Obturator hip dislocation associated with contralateral luxatio erecta humeri: An unusual traumatic association (case report)

Abstract

Introduction and importance

Obturator hip dislocation and luxatio erecta humeri are two extremely rare injuries. We are reporting a very rare case that involves the association of these two injuries.

Case presentation

We reported the case of a 34-year-old male who was a victim of a high-energy road accident. Initial examinations showed a right obturator dislocation associated with a left luxatio erecta humeri without vascular-nervous complication. Further examinations have ruled out life-threatening injuries.

A closed reduction for both joints has been performed under general anesthesia less than 6 h following the trauma. Postoperative examination showed two congruent joints. Functional treatment has been implemented. Weight-bearing was permitted after 6 weeks, and physical rehabilitation of the shoulder was initiated 3 weeks after the trauma.

Last examination (20 months after trauma) showed a painless two-joint with a full range of motion. There was no sign of shoulder instability, and radiographs showed no signs of avascular necrosis of the femoral head.

Clinical discussion

Both injuries are two rare orthopedic emergencies that require prompt diagnosis and immediate reductions.

Conclusions

A good outcome can be expected if functional treatment is applied after prompt closed reduction. Hence, regular monitoring is required to detect complications such as avascular necrosis of the femoral head for the hip and signs of instability for the shoulder.

Highlights

• •Obturator hip dislocation is a rare injury resulting from high-energy trauma.
• •Luxatio erecta humeri is also a rare shoulder injury resulting from an indirect mechanism.
• •The association between these two injuries has never been reported in the literature.
• •A favorable outcome can be expected from functional treatment of these rare injuries if early reductions are performed.

1. Introduction and importance

Traumatic hip joint dislocation is a rare injury, constituting approximately 5 % of all dislocations [1]. Among these, obturator hip dislocations, representing only 6 % of all hip dislocations, are typically caused by forces involving abduction and external rotation [2].

Inferior shoulder dislocation is an exceptionally uncommon injury, representing only 0.5 % of all glenohumeral dislocations. This rare form of dislocation can result from either a direct or indirect mechanism [3].

The co-occurrence of these two injuries reflects the high energy of the trauma, and clinicians must promptly rule out any life-threatening emergencies. Diagnosis is confirmed through clinical and radiological assessments, and urgent reduction of both joints is crucial to prevent complications [1,3,4]. The combination of these two injuries can exacerbate the overall functional prognosis by causing a delay in physical rehabilitation [5] or due to their potential complications [1,3,4,6].

The association of these two injuries is extremely rare and, to the best of our knowledge, has never been reported in the literature.

2. Case presentation

This work has been reported in line with the SCARE criteria [7].

Clinical history: We report the case of a 34-year-old man, a smoker and alcoholic, with no previous medical history, who was a victim of a road traffic accident. He was a motorcyclist struck by a car while driving with his right hip in abduction, flexion, and external rotation. This impact led to the ejection of the patient, landing on the left upper limb in hyperabduction. Three hours after the accident, the patient was admitted to our emergency department.

2.1. Physical examination

The first examination showed a stable condition in terms of hemodynamics, respiratory, and neurological aspects. The patient presented with a right lower limb deformity fixed in flexion, abduction, and external rotation, and a left upper limb deformity with a left shoulder fixed in hyperabduction (Fig. 1). The range of motion of both limbs was extremely painful and restricted. No vascular or nerve complications were noted.

Fig. 1.

Patient presented with a lower limb deformity fixed in flexion, abduction, and external rotation and a contralateral upper limb deformity with a right shoulder fixed in hyperabduction.

2.2. Exploration

A computed tomography body scan was performed, ruling out any life-threatening emergencies. Radiological assessments showed an anterior obturator dislocation of the right hip and a contralateral Luxatio Erecta Humeri associated with greater tuberosity fracture (Fig. 2). The bony window of the non-contrast computed tomography showed anterior dislocation of the right hip associated with partial fracture of the acetabulum without an intra-articular bony fragment or a femoral head fracture (Fig. 3).

Fig. 2.

Initial radiographs that showed a luxatio erecta humeri at the left shoulder (A) and an obturator hip dislocation of the right hip (B).

Fig. 3.

CT-scan that showed an obturator dislocation without a head femoral fracture nor intraarticular bony fragment.

2.3. Treatment

An immediate closed reduction was planned, and the patient was transferred to the operating room 5 h after the accident.

Under general anesthesia, the dislocation of the right hip joint required the coordination of two operators. One operator stabilized the pelvis, while the other attempted to maneuver the hip into flexion, adduction, and external rotation to release the femoral head from the obturator foramen. Subsequently, a progressive axial traction was applied. For the reduction of the shoulder dislocation, only one operator was needed applying simple traction. The reduction of both joints has been confirmed clinically and radiologically (Fig. 4). Following closed reduction, the fracture dislocation of the shoulder was treated orthopedically and immobilized using an arm sling. A skin traction was applied to prevent recurrent dislocation of the right hip.

Fig. 4.

Clinical and radiological confirmation after closed reduction.

3. Outcomes

No vascular or nerve complications were observed. Post-reduction X-rays revealed a concentric reduction of both joints, and a CT scan showed no associated fractures or intra-articular fragments.

Shoulder rehabilitation commenced three weeks post-reduction and partial weight-bearing initiated at six weeks post-reduction after confirming clinical and radiological healing of the shoulder fracture-dislocation. At the last follow-up (20 months), the examination indicated no hip stiffness or pain and no radiological signs of femoral head osteonecrosis (Fig. 5). Shoulder examination revealed unrestricted motion, without signs of instability, and normal activities were resumed three months after the accident.

Fig. 5.

Radiographs of the pelvic (A) and the shoulder (B) at last follow-up.

4. Clinical discussion

Hip dislocations typically result from high-energy trauma. Anterior hip dislocations, less frequent than their posterior counterparts, can be attributed to the robust nature of the anterior capsule and the Y ligament of Bigelow, serving as protective factors against anterior hip displacement [2]. To dislocate the hip anteriorly, the force should be directed on an abducted and external rotated hip [8]. Subsequently, the greater trochanter comes into contact with the acetabular rim, functioning as a lever using a cam effect on the ilium and causing anterior displacement of the femoral head [9]. In our case, the patient experienced a high-energy direct impact to his right lower limb while riding his motorcycle, with his hips in abduction, flexion, and external rotation, resulting in an obturator hip dislocation.

On the other hand, Inferior shoulder dislocation, also recognized as Luxatio Erecta Humeri, was initially described by Middeldorph and Scharm in 1859 [10]. This type of shoulder dislocation is primarily caused by an indirect mechanism: when a high-energy hyper-abduction force is applied to the arm, the proximal humerus is dislocated and assumes a lever arm role. This position is sustained in an erect posture due to the strong and constant pulling influence of the pectoralis major [11,12]. Our patient was forcefully ejected from his motorcycle and landed on the contralateral upper limb in hyperabduction, a protective reflex to shield his head. This maneuver resulted in a left inferior shoulder dislocation.

Hence, inferior shoulder dislocation can be associated with complications. Tsuchida and al. reported that 60 % of patients experienced axillary nerve palsy, 37 % had humerus fractures, and 12 % suffered from rotator cuff tears [13]. Late complications, like adhesive capsulitis and instability were also noted in previous studies [6,10,13].

Several simultaneous fractures or fracture dislocations have been linked to inferior shoulder dislocation within the literature: These include acromion fractures, clavicular fractures, fractures of the body of the scapula, glenoid fractures, and fractures involving both forearm bone [14]. In our case, inferior shoulder dislocation was associated with a comminuted major tubercle fracture, which was successfully reduced and treated orthopedically.

Bilateral cases of Luxatio Erecta Humeri have also been reported in the literature. [10,15].

For simultaneous lower limb injuries, Foad and LaPrade reported a case of bilateral knee dislocations associated with an inferior dislocation [16]. Demiral and al have reported a case of Luxatio Erecta Humeri and a concurrent posterior hip fracture dislocation [17]. To the best of our knowledge, this is the third case report describing Luxatio Erecta Humeri associated with hip dislocation [17,18] and the first case reported with an associated obturator hip dislocation.

Early reduction of inferior shoulder dislocation and hip dislocation is recommended to prevent complications [1,4,6,9,18]. Many cases can be successfully treated in the emergency room using an opposite traction with adequate analgesia and sedation [12]. In our case, the reduction of the shoulder was performed successfully and easily in the operating room using simple traction, conducted by one operator.

For hip dislocations, the current recommendation is for immediate reduction within 6 h of injury [19], performing the reduction in this timeframe reduces the incidence of avascular necrosis by more than 50 % [20]. Although this complication is most commonly associated with posterior dislocation of the hip (7.5 %), it occurs in 1.5 % of all anterior and obturator dislocations [21]. The risk of a vascular necrosis was evaluated at 40 % after open reduction of the hip according to Stewart and al, [22]. However, the existence of accompanying injuries, particularly fractures of the femoral head, or intra-articular fragmentary incarceration, makes the dislocation irreducible [4,8,23]. In such cases, a surgical approach using an iliofemoral approach becomes necessary for reduction and synthesis [4]. Bastian et al. recommended surgical intervention and a bone graft for obturator hip dislocations in cases where femoral head defects exceeded four millimeters, considering the associated risk of post-traumatic arthritis [24]. Bagaria and al suggested the use of hip arthroscopy for the extraction of intra-articular fragments or the assessment of intra-articular injuries to cartilage, capsule, and labrum [25]. Many possible complications of hip dislocations are reported in the literature, including post-traumatic arthritis, heterotopic ossification, and neurovascular injury [22].

Post-reduction management depends on whether the dislocation is isolated or associated with bone lesions. In our case, we chose skin traction for 3 weeks to alleviate pain, reduce intra-articular pressure, and minimize the risk of femoral head necrosis [1,26]. The timeframe for non-weight bearing remains a subject of debate. Some authors suggested that immediate partial weight-bearing poses no significant risk [27]. In our case, we authorized the partial weight-bearing and the use of clutches at 6 weeks after a confirmed healing of the shoulder fracture dislocation.

At the last follow-up examination, our patient demonstrated a painless hip with a full range of motion and no signs of avascular necrosis. Nevertheless, close follow-up is crucial for identifying potential complications. An MRI should be promptly conducted to detect early signs of avascular necrosis [28].

5. Conclusion

Obturator dislocation and Luxatio Erecta Humeri are two extremely rare injuries. To the best of our knowledge, this is the first case report describing their association. Immediate reduction for both joints under general anesthesia is recommended. A favorable outcome can be expected with early reduction, followed by immobilization and the timely onset of physical rehabilitation. Close follow-up is necessary to promptly detect any potential complications, such as avascular necrosis of the femoral head for obturator dislocation, which may lead to coxarthrosis and necessitate total hip arthroplasty, and shoulder instability for the inferior dislocation.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Consent statement

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

The ethical committee approval was not required given the article type (case report).

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Guarantor

• Habboubi Khalil

• Ben Brahim Safouen.

Research registration number

Not applicable.

CRediT authorship contribution statement

• Ben Brahim Safouen: Original draft writing.

• Habboubi Khalil: Data analysis, paper validation.

• Meddeb Mehdi: Paper editing.

• Mzid Ahmed: Supervision.

• Makhlouf Hassen: Supervision.

• Mestiri Mondher: Supervision.

Declaration of competing interest

The author(s) declared no potential conflicts of interest.