Bilateral fracture of the shoulders following epileptic seizures: a case report / Fratura bilateral de ombros após convulsões epilépticas: relato de caso

Convulsive seizures caused by hyponatremia occur when this condition is severe and develops quickly, resulting in a brain's adaptive inability to contain brain swelling. Seizures are rarely the cause of shoulder fractures. This is a case report of bilateral humerus fracture following a single epileptic seizure caused by drug hyponatremia, an unconventional event in medical practice. A 69-year-old woman was admitted to the emergency room after a single tonic-clonic seizure with spontaneously ceased sphincter relaxation, showing Glasgow 6. No falls or restraint were reported by observers. When alert, the patient reported pain and difficulty moving both arms. During examination, the movement was li- mited to the right and left. Anteroposterior radiographs revealed bilateral fracture at the neck of humerus. To complement inves- tigation for further lesions, a computed tomography confirmed bilateral fracture-dislocation with impaction of the humeral head with the glenoid. Atraumatic bilateral fracture-dislocation of the humerus after epileptic seizure is a very rare event. It is believed that some of these diagnoses have been neglected due to the difficulty of characterizing the patient's pain in a postictal state. The importance of a detailed physical examination shall be emphasized in risk groups such as the polymedicated elderly.

Convulsive seizures caused by hyponatremia occur when this condition is severe and develops quickly, resulting in a brain's adaptive inability to contain brain swelling. Seizures are rarely the cause of shoulder fractures. This is a case report of bilateral humerus fracture following a single epileptic seizure caused by drug hyponatremia, an unconventional event in medical practice. A 69-year-old woman was admitted to the emergency room after a single tonic-clonic seizure with spontaneously ceased sphincter relaxation, showing Glasgow 6. No falls or restraint were reported by observers. When alert, the patient reported pain and difficulty moving both arms. During examination, the movement was li- mited to the right and left. Anteroposterior radiographs revealed bilateral fracture at the neck of humerus. To complement inves- tigation for further lesions, a computed tomography confirmed bilateral fracture-dislocation with impaction of the humeral head with the glenoid. Atraumatic bilateral fracture-dislocation of the humerus after epileptic seizure is a very rare event. It is believed that some of these diagnoses have been neglected due to the difficulty of characterizing the patient's pain in a postictal state. The importance of a detailed physical examination shall be emphasized in risk groups such as the polymedicated elderly.

Scapulothoracic dissociation and blunt vertebral vascular injury: case report / > Disociación escapulo-torácica y trauma cerrado de arteria vertebral: reporte de un caso

Abstract Case Description: A 24-year-old male suffers from a motor vehicle accident with penetrating neck trauma and concomitant closed left cervicothoracic trauma. Clinical Findings: High impact trauma causing hypovolemic shock, left zone I penetrating neck trauma, ischemia due to blunt trauma to the axillary vessels, and brachial plexus injury. Transection of the vertebral artery on angiotomography. Diagnosed with scapulothoracic dissociation and vertebral artery trauma. Treatment and outcome: Axillary arteriovenous reconstruction, fasciotomies, non-surgical approach of the vertebral artery trauma, and deferred treatment of the brachial plexus trauma were performed. Survival of the patient and his limb, with major neurologic sequelae Clinical Relevance: The case presented here is an example of scapulothoracic dissociation with associated trauma to the vertebral artery, injuries that are uncommon and associated with high morbidity and mortality. Early recognition of the injuries and a multidisciplinary approach for this complex case by surgical board reviews at various levels within the course of care were key determinants in the patient's improved prognosis. This case report presents an analysis of the diagnostics, treatment, and course; considering in-hospital care and the decision-making process as determinants for the prognosis in a polytrauma patient.

Resumen Descripción del caso: Varón de 24 años que sufre accidente automovilístico con trauma penetrante de cuello y trauma cerrado cervico torácico izquierdo concomitante. Hallazgos clínicos: Shock hipovolémico, trauma en zona I cuello izquierdo, isquemia por trauma cerrado de vasos axilares y lesión por trauma cerrado del plexo braquial; producto de trauma de alto impacto. Sección de arteria vertebral por angiotomografia. Se diagnostica disociación escapulo-torácica y trauma de arteria vertebral. Tratamiento y resultado: Reconstrucción vascular arterio-venosa axilar, fasciotomías y abordaje no operatorio del trauma de arteria vertebral, con manejo diferido del trauma del plexo braquial. Sobrevida del paciente y su extremidad, con secuelas neurológicas mayores. Relevancia clínica: Es un caso de disociación escapulotorácica y lesión de arteria vertebral concomitante, siendo esta una asociación infrecuente y de alta morbi-mortalidad. El reconocimiento temprano de las lesiones y un abordaje multidisciplinario de este escenario de complejidad por medio de juntas quirúrgicas en varios niveles del proceso de atención, fueron determinantes para cambiar el pronóstico del paciente. Se presenta un análisis del diagnóstico, manejo y evolución; considerando el proceso de atención hospitalaria, toma consensuada de decisiones y el pronóstico en un paciente politraumatizado.

