Case Presentation: A 33 year old previously healthy male with no significant past medical history presented to the ED with two days of severe bilateral shoulder pain and chest swelling, found to have bilateral anterior shoulder dislocations with humerus fractures, an AKI and rhabdomyolysis. Patient stated he awoke from sleep two days prior with severe pain in both shoulders. He initially presented to urgent care where CXR showed normal lung fields. He was prescribed methocarbamol for musculoskeletal pain and returned home. The following day, the pain had intensified and the patient presented to the ED. He denied prior trauma, recent strenuous activity, use of new medications/supplements, illicit drug use, and heavy alcohol use. His last drink was four days prior to symptom onset and he described himself as a light-moderate weekend drinker. No personal or family history of seizures and he was not electrocuted or struck by lightning to his knowledge. Exam was notable for bilateral shoulder and chest tenderness and shoulder range of motion limited by pain. His chest x-ray again showed clear lung fields but was concerning for bilateral shoulder dislocations. Labs were notable for troponin mildly elevated at 0.05, creatine kinase 18,435, creatinine 1.64 (from baseline of 0.9) and UA was positive for blood without red blood cells. EKG showed sinus tachycardia without acute ischemic changes. Left and right shoulder x-rays confirmed bilateral anterior shoulder dislocations with bilateral displaced humerus fractures. Orthopedic surgery and neurology were consulted. On physical exam neurology noted a tongue bite. MRI was negative and EEG showed no epileptiform activity. The patient was given maintenance fluids for rhabdomyolysis and AKI, and orthopedic surgery performed bilateral open reduction and internal fixation procedures. Following surgery the patient opted to defer starting anti-epileptic drugs. Patient was discharged two days post-procedure with his AKI resolved, CK downtrending, and satisfactory pain control.
Discussion: While shoulder dislocations are commonly seen, bilateral dislocations are rare and bilateral anterior dislocations rarer still. The majority have occurred in men with the average age being 33 years old. The first recorded case occurred in 1902 and was attributed to a camphor induced seizure of which the patient had no recollection. 50% of reported cases have been secondary to trauma, 37% to muscle contractions such as seizures or electrocution, and 13% atraumatic. Of 70 reviewed cases, nearly half presented with associated fractures in the shoulder region. Predictably, early diagnosis has been found to be an important prognostic factor. [1]
Conclusions: Through this case report we aim to highlight a rare, but important etiology of bilateral shoulder pain. On initial CXR obtained in urgent care, the patient did have evidence of dislocation, although this was not commented on as the image was obtained solely for the question of chest pain. This highlights the importance of considering a broad differential as well as conducting a thorough physical examination and personally reviewing all imaging studies. Drug and alcohol related ailments are very common presentations for most hospitalists, however it is critical to avoid the availability bias and risk misattributing findings. Furthermore, this patient’s tongue bite was not found until several hours following admission and this is a pertinent reminder that a thorough physical exam can help with early diagnosis and therefore lead to better outcomes.