplasty and total shoulder arthroplasty.

Decision-making for treatment as well as prognosis depend on the extent of the articular defect size of the humeral head, duration of the dislocation and patient-specific conditions such as age and activity levels.

Cite this article: EFORT Open Rev 2019;4:194-200. DOI: 10.1302/2058-5241.4.180043

Simultaneous, Bilateral Acute Subscapularis Ruptures and Their Arthroscopic Management

We present the first known case of bilateral, acute ruptures of the subscapularis tendons following a bicycle accident in a 43-year-old male. He underwent right shoulder arthroscopic, anatomic subscapularis tendon repair two weeks postinjury, with the left side staged for surgical treatment six weeks after the index procedure. Postoperatively, the patient remained in a sling for 6 weeks before advancing with therapy protocols. The interval between arthroscopic treatments allowed for independence with activities of daily living and focused, early therapy for each shoulder. This approach yielded a right-sided constant score of 89 and subjective shoulder value of 90%; the left side was 87 and 90%, respectively, at 33 months postoperatively. The patient’s only postoperative complaint was slightly diminished external rotation, a near-universal limitation after unilateral repair. This represents a successful outcome that balances functional independence, concentrated rehabilitation, and adherence to safe indications for primary repair. While bilateral traumatic shoulder injuries in a young person is a rare clinical entity, early and staged treatment can lead to good patient outcomes.

No Sweat! Bilateral Shoulder Reduction Using a Modified Davos Technique

Shoulder dislocations are a common entity seen and treated in the everyday practice of emergency physicians. Bilateral simultaneous shoulder dislocations, however, are rare and are only described in the literature through case reports with no consensus about how to effectively and efficiently reduce them. We present a case of a 21-year-old male who sustained bilateral simultaneous anterior shoulder dislocations after a suspected seizure. Following confirmation with radiographs, the patient's dislocations were reduced successfully and in a timely manner using a novel method: the modified Davos technique.

The aetiology of posterior glenohumeral dislocations and occurrence of associated injuries

Aims

The glenohumeral joint is the most frequently dislocated articulation, but possibly due to the lower prevalence of posterior shoulder dislocations, approximately 50% to 79% of posterior glenohumeral dislocations are missed at initial presentation. The aim of this study was to systematically evaluate the most recent evidence involving the aetiology of posterior glenohumeral dislocations, as well as the diagnosis and treatment.

Materials and Methods

A systematic search was conducted using PubMed (MEDLINE), Web of Science, Embase, and Cochrane (January 1997 to September 2017), with references from articles also evaluated. Studies reporting patients who experienced an acute posterior glenohumeral joint subluxation and/or dislocation, as well as the aetiology of posterior glenohumeral dislocations, were included.

Results

A total of 54 studies met the inclusion criteria. In total, 182 patients were included in this analysis; study sizes ranged from one to 66 patients, with a mean age of 44.2 years (sd 13.7). There was a higher proportion of male patients. In all, 216 shoulders were included with 148 unilateral injuries and 34 bilateral. Seizures were implicated in 38% of patients (n = 69), with falls, road traffic accidents, electric shock, and iatrogenic reasons also described. Time to diagnosis varied across studies from immediate up to a delay of 25 years. Multiple associated injuries are described.

Conclusion

This review provides an up-to-date insight into the aetiology of posterior shoulder dislocations. Our results showed that seizures were most commonly implicated. Overall, reduction was achieved via open means in the majority of shoulders. We also found that delayed diagnosis is common.

Locked posterior dislocation of the shoulder: A systematic review

Locked posterior dislocation of the shoulder is very rare. Seizures and trauma are the most common causes of this injury.There is no current benchmark treatment strategy for these rare cases.This study has shown that reconstruction of the shoulder joint in an anatomical way in acute and chronic cases up to 16 weeks provides good results.The purpose of this study is to evaluate the results of different treatment procedures with outcomes and to compare the results of the same procedures in acute and chronic cases. Cite this article: EFORT Open Rev 2017;3:15-23. DOI: 10.1302/2058-5241.3.160089.

Check-Rein Technique for Management of Neglected Locked Posterior Shoulder Dislocations: Evaluation of Mid-term Outcome of a Novel Technique

Introduction: Neglected locked posterior shoulder dislocations, although rare, are quiet perplexing to manage. Various treatment methods have been explained for their management, but a consensus is still lacking. Besides describing a novel technique for the management of these lesions, this study aims to evaluate the mid-term outcome of this technique.