Luxação glenoumeral anterior bilateral: caso clínico / Bilateral anterior glenohumeral dislocation: clinical case

A luxação glenoumeral anterior bilateral é uma ocorrência rara. Apresentamos um caso de luxação glenoumeral anterior bilateral com origem após uma queda da própria altura. O interesse desta publicação reside no fato de se tratar de uma raridade clínica com poucos casos descritos na literatura. Paciente do sexo feminino com 89 anos recorre ao serviço de urgência (SU) após queda referindo dor intensa e incapacidade de mobilização de ambos os ombros. Ao exame objetivo apresentava sinais clínicos suspeitos de luxação glenoumeral anterior bilateral confirmados por radiografia. Ambas as luxações foram reduzidas no SU pela técnica de Milch modificada, com sucesso. Quando existe uma força simétrica e síncrona sobre os ombros e estes se apresentarem dolorosos e com limite funcional significativo, a suspeita de luxação glenoumeral bilateral, embora rara, é um diagnóstico diferencial a ter em conta.

Bilateral anterior glenohumeral dislocation is a rare occurrence. We present a case of bilateral anterior glenohumeral dislocation caused by a fall. The interest in publishing this case is that this is a clinical rarity with few cases reported in the literature. An 89-year-old female patient was brought to the emergency department after a fall, complaining of intense pain in both shoulders and inability to move them. Objective examination showed clinical signs giving the suspicion of bilateral anterior glenohumeral dislocation, which was confirmed by x-ray imaging. Both dislocations were successfully reduced in the emergency department using the modified Milch technique. When a synchronous and symmetrical force has acted on both shoulders and these are painful with significant functional limitation, the suspicion of bilateral glenohumeral dislocation is a differential diagnosis to be considered, even though it is rare.

Cementless shoulder surface replacement with glenoid levelling in posttraumatic glenohumeral arthritis

Degenerative glenohumeral arthritis is a possible complication after traumatic glenohumeral dislocation. Shoulder surface replacement arthroplasty has been established for several decades as a mean to restore comfort and function of the shoulder for many afflictions that derange the normal anatomy. The surface replacement may offer some advantages over the stemmed prostheses. We encountered a case with glenohumeral arthritis following neglected fracture dislocation of the shoulder. Copeland cementless surface replacement together with glenoid levelling was done. Six months postoperatively the constant score was markedly improved [82 points]. The patient showed complete relief of pain with marked improvement of the range of movement of the shoulder. The early results in this patient with the use of Copeland cementless surface replacement for treatment of posttraumatic glenohumeral arthritis together with levelling of the glenoid surface were encouraging. The levelling of the glenoid facilitates the smooth gliding of the prosthesis which in turn improves the range of motion and avoids the replacement of the glenoid with its high risk of future loosening. More cases with longer follow-up to document these findings are necessary

Efficacy of shoulder slings in shoulder subluxation of stroke patients.

OBJECTIVE: To assess the efficacy of the two types of shoulder slings in reducing shoulder subluxation in acute stroke patients. MATERIAL AND METHOD: Twenty-one acute stroke patients with shoulder subluxation were assessed for the subluxation distance before and after wearing the slings by physical examination and radiological measurement. The comparison by radiological measurement was performed by two radiologists who were blinded to each other as well as to the types of sling used. RESULTS: The mean difference of subluxation distance on the affected side after wearing the slings number 1 and 2 were 0.48 mm and 1.14 mm respectively on physical examination and 2.09 mm and 1.14 mm respectively on radiological assessment. There was no statistically significant difference of subluxation distance on either physical examination or radiological assessment (p > 0.05). CONCLUSION: There was no difference in efficacy of shoulder slings in reducing shoulder subluxation in acute stroke patients.

