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Year : 2018  |  Volume : 17  |  Issue : 1  |  Page : 34-39

Accidental electric shock injuries around the shoulder joint: A case report of two patients

Department of Orthopaedics, JSS Medical College and Hospital, Mysore, Karnataka, India

Date of Web Publication30-Jul-2018

Correspondence Address:
Dr. Supreeth Nekkanti
Department of Orthopaedics, JSS Medical College and Hospital, Mysore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njot.njot_2_17

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Fracture-dislocations of the shoulder are grave injuries. These injuries rarely are caused by electrocution injuries. The diagnosis of these injuries is tricky. Missed diagnosis of these injuries is common due to inadequate radiological examination. We report two cases of fracture-dislocation of the shoulder following accidental electrocution injuries. Our case report includes two patients who injured their shoulder joints after suffering accidental electric shock injuries. Our first patient was an 80-year-old female who suffered an anterior fracture-dislocation of the shoulder and second patient was a 28-year-old male who suffered a posterior fracture-dislocation. Both the patients were treated by osteosynthesis using the deltopectoral approach. Our patients had a good function of their shoulders at the end of 1-year follow-up. Fracture-dislocations of the shoulder pose a significant diagnostic threat and are often missed due to inadequate radiographs. These injuries can be successfully treated by early diagnosis and anatomical fixation of the fracture. Avascular necrosis of the head of the humerus is the significant complication to these injuries.

Keywords: Electrocution injury, fracture-dislocation shoulder joint, osteosynthesis

How to cite this article:
Mruthyunjaya M, Nekkanti S, Siddartha A, Santosh M S, Punith N. Accidental electric shock injuries around the shoulder joint: A case report of two patients. Niger J Orthop Trauma 2018;17:34-9

How to cite this URL:
Mruthyunjaya M, Nekkanti S, Siddartha A, Santosh M S, Punith N. Accidental electric shock injuries around the shoulder joint: A case report of two patients. Niger J Orthop Trauma [serial online] 2018 [cited 2023 Dec 11];17:34-9. Available from: https://www.njotonline.org/text.asp?2018/17/1/34/237834

  Introduction Top

Fracture-dislocations of the shoulder joint are serious injuries. They are rare complications of electrocution injuries. The diagnosis of posterior fracture-dislocations is frequently missed.[1],[2],[3],[4] The diagnosis is not made in the first consultation in more than 50% of the cases.[5] Epilepsy, electrocution injury and extreme trauma commonly referred to as the “EEE” syndrome are the most common reported causes of fracture-dislocation of the shoulder joint.[6] These injuries are usually defined based on Neer's classification. The early diagnosis and management of these injuries is essential to avoid complications such as avascular necrosis of the head of the humerus, axillary nerve injury and soft-tissue injury and to ensure the better functional outcome of the shoulder.[2],[3] The goals of management include an early diagnosis by a complete and thorough radiographic study of the shoulder, early reduction of the dislocated shoulder joint by open or closed technique, thereby minimising vascular insult to the head of the humerus.[1],[3] We report two cases of fracture-dislocation of the shoulder joint following electrocution injury, which were successfully managed.

  Case Reports Top

Case 1

An 80-year-old female patient presented to the emergency department 5 hours after an accidental electrocution injury at her residence following contact with the television cable. She consequently fell and injured her right shoulder. She was unable to move her right shoulder. She did not suffer other injuries or lose her consciousness. She was taken to local hospital, where closed reduction of the shoulder joint was attempted but was unsuccessful. She was then referred to us for further management. Initial radiographs taken at the local hospital were not available with the patient.

On examination, the patient was conscious, well oriented to time, place and person. An entry wound seen over right thumb with no visible exit wound [Figure 1]. There was a diffuse swelling observed around the right shoulder with no open wound. There were palpable crepitus and restricted movement of her right shoulder. Repeat radiographs of the right shoulder at our centre revealed an anterior fracture-dislocation, for which she was operated 2 days later [Figure 2] and [Figure 3]. An open reduction with internal fixation was performed with a four-holed PHILOS plate using the deltopectoral approach.
Figure 1: Clinical photograph showing the entry wound of the electrocution injury of Case 1

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Figure 2: Preoperative plain radiographs showing posterior fracture-dislocation of Case 1

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Figure 3:

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Case 2

A 28-year-old male presented to the emergency department 3 h following an accidental electrocution injury (household supply) following which he sustained an injury to his right shoulder. He did not suffer any other injuries. He had pain and swelling in the right shoulder and could not move his shoulder due to pain.

