International Journal of Surgery Case Reports 114 (2024) 109114

Contents lists available at ScienceDirect

International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Pathological unstable dislocation of shoulder secondary to septic arthritis:

A case report
Dinesh Kumar Pandit 1, Suveksha Shaurya Shah *, 1, Gaurav Parajulee, Nand Kishor Shah,
Paras Khakurel
Janaki Medical College Teaching Hospital, Janakpur, Nepal

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Pathological unstable dislocation of the glenohumeral joint following septic arthritis is a rare
Septic arthritis condition. We report a case of 40 years old patient with pathological shoulder dislocation secondary to septic
Shoulder dislocation arthritis.
Adult
Case presentation: A 40 years old male patient presented to the Department of Orthopedics with chief complain of
swelling and pain of Right upper extremity for 6 days. He had history of IV canula insertion to give fluids. Then
he developed swelling of hand which progressively increased up to right shoulder. He also complained of severe
pain over that region. X-ray showed anteromedial dislocation of humeral head. Aspiration of joint was done and
the aspirate was sent for culture and sensitivity, which revealed Staphylococcus aureus. Incision and drainage was
performed, about 500 ml of straw-colored pus mixed with synovial fluid extending up to sternum, posteriorly up
to clavicle and laterally up to deltoid was estimated. Then we planned for open reduction and percutaneous
pinning with K-wire. The intervention led to substantial loss of disability and regain of limited range of motion.
Discussion: Septic Arthritis in adults is uncommon and complete dislocation of the glenohumeral joint associated
with it is rare. Septicemia was a common complication among all treatment groups, with cultures most
frequently indicating Staphylococcus aureus as the causative organism. Septic arthritis is most commonly caused
by hematogenous but recently, the incidence of hematogenous septic arthritis has decreased, while local
injection-induced septic arthritis has been increased specially in shoulder.
Conclusion: Septic arthritis of the glenohumeral joint is rare condition in comparison with knee and hip joints.
Therefore, the diagnosis requires a high index of suspicion, early evaluation and treatment of the affected
shoulder. Our case is a good example of how we can use simple surgery techniques like open reduction and
percutaneous fixation with K-wire in low and middle income countries where patient is not economically sound
to afford arthroplasty.

1. Introduction 2. Case presentation

Pathological unstable dislocation of the glenohumeral joint
following septic arthritis is a rare condition [1]. Among the cases of
septic arthritis, only 3 % accounts for septic arthritis due to gleno­
humeral joint [2]. We could not find any other reported cases of
Staphylococcus aures seeding the shoulder joint secondary to IV can­
nulation. We report a case of 40 years old patient with pathological
shoulder dislocation secondary to septic arthritis, following SCARE 2020
guideline [3].
A 40 years old male patient presented to the Department of Ortho­
pedic Surgery with chief complain of swelling and pain over Right upper
extremity for 6 days. According to patient he was apparently well 6 days
back when he developed loose stools for which IV canula was opened to
administer fluids. Then he developed swelling of hand which progres­
sively increased up to right shoulder. He also complained of severe pain
over right shoulder. He had history of fever and passage of concentrated
urine and had no history of any direct or indirect trauma. He had a past
history of right lower limb monoplegia 6 years back for which he had

* Corresponding author.
E-mail address: suvekshashauryashah@gmail.com (S.S. Shah).
1
Dinesh Kumar Pandit and Suveksha Shaurya Shah accepts the first authorship.

https://doi.org/10.1016/j.ijscr.2023.109114
Received 30 September 2023; Received in revised form 27 November 2023; Accepted 2 December 2023
Available online 6 December 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
D.K. Pandit et al. International Journal of Surgery Case Reports 114 (2024) 109114

