Luxofractura posterior bilateral de hombro secundaria a episodio de convulsión: importancia del diagnóstico oportuno. A propósito de un caso / Bilateral posterior glenohumeral fracture-dislocation secondary to a seizure episode: the importance of early diagnosis. A case review

Resumen: Introducción: la luxofractura glenohumeral posterior (LFGHP) es una lesión poco frecuente. Puede ser secundaria a una crisis convulsiva, casos de electrocución, o por traumatismo directo. Su diagnóstico suele ser tardío, lo que aumenta la tasa de complicaciones y secuelas. Caso clínico: paciente de sexo masculino de 52 años, trasladado a centro de alta complejidad por convulsión tónico-clónica y LFGHP derecha. En el estudio inicial con radiografías se confirma lesión de hombro derecho y se diagnostica luxación glenohumeral posterior simple de hombro izquierdo no pesquisada previamente. Se complementa estudio con tomografía computarizada (TC) de ambos hombros, observándose una LFGHP bilateral, lo que demuestra agravamiento intrahospitalario de la lesión del hombro izquierdo. Se realiza reducción abierta y osteosíntesis con placa bloqueada bilateral en un tiempo. El hombro izquierdo requirió dos reintervenciones, una por falla de osteosíntesis y otra para liberación articular. Dos años después del procedimiento el paciente evoluciona satisfactoriamente con 5% en la escala Quick DASH y un puntaje de 72 y 76 en la escala de Constant en el hombro derecho e izquierdo, respectivamente. Conclusión: la LFGHP es una lesión poco frecuente que requiere un alto índice de sospecha para evitar el retraso diagnóstico y la aparición de secuelas. En casos de convulsión se debe sospechar compromiso bilateral. Con un tratamiento quirúrgico oportuno se pueden obtener resultados satisfactorios y reintegración del paciente a sus actividades habituales.

Abstract: Introduction: posterior glenohumeral fracture dislocation (PGHFD) is a rare injury. It may present secondary to a seizure, electrocution or due to direct trauma. It is usually missed, and late diagnosis is common which increases the rate of complications and sequalae. Case report: 52 year old male, transferred to a reference trauma center due to a tonic-clonic seizure and a right PGHFD. Upon admission radiographs are requested and right shoulder injury is confirmed. Additionally, a simple left posterior glenohumeral dislocation (that was missed in the initial assessment of the patient) is observed. A computed tomography (CT) scan is obtained for both shoulders to plan surgery. The CT scan showed a bilateral PGHFD with severe comminution in the left shoulder, showing considerable worsening of the left shoulder since admission. Open reduction and bilateral locked plate osteosynthesis were performed in a one stage surgery. At two years follow up the patient evolved favorably with a Quick DASH score of 5% and a CONSTANT score of 72 and 76 for his right and left shoulder, respectively. Conclusion: PGHFD is an infrequent injury, which requires a high level of suspicion to avoid diagnostic delay and prevent complications and sequelae. Bilateral cases may be seen in cases of seizure. With prompt surgical treatment, satisfactory results can be achieved with a complete return to normal activities.

[Bilateral posterior glenohumeral fracture-dislocation secondary to a seizure episode: the importance of early diagnosis. A case review]. / Luxofractura posterior bilateral de hombro secundaria a episodio de convulsión: importancia del diagnóstico oportuno. A propósito de un caso.

INTRODUCTION: posterior glenohumeral fracture dislocation (PGHFD) is a rare injury. It may present secondary to a seizure, electrocution or due to direct trauma. It is usually missed, and late diagnosis is common which increases the rate of complications and sequalae. CASE REPORT: 52 year old male, transferred to a reference trauma center due to a tonic-clonic seizure and a right PGHFD. Upon admission radiographs are requested and right shoulder injury is confirmed. Additionally, a simple left posterior glenohumeral dislocation (that was missed in the initial assessment of the patient) is observed. A computed tomography (CT) scan is obtained for both shoulders to plan surgery. The CT scan showed a bilateral PGHFD with severe comminution in the left shoulder, showing considerable worsening of the left shoulder since admission. Open reduction and bilateral locked plate osteosynthesis were performed in a one stage surgery. At two years follow up the patient evolved favorably with a Quick DASH score of 5% and a CONSTANT score of 72 and 76 for his right and left shoulder, respectively. CONCLUSION: PGHFD is an infrequent injury, which requires a high level of suspicion to avoid diagnostic delay and prevent complications and sequelae. Bilateral cases may be seen in cases of seizure. With prompt surgical treatment, satisfactory results can be achieved with a complete return to normal activities.