Method: This prospective study involved seven consecutive patients with locked posterior dislocation of the shoulder with humeral defect between 25% and 50%. All patients underwent open reduction of the locked posterior dislocation with the current technique. The final outcome was assessed at a mean follow up of 3.5 years (range 2-5 years) using the DASH score.

Result: The mean age of the patients was 32 years (range 21-44) and all were men. The mean time to presentation from initial injury was 2.4 years (range 2-4 years). The patient related outcome as measured by DASH score improved from a preoperative mean of 59.1 to mean value of 8.6 at the time of final follow up. There were no cases of graft pull out, nonunion at the graft site or infection.

Conclusion: This technique results in pain-free range of motion with a stable shoulder though a larger sample population with a longer follow up is required to further support our observations.

Simultaneous bilateral shoulder and bilateral central acetabular fracture dislocation: What to do?

Musculoskeletal injuries following seizures have a high morbidity and mortality. These injuries are often missed and the diagnosis is delayed due to a lack of clinical suspicion and appropriate investigations.We report a case of 72 years old male with simultaneous bilateral central acetabular fracture dislocation and bilateral posterior shoulder fracture dislocation secondary to an epileptic seizure. Present study high- lights the significance of clinical suspicion and clinico-radiological evaluation for diagnosis of a rare injury following episode of seizures. Simultaneous fracture dislocation of all four limbs treated with a holistic approach can lead to a good functional recovery. Surgical management with open reduction and internal fixation is preferred and replacement arthroplasty should be reserved for cases with implant failure and elderly patients.

Neglected posterior dislocation of the shoulder: A systematic literature review

Posterior dislocation of the shoulder (PSD) is a rare injury; the diagnosis is often missed on initial examination. We present a systematic review of the current literature and discuss the key of the diagnosis of PSD. We searched the MEDLINE, PubMed, EMBASE, MD Consult, and the Cochrane Controlled Trial Register databases for the articles according to our eligibility criteria. Finally, 53 articles were included in our systematic review. There were 242 shoulders in 205 patients. In total, in the initial assessment with anteroposterior radiographs in 166 cases, only 19 (11.4%) cases confirmed the right diagnosis. When anteroposterior combined with axillary or Y view radiographs or computed tomography were present as the initial assessments in 36 cases, the diagnoses were made correctly and timely (100%). When axillary or Y view radiographs or computed tomography were taken subsequently, the diagnosis was confirmed in all 205 patients.

Bilateral anterior shoulder dislocation

Shoulder dislocations are the most common major joint dislocations encountered in the emergency departments. Bilateral shoulder dislocations are rare and of these, bilateral posterior shoulder dislocations are more prevalent than bilateral anterior shoulder dislocations. Bilateral anterior shoulder dislocation is very rare. We present a case of 24-year-old male who sustained bilateral anterior shoulder dislocation following minor trauma, with associated greater tuberosity fracture on one side. Prompt closed reduction followed by immobilization in arm sling and subsequent rehabilitation ensured a good outcome.

Modified McLaughlin technique for neglected locked posterior dislocation of the shoulder

Several surgical techniques have been described for the treatment of posterior shoulder dislocation depending on the time elapsed between injury and surgery and the size of the humeral head impression fracture. When the bone defect is between 25% and 50% of the articular surface of the head, the procedures of choice are autologous bone graft or allograft or subscapularis tendon or lesser tuberosity transfer. In neglected cases in which patients undergo surgery more than 3 weeks after injury, no standard accepted treatment for this injury exists. This article presents a modification of the McLaughlin technique for patients with neglected locked posterior dislocation of the shoulder. Using this technique, the shape of the humeral head was nearly restored with impaction of morselized bone allograft; two suture anchors were inserted into the defect, and the lesser tuberosity with the attached sub-scapularis tendon was transferred into the defect and secured with sutures. Postoperative rehabilitation included immobilization of the shoulder with an external rotation brace for 6 weeks followed by progressive passive, active-assisted, and active range of motion and rotator cuff strengthening exercises for another 6 weeks. This technique resulted in pain-free range of motion, a stable shoulder, and good joint congruency.

