Erecta dislocation of the shoulder joint-A rare injury: About four cases

The 'Holy Grail' of shoulder dislocations: a systematic review on traumatic bilateral luxatio erecta; is it in reality a once-in-a-lifetime experience for an orthopaedic surgeon?

INTRODUCTION

Even though shoulder dislocation is thought to be the most common dislocation treated in the Emergency Department, inferior ones, known as Luxatio Erecta, comprise only 0.5% of them. Taking into consideration the rareness of unilateral Luxatio Erecta, bilateral cases should be even fewer. The purpose of this paper is to identify the reported number of cases of Traumatic Bilateral Luxatio Erecta in the literature over the last 100 years and to summarize the mechanism of injury, the initial management, and the complications of these patients.

MATERIALS AND METHODS

We performed a systematic review of the literature regarding Traumatic Bilateral Luxatio Erecta. All articles published until 31st of December 2022 in PubMed and Google Scholar databases were searched using the terms "luxatio erecta", 'inferior dislocation", and "bilateral".

RESULTS

Eighty-two articles were retrieved from PubMed and Google Scholar search. Forty-four of them were initially included in our review. Six additional articles meeting the inclusion criteria were found from cross-references.

CONCLUSION

The presence of this injury is extremely rare with only 51 cases in the literature. The incidence of concomitant injuries and complications seems to be extremely high and neurological deficits were detected on 42.8% of patients with Bilateral Luxatio Erecta. To our knowledge, this is the first systematic review of the literature regarding Traumatic Bilateral Luxatio Erecta that includes articles not only in English, a fact that provides more reliability on the estimation of the real number of cases of this rare injury compared to any other review on this subject to date.

Luxatio Erecta Humeri: A Case Report

Introduction

Luxatio erecta humeri (LEH) is a rare type of inferior shoulder dislocation (ISD) and easy misdiagnosed or missed. We reported a case of a traumatic LEH with a radiological interpretation of ISD. We felt that the physical presentation was compatible with the LHE type and the closed reduction by the traction and countertraction method we accomplished without complications.

Case Report

We present a case of 38-year-old man with a LEH. We performed for the early diagnosis the clinical examination and the X-rays. We felt that the physical presentation was compatible with an erecta dislocation of the humerus, whereas radiologically, this injury was interpreted simply as the inferior dislocation of the right shoulder. The closed reduction by the traction and countertraction method was accomplished without complications. We kept the reduction with a Velpeau arm sling shoulder immobilizer brace for 3 weeks and after a shoulder rehabilitation, the outcome was good.

Conclusion

The luxation erecta humeri is a type of ISD still little known but the singular and unmistakable physical presentation should allow for an early diagnosis to obtain an easy closed reduction and a good outcome.

Atypical presentation of an inferior shoulder dislocation with an engaging Hill-Sachs lesion: A case report

Case

Inferior shoulder dislocations (ISD) are very rare occurrences estimated to make up only 0.5% of all shoulder dislocations and are typically associated with high-energy trauma and humerus fractures. We present an unusual case of an ISD due to the absence of the pathognomonic arm posture, mimicking an anterior shoulder dislocation. After multiple failed attempts at closed reduction in the Emergency Department, orthopaedics was consulted for further evaluation. Appropriate imaging was ordered, including an axillary radiograph and CT scan, which demonstrated an ISD with an engaging Hill-Sachs lesion and displaced greater tuberosity fracture. The patient was taken to the operating room the same day and underwent a successful closed reduction utilizing intraoperative fluoroscopic imaging.

Conclusion

Early reduction of ISD is critical to preventing complications, such as axillary neuropraxia and brachial plexopathy. However, closed reduction of ISD is often difficult. The two-step maneuver under general anesthesia in the operating room with procedural fluoroscopy is recommended to ensure a safe, adequate, and timely reduction.

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Inferior shoulder dislocations are rare and usually present with the affected arm locked overhead.

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They may present atypically mimicking anterior shoulder dislocations, leading to the use of improper reduction techniques.

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When evaluating shoulder dislocations, it is important to identify concomitant osseous and neurological injuries.

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Inferior dislocations can be reduced under general anesthesia if initial reduction attempts in the ER are unsuccessful.

Axillo-subclavian dissection and pseudoaneurysm following inferior glenohumeral dislocation: Case report and literature review

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This is a rare case of Axillo-subclavian dissection and pseudoaneurysm following blunt chest injury.

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Inferior shoulder dislocation is uncommon but may cause serious vascular injury and life-threatening hemorrhage.

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An endovascular approach was life-saving for our patient considering her advanced age and medical comorbidities.

Introduction

Axillo-subclavian arterial injuries are generally associated with penetrating trauma. On rare occasion, blunt mechanisms can cause these injuries in the setting of high-energy trauma, humeral head or neck fractures, and severe glenohumeral dislocations. Glenohumeral dislocations sustained from ground-level falls are generally reduced in the emergency department without associated morbidity.

Presentation of case

An 80-year-old woman presented with an inferior glenohumeral dislocation after a ground-level fall that was found to be complicated by axillary dissection, pseudoaneurysm, and acute hemorrhage. Endovascular intervention with a balloon-inflatable stent successfully controlled extravasation and restored perfusion to the affected upper extremity. After a short hospitalization, the patient was discharged with intact neurovascular status.

Discussion

Blunt axillary artery injury and inferior glenohumeral dislocations are both uncommon entities. A correlation exists between inferior dislocations and neurovascular complications. Accordingly, there may be a role for diagnostic vascular imaging for patients with inferior glenohumeral dislocations. Endovascular stenting was successful in our case and backed by case series and cohort studies in the literature. Some controversy exists regarding stent patency and follow-up planning in trauma patients.

Conclusion

This case represents a critical vascular injury from an unexpected mechanism. Inferior glenohumeral dislocations, regardless of injury mechanism, should raise the index of suspicion for vascular involvement. Endovascular repair in our patient was life-saving given her advanced age, acute blood loss anemia, rarity and severity of her injuries and multiple medical comorbidities.