undergone spine surgery. Table 1

On general examination he was conscious, and well oriented. He had Table for Laboratory Investigations.
pallor over his bilateral lower palpebral conjunctiva, palpable right S. Tests Results Unit Reference
axillary lymph nodes, no signs of icterus, cyanosis, clubbing, edema and No. Range
dehydration. The patient’s body temperature was 101 0.5 ◦ F, blood 1. Total Leukocyte Count 10,000 Per μl 4000–11,000
pressure 100/60 mm of Hg, respiratory rate 12 beats per minute and 2. Differential Leukocyte
Oxygen saturation was 94 % measured with pulse oximeter. On local Count
examination he had generalized swelling over right upper limb, which Neutrophil 85 % 40–75
Lymphocyte 10 % 20–45
was tender with increased temperature, and wound of size 3 cm × 3 cm Eosinophil 03 % 1–6
(approx.) with discharge was present over right shoulder. On radio­ Monocyte 02 % 2–10
graph, a complete anteromedial glenohumeral dislocation with Basophil 00 % 0–1
widening of acromioclavicular joint was evident (Fig. 1). Blood Inves­ 3. Total RBC count 2.97 × 106 106/ μl 4–5.5
4. Hemoglobin 8.6 g/dl 11–16
tigation for complete cell count, blood sugar and creatinine was sent and
5. Hematocrit 25.9 % 36–52
results were as shown in Table 1. 6. MCV 87.0 fl 76–96
Then aspiration of joint was done and the aspirate was sent for cul­ 7. MCH 28.9 pg 27–32
ture and sensitivity, till the results came patient was given Cefuroxime 8. MCHC 33.0 g/dl 30–35
75 mg IV BD. Culture came positive for Staphylococcus aureus and 9. Total Platelet Count 294 × 103 103/ μl 150–400
10. Blood Sugar- Random 110.0 mg/ mg/dl 80–120
Antibiotic Susceptibility test came sensitive for Linezolid and Clinda­ dl
mycin, following which the patient was started with Clindamycin IV 11. Serum Creatinine 1.0 mg/dl 0.5–1.5
300 mg BD and Incision and Drainage was planned for next day. Incision
of size 2 cm × 2 cm was made over anterolateral aspect of right shoulder
and 500 ml of pus was drained. An attempt on reducing the subluxated Acromion process had rough surface with periosteal erosion suggestive
joint followed by immobilization of joint was done. Regular wound of osteomyelitis of acromion process. Wound was cleaned and joint was
dressing was done and about 100 ml of serous discharge was drained. reduced and humeral head was fixed with multiple K-wires over glenoid
During wound dressing, shoulder was unstable so we tried to reduce it in (Fig. 2). Wound was closed with stay sutures and drain was placed under
ward but it was unsuccessful due to decayed rotator cuff and soft tissues. negative pressure and shoulder immobilizer was applied. (Fig. 3).
We planned for wound debridement and shoulder joint relocation under Clindamycin was continued for 2 weeks, Gentamycin IV 80 mg BD
C- arm guidance (Fluoroscopy). Next day, patient was posted for sur­ and Metronidazole IV 500 mg TDS for 1 week was added. Regular pin
gery. Under Interscalene block, a deltopectoral incision of 5 cm was site and wound dressing was done each day the following week. After a
made. About 200 ml of serous fluid was drained and site was irrigated week, drain was nil so it was removed, wound was closed and secondary
with povidone iodine, normal saline and gentamycin. suture was applied. After a month, blood counts came normal and the
Intraoperatively, we found that Rotator cuff and surrounding soft patient was discharged with shoulder immobilizer, Tab Vit C, B complex
tissue was necrosed and humeral head was subluxated anteromedially. and high protein diet (Fig. 4).
The patient was followed up after 14 days and K-wire was removed

Fig. 1. AP View of X-ray showing shoulder dislocation.

2
D.K. Pandit et al. International Journal of Surgery Case Reports 114 (2024) 109114

Fig. 2. A post operative X-ray of patient after open reduction and percutaneous fixation with K-wires.

Fig. 3. A post operative picture after K-wire fixation.

and Range of Motion (ROM) exercise was started by physiotherapist. He 3. Discussion

attained 250 abduction, 250 flexion, 150extension with restricted
external and internal rotation. The patient was having shoulder stiffness Septic Arthritis in adults is uncommon and complete dislocation of
and deltoid wasting for which physiotherapy was recommended. the glenohumeral joint associated with it is rare. The exact mechanism

3
D.K. Pandit et al.
Fig. 4. X-ray taken after removal of K-wires.
of shoulder dislocation in septic arthritis has not been proved. The most
probable mechanism is due to incompetence of glenohumeral ligaments
due to gradual expansion of joint capsule because of fluid/pus accu­
mulation [1].
Patients with septic arthritis of the shoulder frequently experience
substantial systemic complications regardless of the treatment method.
Septicemia was a common complication among all treatment groups,
with cultures most frequently indicating Staphylococcus aureus as the
causative organism [4] similar to the case we have reported. Septic
arthritis is most commonly caused by hematogenous but recently, the
incidence of hematogenous septic arthritis has decreased, while local
injection-induced septic arthritic has been increased specially in shoul­
der [5]. In our case, also the most probable cause of patient developing
septic arthritis is due to lack of aseptic technique of IV Cannulation.
Non-traumatic shoulder subluxation resulting from hemiplegia or
brachial plexus injury has been reported [6]. Bilateral glenohumeral
dislocation in few patients of Rheumatoid Arthritis have been reported
to develop septic arthritis secondary to long term steroid use [7]. Infe­
rior dislocation of the humeral head secondary to staphylococcal
arthritis after steroids use has been reported [8].
The present case happened after the patient received intravenous
fluids for the diarrhea he had by non-trained, non-medical personnel.
Four-fold increased incidences of septic arthritis has been attributed
intravenous drug use [9].
4
International Journal of Surgery Case Reports 114 (2024) 109114
Pyogenic arthritis is usually developed hematogenous from osteo­
myelitis around the neighboring metaphysis and by direct penetration
by injection, trauma, or surgery. Staphylococcus aureus has been isolated
in 6 patients out of the followed up 13 patients who underwent opera­
tion for the treatment of pyogenic glenohumeral arthritis that developed
after injections around the shoulder joint. Such arthritis has been shown
to be better treated with open surgery than arthroscopic surgery [10].
Open reduction and internal fixation with K-wires came to be successful
for this case. Deformities following neglected septic arthritis of shoulder
joint are often combinations of various degrees of shoulder dysplasia,
progressive humeral shortening, angular deformities of the humerus and
subluxation of the glenohumeral joint or rarely dislocations [11]. The
above case had restricted range of motion as its complication post
operatively.
4. Conclusion
Septic arthritis of the glenohumeral joint is rare condition in com­
parison with knee and hip joints. Therefore, the diagnosis requires a
high index of suspicion, early evaluation and treatment of the affected
shoulder. Our case is a good example of how we can use simple surgery
techniques like open reduction and percutaneous fixation with K-wire in
low and middle income countries where patient is not economically
sound to afford arthroplasty.
D.K. Pandit et al.
5. Patient perspective
“I am satisfied with the treatment I have received. I can at least
pickup 2-3 kgs weight, flex my elbow and take my own food and to do
my basic daily activities.”
Ethical approval
Ethical approval is not required for case reports in our institution.
Patient consent is required for publication of case report. A written
informed consent of patient has been taken for publication of data and
images.
Funding
There was no Funding.
CRediT authorship contribution statement
Concept and writing paper: Suveksha Shaurya Shah
Treating physician and review: Dinesh Kumar Pandit
Writing paper, Refrences: Gaurav Parajulee
Review: Nand Kishor Shah
Review: Paras Khakurel
SSS and GP drafted the manuscript. DP,NKS,PK were the treating
physician, senior author and supervisor and revised the manuscript.
Guarantor
Suveksha Shaurya Shah accepts full responsibility for the work and/
or the conduct of the study, had access to the data, and controls the
decision to publish.
Consent
Written informed consent was obtained from the patient for
International Journal of Surgery Case Reports 114 (2024) 109114
publication of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.
Declaration of competing interest
None.
References
[1] F. Bagheri, M.H. Ebrahimzadeh, S.R. Sharifi, H. Ahmadzadeh-Chabok, J. Khajah-
Mozaffari, A.S. Fattahi, Pathologic dislocation of the shoulder secondary to septic
arthritis: a case report, Cases J. 2 (2009) 9131. Published 2009 Dec 2, https://doi.
org/10.1186/1757-1626-2-9131.
[2] C.S. Resnik, Septic arthritis: a rare cause of drooping shoulder, Skelet. Radiol. 21
(5) (1992) 307–309, https://doi.org/10.1007/BF00241770 (PMID: 1302469).
[3] R.A. Agha, A.J. Fowler, A. Saeta, I. Barai, S. Rajmohan, D.P. Orgill, et al., The
SCARE statement: consensus-based surgical case report guidelines, Int. J. Surg. 34
(2016) 180–186.
[4] J.J. Jiang, H.I. Piponov, D.P. Mass, J.G. Angeles, L.L. Shi, Septic arthritis of the
shoulder: a comparison of treatment methods, J. Am. Acad. Orthop. Surg. 25 (8)
(2017 Aug 1) e175–e184.
[5] E.J. Gordon, G.A. Hutchful, Pyarthrosis simulating ruptured rotator cuff syndrome,
South. Med. J. 75 (6) (1982 Jun 1) 759–762.
[6] B.M. Leslie, J.M. Harris 3rd, D.O. Driscoll, Septic arthritis of the shoulder in adults,
JBJS 71 (10) (1989 Dec 1) 1516–1522.
[7] B.M. Gompels, L.G. Darlington, Septic arthritis in rheumatoid disease causing
bilateral shoulder dislocation: diagnosis and treatment assisted by grey scale
ultrasonography, Ann. Rheum. Dis. 40 (6) (1981 Dec 1) 609–611.
[8] E. Thomas, J.L. Leroux, M.J. Azema, F. Blotman, Inferior glenohumeral
subluxation: an indirect sign of sepsis of the shoulder, Revue du Rhumatisme (Ed.
Francaise: 1993) 61 (5) (1994 May 1) 349–352.
[9] I.S. Lossos, O. Yossepowitch, L. Kandel, D. Yardeni, N. Arber, Septic arthritis of the
glenohumeral joint: a report of 11 cases and review of the literature, Medicine 77
(3) (1998 May 1) 177–187.
[10] Y.G. Rhee, N.S. Cho, B.H. Kim, J.H. Ha, Injection-induced pyogenic arthritis of the
shoulder joint, J. Shoulder Elb. Surg. 17 (1) (2008 Jan 1) 637.
[11] U. Pawar, M. Bapat, Management of sequalae of neglected septic shoulder. Indian,
J. Orthop. 43 (1) (2009 Jan 1) 90.