A Peiro

CS Neer

DC Markel

G Mouzopoulos

HT Dinopoulos

KL Devalia

L Connor-Read

L Solomon

N Lasanianos

R Honner

English

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An undiagnosed bilateral anterior shoulder dislocation after a seizure: a case report

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Cases Journal

BioMed CentralCases Journal
ssOpen AcceCase Report
An undiagnosed bilateral anterior shoulder dislocation after a 
seizure: a case report
N Lasanianos* and G Mouzopoulos
Address: Department of Trauma and Orthopedic Surgery, General Hospital of Athens "Evangelismos", 45-47 Ypsilantoy St., 10676, Athens, Greece
Email: N Lasanianos* - lasagrc@hotmail.com; G Mouzopoulos - gmouzopoulos@yahoo.gr
* Corresponding author    
Abstract
Introduction: Late diagnoses of orthopaedic injuries after epileptic crisis are a matter of concern.
The rarity of correlation between seizure and specific trauma incidences such as bilateral anterior
shoulder dislocation, may lead to improper estimation of the patient's clinical state, wrong
treatment and unpleasant complications.
Case presentation: We report the rare case of an undiagnosed bilateral anterior shoulder
dislocation in an epileptic young man of 25 years of age. The way of treatment is described as well
as the treating alterations, if needed, because of the 3 weeks delay from injury. The article focuses
on the reasons of the non-diagnosis at the first place and proposes a possible explanation for the
mechanism of the injury. This is the second documented case of a missed bilateral anterior shoulder
dislocation following a seizure and the first one that was treated not earlier than 3 weeks post
injury.
Conclusion: Although not a matter of routine, the high importance of radiographic control after
seizure, in case of suspicion, is concluded. The etiology causing the injury shall not disorientate the
doctors from the possible diagnoses.
Background
Unilateral shoulder dislocation is the most common con-
cerning 85% of all dislocations. Ninety-five per cent of all
dislocations are anterior and 15% of them are combined
with greater tuberosity fractures [1]. The most common
bilateral shoulder dislocation is posterior resulting from
seizure or convulsion due to epilepsy, electric shock or
other reasons [2,3]. Simultaneous bilateral anterior shoul-
der dislocation is usually of traumatic origin and occurs
rarely [4,5]. Seizure has been charged in the past for bilat-
eral anterior shoulder fracture-dislocation [1,6,7]. Up to
our knowledge though, this is the first case concerning
treatment of such an undiagnosed post-seizure injury,
three weeks after its occurrence. The difficulties of the
diagnosis as well as the treatment are been described. A
possible explanation for the mechanism of the injury is
stated.
Case presentation
A 25 years old male patient presented for examination.
Several incidents of Grand Mal epileptic seizure were
referred with the last one three weeks ago. After the last
episode both shoulders' range of motion was regressed
and pain was elicited with movement. The patient visited
a hospital at that point and without radiographic control
performed, the diagnosis of bilateral shoulder contusions
was posed. About three weeks later and as the patient real-
ised that his injury was irreversible, he presented to the
Published: 21 November 2008
Cases Journal 2008, 1:342 doi:10.1186/1757-1626-1-342
Received: 14 October 2008
Accepted: 21 November 2008
This article is available from: http://www.casesjournal.com/content/1/1/342
© 2008 Lasanianos and Mouzopoulos; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:342 http://www.casesjournal.com/content/1/1/342emergency room of our hospital. Clinical examination
made clear that bilateral anterior shoulder dislocation was
the point. (Fig. 1). No neurovascular injury was diagnosed
in any arm. At the time of examination the patient was
able to perform flexion and abduction of both arms up to
60 degrees as well as almost full external rotation with no
pain restraint. From the patient's history no previous inci-
dence of shoulder dislocation was referred. Radiographic
control and Computed Tomography Scanning revealed
the dislocations as well as a sizeable greater tuberosity
fracture of the left humerus and Hill Sachs lesion at both
sides. (Fig. 2a–2b).
Bilateral reductions under general anaesthesia and inter-
nal fixation of the left greater tuberosity fracture were per-
formed (Fig. 3). The reductions were easy to perform and
shoulders' stabilisation was not carried out. No post
manipulation neurovascular deficit was observed. Ultra-
sonography performed 4 days post surgery confirmed the
integrity of rotator cuffs in both shoulders. Broad arm
polyslings in abduction and internal rotation were used
for 2 weeks and progressive mobilization started with
pendulum exercises, forward flexion and abduction. A
physiotherapy program of muscle enforcement was added
at 3 weeks. The recovery was successful and after 2 months
the patient had regained a normal range of motion in
both shoulders with a minor lack at the last degrees of
flexion and internal rotation of the left shoulder. Four
months post-operatively the range of motion was fully
recovered bilaterally and at the final follow-up, 2 years
post surgery, the patient had not undergone any recurrent
dislocation. Discussion
Anterior shoulder dislocations, unlike posterior, happen,
almost always, secondary to trauma. Posterior shoulder
dislocations usually occur following unbalanced muscle
contractions (electric shock, epileptic seizure etc) [5,8].
The reason why the shoulder dislocates anteriorly after
trauma is that as the arm extends and abducts, impinge-
ment of the greater tuberosity on the acromion levers the
humeral head out of the glenoid [5]. Moreover the rotator
cuff pushes downwards the humeral head which is finally
displaced anteriorly by the flexors and external rotators.
The posterior dislocations are more common after seizure
since the contraction of the relatively weak external rota-
tors and the posterior fibers of the deltoid are overcome
by the more powerful internal rotator. The succeeding
adduction and internal rotation usually causes the