The patient was graded 15/15 as per the Glasgow Coma Scale. His vitals were stable, with an entry wound over the right hand on thumb and middle finger [Figure 4]. There was no exit wound observed. The patient had diffuse swelling over the right shoulder. There was palpable crepitus. The range of movements could not be elicited because of pain. The Vitamin D level in this patient was 24.84 (30–74 ng/ml). This test was done because patient gave us a previous history of being treated for Vitamin D deficiency. Radiographs revealed a posterior fracture-dislocation of the shoulder [Figure 5]. The patient was operated upon by open reduction and internal fixation (ORIF) with PHILOS plate using the deltopectoral approach.
Figure 4: Clinical photograph showing the entry wound of the electrocution injury of Case 2

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Figure 5: Preoperative radiographs showing anterior fracture-dislocation of Case 2

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Both the patients were taught shoulder pendulum exercises, elbow, wrist and finger movements the day after surgery. The post-operative period was uneventful. He was discharged on post-operative day 5. Both the patients were followed up to 1 year [Figure 6] and [Figure 7].
Figure 6: One-year follow-up radiograph of Case 1

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Figure 7: One-year follow-up radiograph of Case 2

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  Discussion Top

Accidental electrical injuries are rare, and often the patient is unconscious or in a delirious state of mind. Initial sequelae of electric shock include thermal myonecrosis which leads to acute renal failure which can be complicated by cardiac arrest or cardiac arrhythmias. Hence, in the emergency room, the patient must be carefully screened for cardiac and renal anomalies. Electrocardiogram with renal function tests with 24 h monitoring is usually sufficient to rule out such complications.[7],[8],[9]

Bone tissue provides the highest resistance to electric current as it is the poorest conductor of electricity. The bone tissue, therefore, absorbs all the energy of the conducted electric current. It has been studied that muscle contractions occur with at least 20 mA of direct current and 10 mA of alternating current.[10] The severity of damage to the human tissue can be classified according to the intensity of electric current (high voltage versus low voltage), type of current (direct/indirect) and amount of electricity.[11] At the time of electric shock, the human body acts as a conductor of electricity wherein electric energy is converted to thermal energy which in turn damages the skin, soft tissue, muscles and bones. This is clinically evident by blackening of the skin at entry and exit points as seen in our patients.[11],[12]

Low voltage electric burn injuries are injuries caused by electric currents of 110–220 voltage. They form 72.8%–76.3% of all electric injuries, but Kym et al. reported an incidence of 29.6% in his study in Korean population.[11] High voltage injuries, on the other hand, occur in 70.4% of the injuries in the age group of 20–50 years old.[11] Low voltage injuries are similar to small thermal injuries without transmission to deeper tissues and are defined in the local area of contact. High voltage injuries, on the other hand, can involve the deeper tissues to varying degrees. They are characterised by entry and exit wounds. They may have systemic complications such as cardiac arrhythmias, muscle or tissue necrosis due to thrombus formation in small vessels.[11],[12] Our patients suffered high voltage injuries. They were initially stabilised in the emergency department and were screened for all systemic complications after which orthopaedic management was initiated.

Nekkanti et al. in his study reported that men were more prone to fractures following electrocution injuries owing to stronger muscle contractions of the bulkier and well-toned muscles in men.[10] This probably explains why the male patient suffered a posterior fracture-dislocation. Furthermore, the position of the shoulders at the time of impact was in forward flexion and internal rotation. Although it is not entirely the strength of muscle contractions that cause a fracture-dislocation, it is an important contributing factor in such injuries.

In our review of the literature, posterior shoulder dislocations, fractures of the proximal humerus and fracture of scapula have been reported following electric shock injuries due to vigorous muscle contractions around the shoulder.[13],[14],[15] The possible explanation as to why the female patient (Case 1) suffered an anterior fracture-dislocation could be attributed to the force of muscle contractions around the shoulder in addition to the attitude of the limb during the fall (fall on outstretched hand).

In the forearm, Galeazzi and distal radius fractures have been reported.[13],[16],[17] In the spine, L4 burst fractures and transient spinal quadriparesis have been reported.[13],[17],[18] In 1956, Andreini studied that simultaneous contraction of pelvitrochanteric muscles as the main cause of fractures around the hip following an electrical shock injury.[19] He explained that only these muscles could apply their force irrespective of the position of pelvis and femur, leading to pelvitrochanteric fractures. Screening of pelvis, spine and shoulder is, therefore, essential to avoid missing these rare injuries.[19],[20],[21]

Fracture-dislocation of the shoulder is a rare complication following electrocution injury. These injuries may present with dislocation of the shoulder joint in the anterior or posterior plane, the latter being rare injuries. Posterior dislocation usually occurs secondary to seizures or electrocution injuries due to vigorous contractions of the internal rotators of the shoulder joint.[2] Posterior fracture-dislocations of the shoulder joints occurs due to unbalanced forceful muscle contractions, classically following electrocution injuries or seizures.[4] Electrocution injuries cause the muscles around the shoulder to contract vigorously. The internal rotators of the shoulder joint are bigger in bulk and more powerful compared to the external rotators leading to the shoulder adopting an adducted and internal rotated attitude forcing the head out of the glenoid cavity. Further contractions lead to the impaction of the head of humerus against the glenoid rim, leading to fracture-dislocation of the shoulder joint.