Luxação recidivante do ombro: do papiro de Edwin Smith à capsuloplastia térmica / Shoulder recurrent dislocation: from Edwin Smith's papyrus to thermal capsuloplasty

O primeiro registro de luxação glenoumeral remonta ao papiro de Edwin Smith (3000-2500 a.C.), sendo conhecida e estudada por Hipócrates (470-377 a.C.). Desde então, houve grande evolução no diagnóstico, entendimento e, especialmente, no tratamento dessa patologia e das lesões a ela associadas. Os avanços dos métodos diagnósticos e o conhecimento anatômico permitiram que novas lesões associadas fossem reveladas (SLAP, GLAD, ALPSA, HAGL), modificando o método de tratamento. O entendimento da avulsão do lábrum, conhecida como lesão de Bankart, e denominada "lesão essencial", foi fundamental para o aprimoramento da técnica cirúrgica. As técnicas cirúrgicas antigas, que visavam a estabilização através de encurtamento capsular ou bloqueio da rotação externa, sem corrigir a lesão labral, foram substituídas pela reinserção do lábrum, restaurando a anatomia. O emprego das âncoras de sutura diminuiu o tempo cirúrgico e facilitou tecnicamente o procedimento. O entendimento dos conceitos de instabilidade e de frouxidão capsuloligamentar foram igualnente importantes na escolha da técnica apropriada. As técnicas cirúrgicas atuais visam a reconstrução das lesões associadas, sem causar restrição da mobilidade ou de atividade do paciente. A análise de diversas publicações demonstra que a técnica aberta para o tratamento da luxação recidivante é um procedimento com resultados conhecidos e com baixo índice de recidiva e outras complicações, sendo considerado ainda como o golden standard. A técnica artroscópica, minimamente invasiva, sem dúvida trouxe grande avanço, com melhor conhecimento das lesões associadas, melhor cosmese e com preservação do músculo subescapular. Apresenta resultados comparáveis aos da técnica aberta, quando a adequada seleção do paciente é realizada. A cirurgia de Bristow permanece sendo um procedimento de "salvação", nos casos de grande fratura do rebordo da glenóide e falha da técnica convencional. A capsuloplastia térmica produz resultados incertos e seu uso vem sendo abandonado

Comparison between Conventional MR Arthrograhphy and Abduction and External Rotation MR Arthrography in Revealing Tears of the Antero-Inferior Glenoid Labrum

OBJECTIVE: To compare, in terms of their demonstration of tears of the anterior glenoid labrum, oblique axial MR arthrography obtained with the patient's shoulder in the abduction and external rotation (ABER) position, with conventional axial MR arthrography obtained with the patient's arm in the neutral position. MATERIALS AND METHODS: MR arthrography of the shoulder, including additional oblique axial sequences with the patient in the ABER position, was performed in 30 patients with a clinical history of recurrent anterior shoulder dislocation. The degree of anterior glenoid labral tear or defect was evaluated in both the conventional axial and the ABER position by two radiologists. Decisions were reached by consensus, and a three-point scale was used: grade 1=normal; grade 2=probable tear, diagnosed when subtle increased signal intensity in the labrum was apparent; grade 3=definite tear/defect, when a contrast material-filled gap between the labrum and the glenoid rim or deficient labrum was present. The scores for each imaging sequence were averaged and to compare conventional axial and ABER position scans, Student's t test was performed. RESULTS: In 21 (70%) of 30 patients, the same degree of anterior instability was revealed by both imaging sequences. Eight (27%) had a lower grade in the axial position than in the ABER position, while one (3%) had a higher grade in the axial position. Three whose axial scan was grade 1 showed only equivocal evidence of tearing, but their ABER-position scan, in which a contrast material-filled gap between the labrum and the glenoid rim was present, was grade 3. The average grade was 2.5 (SD=0.73) for axial scans and 2.8 (SD=0.46) for the ABER position. The difference between axial and ABER-position scans was statistically significant (p<0.05). CONCLUSION: MR arthrography with the patient's shoulder in the ABER position is more efficient than conventional axial scanning in revealing the degree of tear or defect of the anterior glenoid labrum. When equivocal features are seen at conventional axial MR arthrography, oblique axial imaging in the ABER position is helpful.

O ombro doloroso na hemiplegia: uma abordagem para o clínico / The dolorous shoulder in hemiplegia: an approach for the clinician

Os autores fazem uma revisäo bibliográfica, visando fornecer ao clínico geral, uma abordagem diagnóstica, terapêutica e preventiva das complicaçöes do ombro nos pacientes humiplégicos

Tratamiento de la luxación anterior recidivante del hombro por la técnica de Boytchev / Treatment of relapsing anterior shoulder dislocation by the Boytchev's technique

Para la confección de trabajo se revisaron las historias clínicas de los pacientes ingresados en el Servicio de Ortopedia y Traumatología del Hospital Provincial Clínicoquirúrgico Docente "Celia Sánchez Manduley", desde enero de 1981 a diciembre de 1987, con el diagnóstico de luxación anterior recidivante del hombro y que fueron intervenidos quirúrgicamente por la técnica de Boytchev, con el objetivo de evitar la recidiva de la luxación y conseguir una función óptima de la articulación