Pathologic dislocation of the shoulder secondary to septic arthritis: a case report
© Bagheri et al; licensee BioMed Central Ltd. 2009
Received: 5 November 2009
Accepted: 2 December 2009
Published: 2 December 2009
Septic arthritis of the shoulder is uncommon in adults, and complete dislocation of the glenohumeral joint following septic arthritis is extremely rare. We report a case of pathologic shoulder dislocation secondary to septic arthritis in an intravenous drug abuser.
Septic arthritis of shoulder is an uncommon problem. Non-traumatic shoulder subluxation resulting from hemiplegia or brachial plexus injury has been reported . There are few reports of glenohumeral subluxation following septic arthritis [2, 3]. Based on the authors' knowledge, there is no report of complete dislocation of the glenohumeral joint secondary to shoulder joint infection in intravenous - drug abusers in the English medical literature.
A 32-year-old man with a 2 weeks history of left shoulder pain and limited range of motion was referred to our orthopedic clinic at Ghaem Hospital, Mashad University of Medical Science, Iran. He complained of severe pain and restricted ROM of his non-dominant left shoulder. There was no history of direct or indirect trauma to the left shoulder but he reported frequent intravenous heroin injection on his left upper limb. On physical examination, the patient was afebrile, but warmness, swelling and tenderness of the left shoulder were noted. Range of motion was limited in all directions and the humeral head was palpable in antromedial of the shoulder area.
The authors have got informed consent forms signed by the patient for both print and electronic publication of the case and all its components; photographs, images and x-rays.
Discussion and Conclusion
The most common cause of septic arthritis is hematogenous but recently, the incidence of hematogenous septic arthritis has declined significantly, while local injection-induced septic arthritic has been increased specially in shoulder. Intravenous drug abusers are at great risk of septic arthritis of unusual joints with unusual organisms .
Septic arthritis of the glenohumeral joint is relatively rare compared with knee and hip joints, thus the diagnosis requires a high index of suspicion and early evaluation of the affected shoulder by the clinician. In a review of English literature from 1960 to 1996 by Lossos 167 cases of shoulder septic arthritis was reported [1, 5, 6] However, the incidence of septic arthritis of the shoulder may be increasing. This may be associated with aging of the population, the increased survival rate of elderly patients who have chronic debilitating diseases and the increase of intravenous drug abuse and HIV positive patients [7–10].
A few reports of septic arthritis causing shoulder subluxation have appeared in the literature. Gompris and Darlington described a case of rheumatoid arthritis and shoulder septic arthritis causing bilateral glonohumeral dislocation .
Gordon and Hatchful reported a case of inferior shoulder displacement following pyarthrosis .
There are also three reported cases of drooping of the shoulder because of septic arthritis [5, 7, 2]. The present case happened in an intravenous-drug abuser, who tried to hide his addiction. The volume of fluid/pus necessary to cause a dislocation in glonohumeral joint is not known .
The exact mechanism of shoulder dislocation in septic glenohumeral arthritis has not verified yet.
Presumable mechanism may be incompetency of glenohumeral ligaments due to gradual expansion of joint capsule as the fluid/pus accumulates slowly. Expanded loose glenohumeral capsule and its intimately associated ligaments (glenohumeral ligaments) result in incompetency of major static stabilizers of the inherently unstable shoulder joint. Gradual accumulation of fluid/pus seems to be essential prerequisite for the dislocation to occur.
Sudden expansion of joint capsule produces intolerable pain and the patients seeks treatment as soon as possible and dislocation can not be expected.
If the patient is somehow insensitive to pain or intentionally suppresses the pain with narcotics (intravenous drug abusers), fluid/pus can accumulates in the joint in large volumes, distending joint capsule and ligaments gradually and finally result in dislocation. It needs further studies to specify whether these pathologic changes would lead in recurrent dislocation.
Orthopedic surgeons should be familiar with this uncommon complication of shoulder septic arthritis particularly in patients who are intravenous-drug abusers and have immunodeficiency conditions. Intravenous drug abuse, itself, can be considered a risk factor for articular infection . Ang-fonte et al attribute a fourfold increase of septic arthritis to this factor .
Furthermore, the shoulder is the less commonly involved joint among drug abusers . But we should have high suspicion of this disease especially in immune compromised and intravenous drug abuser patients.
The patient has signed out a formal consent form for publication of this case and pictures.
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