humeral head to dislocate posteriorly [8]. One suggestion
about bilateral anterior dislocation following a seizure is
that this may occur not during the muscle contractions
but from the trauma of the shoulders striking the floor,
after the collapse [8]. Bilateral occurrence of anterior
shoulder dislocation is rare because almost always one
extremity takes the brunt of the impact during the trauma
incidence [5,8]. In our report we may suggest that loss of
The clinical view of a 3 weeks neglected bilateral anterior shoulder dislocati n after a seizureFig re 1
The clinical view of a 3 weeks neglected bilateral 
anterior shoulder dislocation after a seizure.
A) Radiographic control before reductionFigure 2
A) Radiographic control before reduction.B) CT scan 
pre reduction and ORIF (Open Reduction & Internal Fixa-
tion) showing a great tuberosity fracture of the left humerus 
and Hill Sachs lesions at both sites.Page 2 of 4
(page number not for citation purposes)
Cases Journal 2008, 1:342 http://www.casesjournal.com/content/1/1/342consciousness after the seizure did not allow the patient to
react and reflexly protect one of his arms by exposing the
other.
Associated fracture of the greater tuberosity occurs in 15%
of the anterior dislocation cases and indicates an associ-
ated rotator cuff tear. If the greater tuberosity fracture is
displaced the diagnosis of a rotator cuff tear is almost cer-
tain [9]. This may cause long term instability and func-
tional impairment if the fragment is not anatomically
reduced [5]. Thus internal fixation after the reduction
must be the rule in such cases.
Closed reduction of a neglected anterior shoulder disloca-
tion can be performed only up to six weeks post injury.
After this period the danger of an iatrogenic fracture or
neurovascular damage raises too high and operative pro-
cedures shall be followed. [10]
In our case the 3 weeks interval between the injury and the
rehabilitation did not seem to influence the final func-
tional outcome. Shoulder stabilization was not performed
but the patient experienced no recurrent dislocation after
two years of follow-up. As the shoulder is a muscle
dependant joint one could suggest that when rotator cuff
tears can be excluded, a proper physiotherapy program of
muscle enforcement alone could be sufficient for a very
good functional result, even in neglected cases like this
one.
The literature suggests that over 10% of documented bilat-
eral anterior shoulder dislocations following trauma were
diagnosed late [5]. As there is a greater awareness of ante-
rior shoulder dislocations for trauma patients, it would be
reasonable to assume that there may be a higher incidence
of delayed diagnosis of such an injury following a presen-
tation with an indirect complaint, such as a seizure. The
unusual presentation combined with the patient's post-
ictal discomfort and drowsy state may potentially delay
the diagnosis. As this could affect the prognosis, early rec-
ognition is vital. [8]
Conclusion
Bilateral anterior fracture dislocation is a rare injury fol-
lowing seizure but emergency room doctors shall be
familiar with this clinical situation. The etiology causing
the injury shall not disorientate the doctor from the pos-
sible diagnoses. Although full musculoskeletal examina-
tions are not routinely performed following a seizure,
radiographic control of the shoulders shall be indispensa-
bly performed in case of suspicion.
Consent
The authors of the study herein state that written
informed consent was obtained from the patient for pub-
lication of this case report and any accompanying images.
A copy of the written consent is available for review by the
Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
NL collected the data and drafted the manuscript. GM has
been involved in revising the manuscript for important
intellectual content. All authors read and approved the
final manuscript.
References
1. Devalia KL, Peter VK: Bilateral post traumatic anterior shoul-
der dislocation.  J Postgrad Med 2005, 51(1):72-73.
Post surgery radiographic controlFigure 3
Post surgery radiographic control.Page 3 of 4
(page number not for citation purposes)
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2. Cave EF, Burke JF, Boyd JF: Trauma Management: Year Book Medical
Publishers. Chicago; 1974:437. 
3. Honner R: Bilateral posterior dislocation of the shoulder.  Aust
N Z J Surg 1969, 38(3):269-272.
4. Peiro A, Ferrandis R, Correa F: Bilateral erect dislocation of the
shoulders.  Injury 1975, 6(4):294-295.
5. Dinopoulos HT, Giannoudis PV, Smith RM, et al.: Bilateral anterior
shoulder fracture-dislocation. A case report and a review of
the literature.  Int Orthop 1999, 23(2):128-130.
6. Segal D, Yablon IG, Lynch JJ, et al.: Acute bilateral anterior dislo-
cation of the shoulders.   Clin Orthop Relat Res 1979:21-22.
7. Markel DC, Blasier RB: Bilateral anterior dislocation of the
shoulders with greater tuberosity fractures.  Orthopedics 1994,
17(10):945-949.
8. Connor-Read L, Bloch B, Brownlow H: A missed orthopaedic
injury following a seizure: a case report.  J Med Case Reports
2007, 10(1):20.
9. Neer CS: Displaced proximal humeral fractures.  J Bone Joint
Surg [Am] 1970, 2:1077-1089.
10. Solomon L, Warwick D, Nayagam S: Injuries of the shoulder,
upper arm and elbow.  In Apleys System of Orthopaedics and Frac-
tures Edited by: Solomon L, Warwick D, Nayagam S. London: Arnold;
2001:587-589. Page 4 of 4
(page number not for citation purposes)


Acute bilateral anterior dislocation of the shoulders.

Bilateral anterior shoulder fracture-dislocation. A case report and a review of the literature. Int Orthop

Bilateral erect dislocation of the shoulders. Injury

Bilateral posterior dislocation of the shoulder.

Blasier RB: Bilateral anterior dislocation of the shoulders with greater tuberosity fractures. Orthopedics

Displaced proximal humeral fractures.

H: A missed orthopaedic injury following a seizure: a case report. J Med Case Reports

JF: Trauma Management:

Nayagam S: Injuries of the shoulder, upper arm and elbow.

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An undiagnosed bilateral anterior shoulder dislocation after a seizure: a case report

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