Bilateral shoulder pain developing after a hypoglycemic seizure

■ Posterior dislocation of the shoulder accounts for less than 4% of all shoulder dislocations, making it a high-risk condition for delayed diagnosis. Maintain a high index of suspicion for these injuries, especially in patients who have had a seizure or sustained a high-voltage electrical shock injury.

■ Physical examination findings are often nonspecific and may be masked by pain or swelling, making it difficult to assess the patient adequately.

■ A keen understanding of the radiographic anatomy of the shoulder is required to accurately evaluate standard radiographic views of the shoulder.

■ The Velpeau view, angle-up view, and scapular lateral view allow for appropriate analysis of the glenohumeral joint when standard axillary lateral radiographs are not possible. These alternate views can be obtained with minimal patient discomfort.

■ Before attempting closed reduction, refer fracture-dislocations of the shoulder involving the anatomic or surgical neck of the humerus to an orthopedic surgeon.

CASE

A 63-year-old male presented to the emergency department (ED) with bilateral shoulder pain. He reported that 4 days earlier, he experienced a hypoglycemic seizure and that the shoulder pain had been constant since then. His wife witnessed the seizure and denied that he had experienced any associated trauma. Immediately after the seizure, the patient refused transport by emergency medical services but acknowledged experiencing the shoulder pain. He presented to his primary care physician the following morning, when routine laboratory tests were ordered, a physical examination was conducted, and referral to a neurologist was made. At the neurology clinic, the patient reiterated his continued shoulder pain, for which bilateral shoulder radiographs were obtained. The radiographs showed that the patient had sustained bilateral fractures of the proximal humerus. The patient was notified and referred to the ED for further evaluation.

History and examination The patient's history was significant for diabetes, mild hypertension, hypercholesterolemia, and benign prostatic hypertrophy. He had no history of seizure disorders. He denied any tobacco use and acknowledged drinking one glass of wine a few nights a week. He stated that he has three to four meals a day and exercised regularly.

The patient was a well-nourished, well-developed white male with mild shoulder discomfort. He appeared to be in good physical condition for his age. His vital signs were stable. Focused examination of the shoulder revealed no open wounds, with mild ecchymosis of the anterior aspect of the shoulder and anterior arm bilaterally. There were no obvious deformities of the shoulder region or the proximal arm, but there was soft tissue swelling and tenderness of the superior and lateral aspect of the deltoid muscle and the anterior aspect of the glenohumeral joint. Active range of motion was limited in forward flexion, abduction, and especially external rotation. Passive range of motion in forward flexion was limited to 60 degrees, abduction to 20 degrees and external rotation to neutral (0 degrees). The elbow, wrist, hands, and fingers were normal. Radial and ulnar pulses were intact bilaterally. Motor and sensory function of the axillary, musculocutaneous, radial, median, ulnar, and the posterior and anterior interosseous nerves were grossly intact bilaterally. Strength was decreased as a result of pain around the shoulders but was equal bilaterally.

Imaging Bilateral anteroposterior (AP) views of the shoulders in internal rotation (Figure 1) and external rotation (Figure 2) revealed no obvious abnormality of the clavicles, acromioclavicular joints, or glenohumeral joints. The left shoulder showed a fracture of the lesser tuberosity, and the right shoulder demonstrated a fracture of the medial aspect of the proximal humerus near the insertion of the pectoralis major. Axillary views (Figure 3) indicated bilateral posterior shoulder dislocations, as well as large lesser tuberosity fragments and reverse Hill-Sachs lesions (compression fracture of the anterior humeral head). The left shoulder axillary view also demonstrated a small fracture of the posterior glenoid rim.

Closed reductions of the dislocations were achieved in the ED using the Brooke Army reduction sequence,¹ and postreduction radiographs and CT scan confirmed articular congruity. The patient was placed in bilateral shoulder slings with abduction pillows and admitted for pain control. The medicine service was consulted for further evaluation and management of the patient's diabetes while operative management was planned and discussed with the patient.