Intended for healthcare professionals

Endgames Spot Diagnosis

A painful shoulder after a seizure

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4511 (Published 08 August 2019) Cite this as: BMJ 2019;366:l4511

Not a simple matter of posterior shoulder dislocation

Dear Editors

I noted the purpose of the article is to demonstrate the "lightbulb sign" in a patient with posterior dislocation of the shoulder, and to consider the possibility of posterior shoulder dislocation in a patient with history of new-onset shoulder with a background of seizure.

However it may interest readers that the lightbulb sign in the example provided by the authors in this article is not as obvious as images available on other websites (for example ref 1) as I suspect that there is a superimposed reverse Hill-Sachs impaction depression lesion on the anteriomedial humeral head.

If this is true then the history provided that "no history of seizures" is suspect as a reverse Hill-Sachs lesion from posterior dislocation implies at least one previous episode of posterior dislocation and often a reflection of chronic recurrence of this uncommon traumatic condition typically caused by generalised tonic-clonic seizure or electrocution.

Some care should be taken when discussing post-reduction management of a posterior-dislocated shoulder; "immobilisation in a sling" for 2 weeks may be a common management for shoulder dislocation but not always the best treatment for someone with a posterior shoulder dislocation. In cases when the shoulder is swollen and unstable, placing the shoulder in a position internal rotation, particularly with a large reverse Hill-Sachs lesion, may predispose the patient to have a recurrence of posterior dislocation.

There is some merit in placing the patient's affected arm (and shoulder) in a neutral position with a shoulder immobiliser and abduction pillow post-reduction of posterior shoulder dislocation with a large reverse Hill-Sachs lesion. Patients should be carefully instructed about how to maintain personal hygiene if this treatment is needed.

While I understand the authors are orthopaedic clinicians, I am also concerned that the management of the adult patient's first seizure was not adequate addressed in the article. The diagnosis of first seizures and differentiation from their “mimics” in adults is frequently poorly performed, much in part due to poor history-taking and clarification. "Following a first seizure of any kind, all patients should be referred to a specialist for investigation"; "after a first seizure, further seizures (that is, epilepsy) occur in between 6% and 82% of patients" (ref 2).

While many will expect emergency clinicians to organise appropriate specialist follow-up for the management of an adult with an unexplained seizure, sometimes in examples where an orthopaedic injury (fracture and/or dislocation) is identified arising from the seizure, then the orthopaedic team may be the only specialist service involved in the episodic care of such patients.

It is important for all clinicians to be mindful of the holistic care of a patient; if a condition is not within their scope of practice to organise or transfer care to another clinician with the appropriate expertise.

An unexplained first seizure in a 25 year-old man may result in significant ramifications in medical, functional (eg driving) and occupational (eg operating heavy machinery) aspects of his life, with possible medico-legal ethical dilemma for his treating doctors (ref 3).

References:
1. https://radiopaedia.org/articles/lightbulb-sign-shoulder-dislocation-2
2. https://www.bmj.com/content/348/bmj.g2470
3. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/con...

Competing interests: No competing interests

10 August 2019
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia