Dysbaric Osteonecrosis in Diving Fisherman: A Case Report: Seher Kurtul, Nejdiye Güngördü
Dysbaric Osteonecrosis in Diving Fisherman: A Case Report: Seher Kurtul, Nejdiye Güngördü
Dysbaric Osteonecrosis in Diving Fisherman: A Case Report: Seher Kurtul, Nejdiye Güngördü
Abstract
Background: Dysbaric osteonecrosis (DON) is defined as avascular bone necrosis, usually involving specific parts
of the long bones, which is seen in divers or compressed-air workers due to exposure to pressure. We describe a case of
DON in an artisanal diving fisherman working underwater for many years. Methods: A 48-year-old male case
was admitted to the occupational disease outpatient with left shoulder and arm pain for 1-2 years. Since the age of
20, he has been artisanal diving fishing with a hookah at a depth of 20-25 meters in the sea. In 2011, he received
hyperbaric oxygen therapy for widespread pain in the whole body due to decompression sickness (DCS). In the case’s
left shoulder joint x-ray and magnetic resonance imaging, degenerative changes in the acromioclavicular joint and
signal changes consistent with osteonecrosis starting from the subcortical area of the humeral head and extending to
the proximal shaft of the humerus were observed. Conclusions: DON is among the most common long-term pa-
thologies in professional divers. In Turkey, as in our case, not applying safe decompression procedures and unsafe div-
ing practices are common among diving fishers. In studies, the frequency of exposure to pressure, duration and depth
of dive, insufficient decompression, formation of DCS and increasing age were associated with DON. Today, DON
remains an occupational hazard with significant medical and social consequences. Diving fishers should be informed
about the sequelae of DCS and trained on the safety measures to be taken.
In Turkey, diving fishermen work in small cockpit for the last 1-2 years, and he applied to underwater
boats to hunt various sea creatures, using compressed medicine outpatient as his complaints gradually in-
air supplied from the surface via a “hookah” system. creased. In the case’s left shoulder joint X-ray and
The hookah system supplies air to the diver through magnetic resonance imaging, degenerative changes
a long hose coming out of the air compressor. This in the acromioclavicular joint and signal changes
method allows diving fishers to stay undersea longer consistent with osteonecrosis starting from the sub-
than the required safe limits. In addition, the desire cortical area of the humeral head and extending to
to earn additional income may cause the safe limits the proximal shaft of the humerus were observed
to be exceeded, and DCS may occur many times in (Figure 1, 2).
diving fishers. We aim to present a case of DON
working as a diving fisherman and diagnosed as a 3. Discussion
result of underwater occupational risks.
Although bone disorders in compressed air tun-
2. Case Reports nel workers and divers have been known for many
years, it has become understandable after the discov-
A 48-year-old male case was admitted to the oc- ery of X-rays. DON was diagnosed for the first time
cupational disease outpatient with left shoulder and in compressed air tunnel workers by bone X-ray in
arm pain for 1-2 years. He has no history of chronic 1911 with two different studies. The first diagnosis
disease, drug use, or cigarette-alcohol habit. Since of DON in divers was much later, in 1941. In the
the age of 20, he has been artisanal diving fishing later years, especially after accepting this disease as
with a hookah at a depth of 20-25 meters in the sea. an occupational disease, studies on the frequency of
During the year, he worked underwater for 6 hours DON were conducted in various countries and dif-
a day, intermittently, every day when the weather ferent occupational groups working in compressed
conditions were suitable for diving, without obey- air [3]. The prevalence of DON varies considerably
ing the required times while diving into the water between different countries, and in some countries,
and coming to the surface. In 2011, he received hy- including our country (Hawaii, Korea, and Japan),
perbaric oxygen therapy for widespread pain in the the high prevalence is most likely due to the lack of
whole body due to DCS. He complained of pain in
the left shoulder and loss of strength in the left arm
Figure 1. X-ray of the shoulder joint. Figure 2. Magnetic resonance imaging of the shoulder joint.
Dysbaric osteonecrosis in diving fisherman 3
safe decompression procedures and the greater fre- taken even if it is impossible to eliminate the hazard
quency of unsafe driving practices, especially among by following the rules of safe diving, possibly reduc-
divers [4]. In studies, the frequency of exposure to ing the risk significantly.
pressure, duration and depth of dive, insufficient de-
compression, formation of DCS and increasing age Declaration of Interest: No potential conflict of
were associated with DON. Although it is thought interest relevant to this article was reported by the authors.
that there is a mechanism associated with inert gas
Informed Consent Statement: Written informed
embolism in the aetiology of DON, there is no clear
consent for publication of their details was obtained from
evidence of a cause-effect relationship. It is thought the patient.
that it is a gradual process that occurs due to more
than one dive [5, 6]. Other causes include mecha- References
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