Two-team simultaneous open surgical treatment in bilateral shoulder fracture dislocation

Different surgical options have been described for the treatment of bilateral shoulder fracture dislocations. We report 2 cases of bilateral shoulder fracture dislocation treated simultaneously by 2 surgical teams. One case had bilateral hemiarthroplasty performed, and the second case had 1 hemiarthroplasty and McLaughlin procedure on the other shoulder. A device to allow holding the patient in a bend chair position, with both shoulders hanging outside the operative table, allowing their free movement, was designed. At 1-year follow-up, neither of the patients had complications and both are pleased with their early result. Simultaneous treatment of both the shoulders by 2 different surgical teams in bilateral shoulder fracture dislocations that need surgical treatment has the advantages of reduced overall hospitalization time, reduced anesthetic risk, faster return to work, and reduced overall cost of care. The decision for simultaneous bilateral shoulder surgery must be made in concert with the patient, medical consultant, and anesthesiologist.

LEVEL OF EVIDENCE

Level IV-case series.

Diagnosis and management of humeral head bone loss in shoulder instability

Humeral head bone defects (Hill-Sachs lesions) are caused by anterior shoulder dislocation with impaction of the posterosuperior humeral head onto the anterior glenoid rim. Frequently, these bony lesions are associated with glenohumeral instability, and large lesions may contribute to recurrent instability after failure of a soft tissue repair. To improve outcomes and minimize the risk of persistent instability, a thorough understanding of the biomechanics of humeral bone loss is required. Detection and quantification of clinically relevant humeral head bone loss are performed through an accurate history, physical examination, and interpretation of imaging studies. The diagnosis and treatment options for reverse Hill-Sachs lesions are discussed, and the various treatment options for Hill-Sachs lesions are reviewed, including operative techniques to limit engagement of the deformity by soft tissue transfer, rotational osteotomy, bone grafting, or osteochondral transplantation.

Bilateral neglected posterior fracture-dislocation of the shoulders

Posterior dislocation of the shoulder is an uncommon injury. Diagnosis is difficult and often missed. Once diagnosed, management must be individualized depending on the amount of the defect of the humeral head and the time from injury. This article presents a case of a 40-year-old man with a 4-month history of bilateral locked posterior fracture-dislocation of the shoulders after a grand mal seizure. Imaging showed loss of the glenohumeral joint lines congruency, reverse Hill-Sachs lesions, and articular defects of 35% and 40% of the humeral heads. A modified McLaughlin technique was performed in both shoulders in a single stage. Through the standard deltopectoral approach, the lesser tuberosity was osteotomized with the subscapularis and capsule attached and elevated to expose the humeral head and glenoid. The shape of the humeral head was restored by packing the defect with morselized bone allograft. Before packing the allograft into the defect, 2 absorbable suture anchors were inserted at the bottom of the defect; the lesser tuberosity was transferred into the defect, and fixed with 2 transosseous horizontal mattress sutures. Stable fixation was evaluated intraoperatively, and the wound was closed in layers. Postoperatively, both shoulders were immobilized with external rotation braces for 6 weeks, followed by passive, active-assisted, and progressively active range of shoulder motion and rotator cuff strengthening exercises for the next 6 weeks. At 12 weeks postoperatively, full range of motion was accomplished, and full activity was allowed. At 22-month follow-up, the patient was satisfied with his level of function; both shoulder joints were painless and stable without apprehension or recurrence of instability. Radiographs showed congruent joints and complete incorporation of the allograft into the defect with restoration of the shape of the humeral head.

Incidence of associated injury in posterior shoulder dislocation: systematic review of the literature

OBJECTIVE

Posterior shoulder dislocations are rare and often missed. Classically associated with seizures, very little is known about the incidence and type of associated injuries. Unfortunately, the majority of the literature consists of incidental reports or small case series. Our goal was to increase the strength of available data by performing a systematic review.

DATA SOURCES

We searched EMBASE and PubMed for the terms "posterior shoulder dislocation." Our inclusion criteria were articles in either English or French with the words "posterior" and "dislocation" in the abstract or title. All reports of chronic cases or instability as well as those without patient information were excluded. Data regarding demographics, etiology, investigations, associated injuries, treatments, and outcomes were extracted. All data were analyzed by using SPSS 18.0 (IBM, Chicago, IL).

