Simultaneous bilateral anterior shoulder fracture dislocations in the elderly: case report and focused clinical treatment algorithm

Shoulder dislocations are among the most common musculoskeletal diagnoses treated in emergency room. However, bilateral shoulder rare. The first report literature of a anterior dislocation was made by Sargent 1909.[7]Sargent P.W. Case Bilateral Dislocation with Marked Muscular Wasting.Proc R Soc Med. 1909; 2: 37PubMed Google Scholar In their review literature, Ballesteros noted 47% incidence associated fracture, 78% which were greater tuberosity fractures. They further that 53% fractures bilateral. Due to symmetric appearance upper extremities on presentation, up 15.7% these injuries missed during acute phase.[1]Ballesteros R. Benavente P. Bonsfills N. Chacón M. García-Lázaro F.J. shoulder: seventy cases and proposal new etiological-mechanical classification.J Emerg 2013 Jan; 44: 269-279https://doi.org/10.1016/j.jemermed.2012.07.047Abstract Full Text PDF PubMed Scopus (14) This infrequent injury pattern is commonly secondary trauma (50%) followed seizures (33%). Multiple options exist treat proximal humerus occur after dislocation, including arthroplasty, open reduction internal fixation (ORIF), or closed management. We present case an active 69-year-old female who sustained displaced ORIF utilizing multiple suture anchors double-row repair fashion. Here we discuss case, treatment algorithm, outcome for this patient. To our knowledge, reported significantly elderly patient suture-anchor fixation. An otherwise healthy, presented clinic one week sustaining fracture dislocations. She described traumatic mechanism both shoulders extended, abducted, externally rotated position while performing resistance exercise Pilates machine. tuberosities (Figure 1). Both glenohumeral joints initially reduced at outside hospital discharged slings. Post-reduction radiographs demonstrated significant retraction medialization right fragment posteriorly left 2). Given high prevalence asymptomatic rotator cuff tears patients over 60 years old[9]Sher J.S. Uribe J.W. Posada A. Murphy B.J. Zlatkin M.B. Abnormal findings magnetic resonance images shoulders.J Bone Joint Surg Am. 1995; 77: 10-15Crossref Scholar, elected proceed MRIs evaluate integrity (RTC) Goutallier stage 3). MRI intact RTC tendons minimal fatty infiltration, indicating open-reduction remained viable option restoration function Extensive discussion regarding management, ORIF, reverse total arthroplasty (rTSA) discussed quality her RTC, stage, baseline activity level, displacement fragments, decision ORIF.Figure 2Post-reduction radiographs. Significant medial (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figures 3A-BPreoperative shoulders. (3A) Coronal T2 sequence demonstrating increased compared post radiographs(arrow). (3B) Minimal infiltration Sagittal Tl muscles (SS — supraspinatus, IS infraspinatus, Sub subscapularis).View (PPT) Surgery performed two weeks initial injury. placed supine accessed deltopectoral approach. inflammation within long head biceps tendons. Biceps tenodesis securing tendon cranial border pectoralis major using #2 Fiberwire (Arthrex, Naples, FL, USA) figure-of-8 fashion prior amputation its origin supraglenoid tubercle. donor site identified débrided down bleeding cancellous bone. Number 5 passed anterior-to-posterior through osteotendinous junction aid manipulation fragments. A standard double row technique then 4.75mm pre-loaded tape (Arthrex Speedbridge; Arthrex, just lateral articular margin, footprint, approximately 1cm distal end footprint. footprint cortical read assess reduction. smooth 1.6mm Kirschner wire maintain provisional fragment. placed, inside-out RTC. tensioned, complete knotless repair. Intra-operative range motion examination satisfying humerus, moving as single unit. Final operative seen 3. wound irrigated normal saline, multi-layered closure performed. Postoperatively, coffee-cup weight bearing bilaterally slings comfort. immobilizers not utilized. home assistance from spouse op day 2. Codman exercises initiated 2 postop. Active assist overhead passive started 4 postop addition physical therapy. protocol employed At postop, she had forward flection 100o external rotation 30o bilaterally. 3 months, achieved flexion 120o 40o 6 months improved, 150o 155o, respectively, without pain 5) 45o Abduction measured 155o 130o left. able perform all activities daily living difficulty allowed return Pilates. There radiographic evidence healing early 1-month incorporation fragments (Figures 4). no loss migration fragments.Figure 5Clinical postop.View Traumatic often extremity extension, abduction, rotation, consistent patient’s reformer. Anterior rare displace excessive pull following such electrocution. Furthermore, combined remain particularly infrequent, especially what deemed be “safe controlled” time can 15% cases, index suspicion key diagnosis appropriate treatment.[1]Ballesteros patient, recognition complex timely presentation room undoubtedly helped contribute favorable outcome. Recently, also 41-year old exercise. successfully there case.[5]Ergün Yörük İ. Köyağasioğlu O. Simultaneous pilates reformer exercise: report.Physiother Theory Pract. 2023; 39: 667-674https://doi.org/10.1080/09593985.2021.2024312Crossref (0) have been studies looking outcomes those patients, but paucity dislocations.[1]Ballesteros Scholar,[3]Diallo Soulama Kaboré D.S.R. Dakouré P.W.H. Liverneaux dislocations: relevant literature.Clin Rep. 2020; 8: 3379-3388https://doi.org/10.1002/ccr3.3351Crossref Scholar,[8]Schneider K.N. Schliemann B. Manz S.M. Buddhdev P.K. Ahlbäumeri G. Elderly - Report Review Literature.J Orthop 2017; 7: 42-49https://doi.org/10.13107/jocr.2250-0685.890Crossref et. al. only 9 70 ORIF.[1]Ballesteros patients. Dlimi et al successful rehabilitation 76-year-old dislocations.[4]Dlimi F. Mahfoud Lahlou el Bardouni Berrada M.S. Yaacoubi tuberosity: report.J Clin Trauma. 2012; 3: 122-125https://doi.org/10.1016/j.jcot.2011.04.001Abstract (4) would choice younger similar injury, may given known full-thickness being 28% ≥ 50% old.[2]Brewer Aging cuff.Am J Sports 1979; 102-110Crossref Scholar,[6]Fehringer E v Sun J. VanOeveren L.S. Keller B.K. Matsen F.A. Full-thickness tear correlation co-morbidities sixty-five older.J Elbow Surg. 2008; 17: 881-885https://doi.org/10.1016/j.jse.2008.05.039Abstract (165) Scholar,[9]Sher As such, recommended setting preexisting, tear(s), indicated more advanced staging unlikely tear. Should demonstrate still address resulting mechanical block motion, rTSA should considered optimize functional influenced factors: dislocations, possibility subacromial impingement, level age, questionable preinjury competency based age. Thus, thorough preoperative work-up afforded assessment morphology, location, degree Non management risk impingement. Reverse imaging musculature good recovery could expected assuming healing. Additionally, high, likely limit ability achieve goal Therefore, absence pathology, returning level. arthroscopic approaches displacement, surgeon comfort access adequately reduce approach chosen. utilize approach, opposed deltoid split, axillary nerve facilitate future need arise. 69-year provided focused diagnostic algorithm characteristics technical considerations executing plan. anesthetic event. has excellent >150o regained tolerance pain. Lastly, like emphasize importance supervised