INTRODUCCIÓN: la luxofractura glenohumeral posterior (LFGHP) es una lesión poco frecuente. Puede ser secundaria a una crisis convulsiva, casos de electrocución, o por traumatismo directo. Su diagnóstico suele ser tardío, lo que aumenta la tasa de complicaciones y secuelas. CASO CLÍNICO: paciente de sexo masculino de 52 años, trasladado a centro de alta complejidad por convulsión tónico-clónica y LFGHP derecha. En el estudio inicial con radiografías se confirma lesión de hombro derecho y se diagnostica luxación glenohumeral posterior simple de hombro izquierdo no pesquisada previamente. Se complementa estudio con tomografía computarizada (TC) de ambos hombros, observándose una LFGHP bilateral, lo que demuestra agravamiento intrahospitalario de la lesión del hombro izquierdo. Se realiza reducción abierta y osteosíntesis con placa bloqueada bilateral en un tiempo. El hombro izquierdo requirió dos reintervenciones, una por falla de osteosíntesis y otra para liberación articular. Dos años después del procedimiento el paciente evoluciona satisfactoriamente con 5% en la escala Quick DASH y un puntaje de 72 y 76 en la escala de Constant en el hombro derecho e izquierdo, respectivamente. CONCLUSIÓN: la LFGHP es una lesión poco frecuente que requiere un alto índice de sospecha para evitar el retraso diagnóstico y la aparición de secuelas. En casos de convulsión se debe sospechar compromiso bilateral. Con un tratamiento quirúrgico oportuno se pueden obtener resultados satisfactorios y reintegración del paciente a sus actividades habituales.

Acetylcholinesterase and inhibitors: effects upon normal and regenerating nerves of the rat.

In peripheral nerves, the function of acetylcholinesterase (AChE) is not related to hydrolysis of acetylcholine. To test for a trophic role, AChE or its inhibitors were administered locally to normal and regenerating nerves of rats. In the normal nerve, neither AChE nor serum albumin affected the cytological pattern of the nerve. BW284c51, a specific inhibitor of AChE, resulted in demyelination, proliferation of Schwann cells and sprouting of axons after 5-7 days. Edrophonium or propidium, other specific inhibitors of AChE, did so to a much lesser extent. Vehicle, and iso-OMPA (inhibitor of pseudocholinesterases) did not affect the cytology of the nerve. Elongation of regenerating axons was evaluated at day 3 post-crush. Native AChE applied distal to the crush reduced the elongation of regenerating axons (- 36%), while serum albumin, heated AChE and filtered AChE did not. BW284c51, edrophonium or propidium enhanced the axonal elongation (33%) when they were administered for 2 days before, but not after, the crush. Iso-OMPA or vehicle administered before or after the crush were not effective. Thus, AChE reduces elongation of regenerating axons, while inhibition of AChE enhances elongation and affects the cytology of the normal nerve as well. We propose that AChE has a trophic role in mammalian peripheral nerves.

Regenerating axons of the rat require a local source of proteins.

Regenerating axons need proteins to grow and we explored whether a local supply is necessary. Crushed peroneal nerves were entubulated with silicone sleeves, plain or loaded with cycloheximide (CHX); some nerves were frozen to kill resident cells. When a plain sleeve was placed distal to the crush, axons regrew 5.0 mm in 3 days (pinch test), and 4.6 mm when the sleeve was placed around a frozen nerve (n.s). CHX administered distal to the crush reduced the elongation by approximately 58% (P < 0.01) in unfrozen or frozen nerves whilst its administration central to the crush was ineffectual. Immunostaining of nerves with GAP-43 gave similar values. Under the electron microscope, axonal sprouts were less frequent when CHX was used irrespective of the cellular or acellular condition of the nerve. Therefore, an inhibitor of protein synthesis reduces axonal regrowth, an effect mediated neither by parent neurones nor by resident cells. We propose that axons synthesize proteins.