I woke up like that! – Bilateral Shoulder Pain

This patient had bilateral posterior shoulder dislocation, with associated fractures.

• • Posterior shoulder dislocations make up 2-4% of shoulder dislocations.
  • May go undiagnosed and often missed on physical exam and imaging
  • Epileptic seizures or electrical shocks, sports injuries are the most common causes.

• • Subtle signs on AP X-Ray include:
    • • Light Bulb Sign: Fixed internal rotation of the humeral head, makes the greater tuberosity anterior, giving a symmetrical appearance of the humeral head, that looks like a light bulb.
      • Empty Glenoid Sign: Humeral Head and Glenoid fossa widened articular space
      • Trough Sign: Vertical Line on AP, can indicate compression fracture of the humeral head medially.
  • In suspected Posterior Shoulder Dislocations, you should always get multiple views, including Anterior-Posterior (AP), scapular (Y), and Axillary Views.

• • Rounded posterior shoulder.
  • Prominent coracoid and acromion.
  • Palpable posterior humeral head.
  • Flattened anterior shoulder contour.

• • Neurovascular injuries
  • Rotator cuff tears
  • Osteonecrosis of the humeral head
  • Recurrent posterior shoulder instability or re-dislocation
  • Joint stiffness and post-traumatic osteoarthritis

• • You need to evaluate each case separately. The cases like this patient, with associated fractures, can complicate your management, and hence consulting orthopedic services would be advised, as surgical interventions should be evaluated.
  • If closed reduction fails, usually open reduction is pondered by subspecialty, especially in cases with extensive damage to the humeral head.
  • In cases with no associated fractures, the approach is the reduction of the dislocation. Most of them would require procedural sedation and analgesia.
  • Consider discussing options of procedural sedation and analgesia, with or without intraarticular blocks with your attending, for better and successful procedures, and minimal pain for your patient. The most convenient procedure options should also be discussed with patients, and consent should be taken. 
  • Patients would require pre and post-reduction neurovascular examination and X-rays.
  • Make sure your patient is examined again after the procedure, assessing the stability of the joint for regained full range of motion. 
  • Shoulder immobilization and follow up care plans with orthopedics services should be arranged.
  • Don’t forget, patients with known epilepsy, non-adherence or uncontrolled seizures have to be evaluated as well, and referred to appropriate neurology evaluation.