Simultaneous shoulder and elbow dislocation

Abstract

Ipsilateral shoulder and elbow dislocation is very rare and only six articles are present in the literature mentioning this kind of a complex injury. With this presentation we aim to emphasise the importance of assessing the adjacent joints in patients with trauma in order not to miss any accompanying pathologies. We report a case of a 43-year-old female patient with ipsilateral right shoulder and elbow dislocation treated conservatively. The patient reported elbow pain when first admitted to emergency service but she was diagnosed with simultaneous ipsilateral shoulder and elbow injury and treated conservatively. As a more painful pathology may mask the additional ones, one should hasten to help before performing a complete evaluation. Any harm caused to the patient due to this reason would not be a complication but a malpractice.

Background

Ipsilateral simultaneous shoulder and elbow dislocation is a rare and complex injury. In total 50% of all dislocations are isolated traumatic shoulder dislocations followed by the elbow.^1–3 Fractures around the dislocated joint may accompany. Humeral fracture with shoulder dislocation is much more common than simultaneous ipsilateral shoulder and elbow dislocation.^4–6 In literature we found only six articles about ipsilateral shoulder and elbow dislocation.^{4 7–11}

Decisions about the choice of treatment should be made after full evaluation of the patient's situation including age, occupation, health status, severity of the injury and even whether the affected side is the dominant one or not. Decisions between a surgical intervention and a conservative measure should be made only after considering these factors, but before this a careful evaluation is necessary in order not to complicate the case. We report a case of a 43-year-old female patient with ipsilateral right shoulder and elbow dislocation treated conservatively.

Case presentation

A 43-year-old overweight (body mass index (BMI) 26 kg/m²) female patient was admitted with right elbow pain after falling down from 2 m. After her initial evaluation in the emergency room, deformity of the right elbow, oedema and approximately 2 cm of skin laceration on medial epicondyle were noted. Hypoesthesia of the ulnar nerve trace was also noted without any motor deficit. Radiographic evaluation revealed posterolateral elbow dislocation (figure 1A–D). The patient then was consulted with an orthopaedic surgeon. The following evaluation revealed discomfort and pain in the right shoulder with accompanying limitation of range of motion. Owing to her overweight no epaulette sign was inspected. Before any manipulation, radiographic evaluation of the shoulder was considered and anterior dislocation of the shoulder was diagnosed (figure 2A–C). Axillary nerve was intact. Brachial, radial and ulnar arteries were palpable. Trauma series were also seen in order not to leave a possible pelvic or vertebral injury undiagnosed. Under sedative anaesthesia, first the elbow and then the shoulder dislocations were reduced. Skin laceration was irrigated and sutured with added local anaesthesia. There was no osseous pathology on control radiographic evaluation and ulnar hypoesthesia no longer existed.

Figure 1.

(A) Image before reduction. (B) Anteroposterior X-ray of right elbow. (C) Lateral X-ray of right elbow. (D) Anteroposterior and lateral X-ray of the right elbow after reduction.

Figure 2.

(A) Image of the right shoulder. (B) Anteroposterior X-ray of the right shoulder before reduction. (C) Anteroposterior X-ray of the right shoulder after reduction.

Treatment

A long arm split and shoulder arm strap were used. After 3 weeks of immobilisation, shoulder and elbow rehabilitation programmes were begun simultaneously.

Outcome and follow-up

In the third month after injury, full painless shoulder range of motion was reached. Elbow extension was limited to 5° without any sign of instability.

Discussion

Although isolated shoulder or elbow dislocations are frequently seen, simultaneous ipsilateral shoulder and elbow dislocation is rare. Six articles about simultaneous ipsilateral shoulder and elbow dislocation^{4 7–11} in literature mention the possibility of overlooking shoulder dislocation because of the elbow dislocation being more painful.^7–9 Four of these articles also mention humeral fracture accompanying shoulder and elbow dislocation.^{4 7 8 10} Fractures may be seen neighbouring the joint dislocation and so radiological evaluation of the proximal and distal bones of the involved joint is a must.

When simultaneous dislocation of two neighbouring joints is diagnosed alcohol misuse must also be questioned as this might be the predisposing factor causing muscular relaxation.¹¹ There is a consensus about the mechanism of injury and it is thought to be falling on the flexed elbow while the shoulder is in abduction.^{8 12}

With this kind of trauma one must be very careful about a probable neurovascular injury. Re-examination must be carried out following reduction. In our case, skin laceration on the medial side of the elbow and ulnar nerve hypoesthesia were reasons to suspect ulnar nerve injury but it fully recovered after reduction and motor deficit never existed.

When ipsilateral shoulder and elbow dislocation exists, the elbow must be reduced first in order to have a stable distal part. Shoulder reduction after the elbow is much easier and safer as the distal extremity is stable while reducing the shoulder.^7–9

An orthopaedic surgeon is a consultant of a patient who is first seen in emergency service. Sometimes a consultant may evaluate the patient on the basis of the knowledge given by the doctor of emergency service. This may cause additional pathologies being overlooked. Hurried interventions without a thorough history taking and examination may cause potential harm to the patient, and this is unsuitable to the Hippocratic mandate—primum non-nocere— that is, ‘first do no harm’.

As a more painful pathology may mask the additional ones, one should hasten to help before performing a complete evaluation. Any harm caused to the patient due to this reason would not be a complication but a malpractice.

Although simultaneous ipsilateral shoulder and elbow dislocation is rare, every possibility should be kept in mind before any intervention is made and a detailed examination should be carried out to not overlook an accompanying pathology.

Learning points.

• Ipsilateral simultaneous shoulder and elbow dislocation is a rare and complex injury.

• Decision about the choice of treatment should be made after full evaluation of the patient's situation including age, occupation, health status, severity of the injury and even whether the affected side is the dominant one or not.

• As a more painful pathology may mask the additional ones, one should hasten to help before performing a complete evaluation.