RESULTS

A total of 766 articles were found of which 108 were retained for analysis. A total of 475 patients (543 shoulders) were compiled. Seizures were reported in 34% of cases. A majority of dislocations (65%) had associated injuries. Fracture was most common followed by reverse Hill-Sachs and cuff tears. In the absence of fracture or reverse Hill-Sachs injury, the risk of cuff tear increased nearly fivefold (odds ratio, 4.6; P = 0.016).

CONCLUSION

Our results suggest the amount of associated injuries related to posterior shoulder dislocation is far greater than thought. We propose an investigation algorithm for acute posterior shoulder dislocations.

Acute bilateral posterior dislocation of the shoulder: one-stage reconstruction of both humeral heads with cancellous autograft and cartilage preservation

We present a case of bilateral posterior shoulder dislocation after an epileptic seizure. The anterior humeral-head impression fracture was 60% of the articular surface on the right shoulder and 30% on the left shoulder. We performed an early one-stage reconstruction of both humeral heads. A cancellous autograft was used on the left side and an iliac cortico-cancellous autograft on the right side, with preservation of the patient's cartilage. Three years later, the clinical and morphological results were excellent. The discussion focuses on surgical options that range from conservative treatment with excision of the damaged cartilage to immediate hemiarthroplasty. This case is original because of the preservation of the patient's cartilage during reconstruction.

[A bilateral posterior shoulder dislocation caused by humeral head osteonecrosis]

We report a case of simultaneous bilateral posterior shoulders dislocations in a 46-year-old male with antecedent of high-dose corticotherapy. The mechanism was non-traumatic after a contraction of the sub scapularis muscle in internal rotation. The interscapular pain was not initially diagnosed although a tomodensitometry was realized to eliminate a cardiovascular emergency. After reduction, the shoulders were unstable and the MRI showed an osteonecrosis of the humeral heads. The patient underwent surgery with an iliac spongy bone graft in the humeral nick. At 3 months, there was no recurrence and mobilities were good. Bilateral posterior shoulders dislocations are unusual and it is the first case of non-traumatic dislocation. Aetiology are often epilepsy, electrocution, and extreme traumatism. Diagnosis is often misrecognized and the treatment is not well codified.

Modified MacLaughlin procedure in the treatment of neglected posterior dislocation of the shoulder

Posterior dislocation of the shoulder is an unusual injury that most often occurs secondary to a high-energy trauma. Unfortunately the diagnosis is commonly missed, thus making its treatment a challenge. Neglected posterior dislocation is mainly characterised by an impression fracture on the anterior articular surface of the humeral head, which makes the dislocation often difficult to reduce. Diagnosis is based upon a careful history assessment, physical examination and radiological findings. Several treatment approaches have been described. The modified MacLaughlin procedure in our hands has been shown to be a reproducible technique allowing good results at medium- and long-term follow-up. According to our experience it is possible to adopt this technique also in patients with a locked posterior dislocation older than 6 months or in cases with a humeral head defect up to 50% when a shoulder prosthesis is not a good indication. Poorer results should be expected in patients with an associated fracture of the proximal humerus.

Traumatic posterior glenohumeral dislocation: classification, pathoanatomy, diagnosis, and treatment

Posterior humeral dislocations often go undetected. Proposed explanations for the delay in diagnosis include failure of the evaluating physician to include the condition in the differential diagnosis, suboptimal radiographic evaluation and interpretation, and coincidental injuries such as fractures that can confound the patient's presentation. It is imperative that the orthopedic surgeon develop a complete understanding of the nature of this injury and its treatment so that patients who present with this condition can be diagnosed and treated effectively. This article provides a detailed discussion of the classification, pathoanatomy, diagnosis, and treatment of traumatic posterior glenohumeral dislocation.

Bilateral posterior fracture-dislocation of the shoulder presenting as a dissecting aneurysm of the thoracic aorta: an uncommon presentation of a rare injury

Posterior dislocation or fracture-dislocation of the shoulder is a rare entity, and is often missed in the Emergency Department. The causes include a tonic-clonic seizure, electrocution, and major trauma. The clinical presentations are often misleading and thus the correct diagnosis may be delayed. Proper imaging of the shoulder in suspected cases is important in making the correct diagnosis. We report a rare case of bilateral posterior fracture-dislocation of the shoulders, which presented in the Emergency Department with clinical features suggestive of a dissecting aneurysm of the thoracic aorta. A review of the relevant literature is also presented.