The relatively posterior orientation of the head of the humerus in the resting position of the shoulder during the event of epilepsy or electrocution injury also makes the patient vulnerable to posterior dislocations of the shoulder joint.[22] Anterior dislocations following electrocution injuries, however, could most likely occur due to the external rotation and abduction attitude of the shoulder at the time of impact on the ground.

A study of 2800 patients admitted for seizures revealed that 1.1% (30/2800) of them suffered fractures due to trauma and 0.3% (7/2800) sustained fractures purely as a complication of seizures.[23] It probably explains the rarity of fractures solely due to the violent contractions of the muscles following an electrocution injury or a seizure episode.[22],[23]

The diagnosis of these injuries is often missed due to the paucity of the physical signs. Refractory shoulder pain, inability to move the shoulder joint following an electrocution injury should raise suspicion of possible posterior fracture-dislocation of the shoulder. In patients with posterior dislocation, there will be a complete loss of external rotation and maximal internal rotation possible. Other suggestive clinical signs include prominent coracoid process, flattening of the anterior aspect of the shoulder and prominence of the back of the shoulder. On the contrary, anterior dislocation of the shoulder joint allows further external rotation but not internal rotation. Callaway's test, Hamilton ruler test and Bryants sign are additional supportive signs of anterior dislocation of the shoulder joint.

Incomplete radiographic study of the shoulder has been reported to be the most common cause of missed diagnosis of fracture-dislocation of the shoulder.[1],[3],[24],[25] This could explain why our patient (Case 1) was misdiagnosed and initial treatment failed. A complete three-view radiographic study of the shoulder is mandated to avoid missing such injuries. It includes an anteroposterior view, lateral scapular view and an axillary view.[25],[26] The axillary view is the only useful view to identify posterior fracture-dislocations.[23],[24],[25] Anteroposterior radiographs may show associated lesser tuberosity fractures with posterior dislocations and greater tuberosity fractures with anterior dislocations both of which must be ruled out.[22] Computed tomography (CT) scans are also useful in identifying the extent of comminution of the fractures and the orientation of the fracture fragments. A CT scan was done for our patient (Case 2) as it is sometimes difficult to study the fracture pattern, especially when associated with posterior dislocations. A CT scan gives us a three-dimensional reconstruction of the injured shoulder, giving us an opportunity to plan for surgical fixation.

The treatment of shoulder dislocation depends on the presence of associated fractures, impacted head fractures, the age of the patient, vascularity of the head and the extent of the delay in diagnosis.

The goal of treatment is to reduce the dislocation as early as possible to minimise the vascular insult to the head of the humerus potentially avoiding avascular necrosis and collapse of the head. A simple acute posterior dislocation in the absence of associated fractures could be reduced well by closed reduction using lateral and longitudinal tractions to dislodge the head. The posterior capsule should be stretched by passive internal rotation movements before attempting the closed reduction of a chronic posterior dislocation. Similarly, the anterior capsule could be stretched by passive external rotation before attempting the reduction of chronic anterior dislocation of the shoulder.[10] The head of the humerus is usually locked anterior or posterior to the glenoid cavity, and hence rotatory movements to aid reduction should be performed gently to avoid potential fracture to the shaft of the humerus or the neck of the humerus.[10] Aggressive rotational manoeuvres before reducing the head into the glenoid cavity may render the head or shaft of the humerus fractured.[22] Chronic dislocations in the absence of pain and no functional disability could be left alone. Surgical intervention is not necessarily mandated. Chronic dislocations with associated fractures do require surgical intervention.

The treatment of fracture-dislocations around the shoulder depends on many factors such as severity of the fracture-dislocation, vascularity of the head, delay in diagnosis, the age of the patient and functional demand of the patient.[22] In our study, Case 1 had a delay in presentation to us after a failed initial treatment elsewhere.

Fracture-dislocations of the shoulder with minimal displacement of the fractures with no or minimal vascular insult and <20% of the head of the humerus involved are ideal for closed reduction.[23],[27] If 20%–40% of the articular surface of the head of the humerus is involved, ORIF is preferred. Kirschner wires (K-wires) may be used to aid reduction.[22] Closed reduction is impossible to achieve if the delay in diagnosis and treatment exceeds 3 weeks. When more than 50% of the head is involved, hemiarthroplasty takes precedence over preservation. It is classically indicated in patients older than 65 years, three or four-part fractures and with a high risk of avascular necrosis. When the glenoid cavity and head of the humerus are involved, then total shoulder arthroplasty is recommended.[23],[28]

Both the patients had good functional use of their shoulders at the end of 1-year follow-up. There was no evidence of avascular necrosis of the head of the humerus. The shoulder strength and function were good at the end of 1-year follow-up.

  Conclusion Top

Fracture-dislocations of the shoulder joint following accidental electrocution injuries are rare. Posterior shoulder dislocations usually occur due to vigorous contractions of the internal rotator muscles of the shoulder. We report two such cases of accidental electrocution injuries, leading to shoulder fracture-dislocations with different presentations. Diagnosis and early treatment of these injuries are vital to avoid vascular insult to the head of the humerus and to restore normal function of the shoulder as early as possible.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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