BILATERAL SHOULDER FRACTURES FOLLOWING LOW-VOLTAGE ELECTRICAL INJURY

Annals of Burns and Fire Disasters - vol. XIII - n. 3 - September 2000

BILATERAL SHOULDER FRACTURES FOLLOWING LOW-VOLTAGE ELECTRICAL INJURY

Duman H., Kopal C., Selmanpakoglu N.

Department of Plastic and Reconstructive Surgery and Burn Centre, Gülhane Military Medical Academy, Ankara, Turkey

SUMMARY. Bilateral shoulder fractures resulting from high energy such as traffic accidents or falls from height are usually associated with thoracic, craniofacial, and spinal injuries. The mechanism of shoulder fractures caused by low-voltage electric shock is quite different from those caused by high energy. Such fractures may be due to tetanic muscle contraction involving the upper extremities and shoulder girdles. This study presents a case of bilateral shoulder fracture after a low-voltage electrical injury.

Introduction

Since they require trauma with high energy, bilateral shoulder fractures are not frequently seen. We report a case of simultaneous bilateral shoulder fractures caused by a 220 V electric shock without direct trauma and we discuss its pathomechanical origin. Most fractures due to electrical contact are caused by strong muscle pull.

Case report

A 56-year-old female sustained an electric shock when touching a washing-machine. After the shock, she pulled back her hands within seconds and did not fall or hit anything. She immediately felt bilateral shoulder pain, without losing consciousness. Later she was admitted to the regional clinic with bilateral pain in the shoulders. Bilateral shoulder fractures had not been noticed during the initial physical examination performed at the regional clinic and she had been advised to take anti-inflammatory drugs. After 18 days the patient was admitted to our burn centre, complaining of pain, ecchymosis, and bilateral swelling in the arms and shoulders. On physical examination no entry or exit burns were noted. Inability to abduct the arms and weakness of the elbow and wrist were determined, with normal range of motion. The cervical and thoracic spine was non-tender and there was full range of motion in the neck. Radiography showed bilateral shoulder fracture, including the glenoid process and the head of the humerus (Figs. 1,2). The fractures were successfully operated on the by orthopaedic surgeon. Internal reduction and fixation were performed using nail, lag screw, and K-wire in the right shoulder and shoulder arthroplasty in the left shoulder (Figs. 3,4). The post-operative period was uneventful and the patient gained full active range of motion in three months. The follow-up X-ray film showed good union.

$Fig. 1 - Appearance of fracture of left shoulder, including displacement and dislocation of three segments.$		$Fig. 2 - Dislocation and displacement of fractured segments of right shoulder.$
Fig. 1 - Appearance of fracture of left shoulder, including displacement and dislocation of three segments.		Fig. 2 - Dislocation and displacement of fractured segments of right shoulder.

Fig. 3 - Shoulder arthroplastyperformed in left shoulder		Fig. 4 - Fracture of right shoulder treated by internal reduction and fixation.

Discussion

Bilateral shoulder fracture is usually caused by direct trauma such as traffic accidents and falls. Shoulder fractures due to electric shock without direct trauma are rare and frequently missed. Fractures resulting from high energy are usually associated with other injuries such as thoracic, craniofacial, and spinal injuries, unlike fractures from low electric shock. Few cases have been reported in the literature in which fractures were caused directly by electric shock without falling, but typically involving bones surrounded by large muscle bulk, such as the vertebrae, proximal femur, scapula, and proximal humerus.
Tarquino et al. described pure scapular fractures,' in which there were 18 muscle attachments (either origin or insertion). In the literature, strong muscle pull is considered as the likely explanation of the mechanism responsible for fractures due to electric shock.
Fractures reported in the literature due to electroconvulsive therapy are more frequent than fractures caused by low-voltage electrical injury.
Although fractures due to low-voltage electric shock are rare, it should be borne in mind that after electric shock the presence of pain, swelling, bone tenderness, and impossibility or .limitation of motion may be due to fractures. Orthopaedic surgeons treat the fractures with internal fixation.
The indications for surgical intervention in our cases were bilateral humeral neck fractures. McGahan et al. reported indications of surgical intervention for scapular fracture, including glenoid fractures with dislocation or displacement of the fragments, and coracoid fracture with acromioclavicular separation or associated neuromuscular injury.
In all cases of electrical injury, the victims should therefore be examined carefully and in detail.

RESUME. Les fractures bilatérales de l'épaule causées par la haute énergie, comme par exemple les accidents de la route et les chutes de grande hauteur, sont normalement associées à des lésions thoraciques, craniofaciales ou vertébrales. Le mécanisme des fractures de l'épaule causées par l'electricité de basse tension est totalement différent de celui des accidents causés par la haute tension. Ce type de fracture peut être causé par une contraction musculaire tétanique qui intéresse les extrémités supérieures et les ceintures des épaules. Les Auteurs présentent le cas d'une femme atteinte de fractures bilatérales des épaules après une lésion electrique de basse tension.

BIBLIOGRAPHY

Dumas J.L., Walker N.: Bilateral scapular fractures secondary to electrical shock. Arch. Orthop. Trauma Surg., 111: 287-8, 1992.
David R.B., Steven D.M., Barnes A.U.: Bilateral scapular fractures from low-voltage electrical injury. Ann. Emergency Medicine, 11: 676-7, 1982.
Tarquino T., Weinstein M.E., Virgilio R.W.: Bilateral scapular fractures from accidental electric shock. J. Trauma, 19: 132-3, 1979.
Adams AJ., Beckett M.W.: Bilateral wrist fractures from accidental electric shock. Injury, 28: 227-8, 1997.
McGahan J.P., Rab G.T., Dublin A.: Fractures of scapula. J. Trauma, 20: 880-3, 1980.
Shaheen M.A., Sebat N.A.: Bilateral simultaneous fracture of the femoral neck following electrical shock. Injury, 16: 13-14, 1984.

This paper was received on 8 March 2000.

Address correspondence to: Dr Haluk Duman, G.A.T.A. Plastik ve rekonstrüktif cerrahi A.D., 06018 Etlik, Ankara, Turkey (tel.: 90 312 3045408; fax: 90 312 3045412)