One-stage operation for locked bilateral posterior dislocation of the shoulder

A man of 52 years of age had a grand mal seizure. He presented to our unit three months later with irreducible bilateral posterior dislocation of the shoulder. CT scans revealed large compression defects on the anteromedial aspect of the heads of both humeri. The defect on the right side was of more than 50% of the articular surface, and on the left side of 40%. He was treated by a one-stage operation with a hemiarthroplasty on one side and reconstruction of the head by an osteochondral autograft on the other. Three years later the clinical and radiological results were excellent.

Simultaneous bilateral posterior dislocation of the shoulder: diagnostic problems and management. A case report

We present the case of a patient who sustained simultaneous bilateral posterior dislocation of the shoulder after a possible epileptic fit. The confirmation of the diagnosis was reached only by a computed tomography (CT) scan, after the clinical suspicion. Under general anesthesia, close reduction of both shoulder dislocations was done. Posterior dislocation of the shoulder-especially the bilateral one-is very rare. When the history describes an electric shock or convulsive seizure, any shoulder injury demands a careful clinical and radiological evaluation. It is usually associated with reverse Hill-Sachs lesion (an impression defect of the anteromedial aspect of the humeral head), in which the size determines the treatment options.

[Simultaneous bilateral ventral and dorsal shoulder dislocation following an epileptic convulsion--a rare combination of injuries]

We report about a 29 year old male patient who had a simultaneous bilateral ventral and dorsal shoulder dislocation. The dislocation happened during a first incident of an epileptic convulsion, previously not diagnosed. On the right shoulder following a closed reduction manoeuvre a dislocation fracture was seen. It needed operative open reduction and fixation with angular stable plate osteosynthesis. The locked dorsal shoulder dislocation on the left was operated dorsally secondary via a dorsal approach. In a first step the reduction was carried out and in the same intervention the humeral head defect was lifted and supported in a closed technique under radiographic control.6 months postoperatively the patient was free of pain in both shoulder joints. The range of motion was unimpeded on the left and only with slight deficits in abduction and anteversion on the right. The diagnostics and the treatment strategy for this rare injury combination are described critically in this paper.

Restraining patients and shoulder dislocations during seizures

We describe 3 patients whose shoulders dislocated as the movements of the arm were restricted during a generalized tonic clonic seizure over an 18-month period. The first patient had both shoulders dislocated when observers sat on his arms during the convulsion. The second patient had a convulsion while in a forced lateral decubitus position and dislocated the shoulder on that side. The third patient dislocated the shoulder and fractured the acromion as she was held by her arms in a chair during a convulsion. Despite the large number of patients with refractory epilepsy under our care, no cases of spontaneous shoulder dislocation occurred during that period of time.

Complications of epilepsy and a ruptured pyonephrosis: radiology to the rescue in the Brooks murder case

A woman and her lover were accused of murdering the woman's husband. Five weeks after fracture/dislocations of both shoulders and a central fracture/dislocation of the right hip were diagnosed the woman's husband died of septicaemia consequent on a ruptured infected hydronephrosis. The shoulder and hip injuries and the ruptured hydronephrosis were attributed to a beating with a blunt instrument. A review of the medical records of the deceased, particularly his radiological examinations, led the authors to conclude that his joint injuries and ruptured kidney were not due to the alleged assault. The joint injuries were the consequence of epileptic seizures and the ruptured kidney was also due to natural causes. These medical opinions provided evidence that led to acquittal of the accused.

Bilateral anterior shoulder dislocations in bench pressing: an unusual cause

A case of bilateral anterior glenohumeral dislocation in a young weight trainer is presented. The patient, an insurance clerk, had been using a free weight bar in the bench press position and had become tired when the weight on the bar forced his arms into hyperextension in the mid-abducted position. The humeral shaft gradually pivoted on the bench and the humeral heads were slowly dislocated anteriorly by the weight of the bar. Simple closed reduction under sedation was performed and there were no complications. After six weeks in bilateral broad arm slings, with pendulum exercises from two weeks, the patient began to mobilise his arms and he achieved a full range of movements. This unusual mechanism of injury has not previously been reported and we recommend that bench pressing should be performed with a weight that can be "locked" to prevent crushing of the user. Furthermore, the bench should be narrow enough to allow the shoulders to overhang, allowing greater extension in the abducted position without the arm pivoting on the edge of the bench.