Open Inferior glenohumeral joint dislocation with complete range of motion recovery: Case Report and literature review

Abstract

Luxatio erecta is an inferior glenohumeral dislocation. It is an uncommon pathology with a prevalence of 0.5% of all shoulder dislocations. An open luxatio erecta presentation is rarer. After an extensive literature search, we only could find three complete case reports. From these cases, 2 out of 3 developed complications such as infections and severely limited range of motion, especially in flexion and abduction.

We report the case of a 39-year-old man with an open inferior glenohumeral joint dislocation with complete rotator cuff tear and fracture of the greater tuberosity secondary to a motor vehicle accident. He was treated with open reduction, glenohumeral capsulorrhaphy, and transosseous rotator cuff repair with good clinical outcome.

In conclusion, an open inferior shoulder dislocation is rare, less than 0.1% of all dislocations, with a high incidence of nerve injury. We suggest prompt surgical treatment with immediate administration of antibiotic therapy, wound debridement, irrigation, open reduction, and repair of the rotator cuff as an adequate protocol and focused rehabilitation with early mobilization of the glenohumeral joint.

Introduction

Glenohumeral joint dislocation is the most common dislocation, accounting for up to 50% of all major dislocations with an incidence of 8 to 24 cases/100 000 population/year.^1–3 These injuries are classified according to the etiology as traumatic and atraumatic. Furthermore, they are categorized according to the direction of the humeral head dislocation into anterior, posterior, and inferior. Anterior dislocations are the most common, representing 90% of all injuries.^1,4 Inferior glenohumeral dislocations occur with a much lower frequency, with a prevalence of 0.5% and more frequent in men than women with a ratio of 3:1.^3,5

The clinical presentation of this dislocation is an arm abducted (110–160°) and externally rotated with a palpable mass in the axilla, with the elbow flexed and the forearm pronated, and the hand lying over the patient's head.^5,6

There are reports of fracture-dislocation of the greater tuberosity or a rotator cuff tear associated with this injury in 80% of patients.^5,7 Due to the mechanism of injury, damage to the anterosuperior region of the glenohumeral capsule has been reported, associated with fracture of the proximal humerus.^5,7

Within the number of luxatio erecta cases, there is a subgroup of open luxatio erecta, where only three cases are reported, representing an incidence of 1.5%.^8–10 This presentation commonly occurs in major trauma accidents where the force is sufficient to expose the bone through the soft tissues.

We report a 39-year-old male patient with an open inferior glenohumeral joint dislocation secondary to a motor vehicle accident.

Case report

A 39-year-old man without any previous clinically relevant history arrived at our trauma centre hospital four hours after being involved in a motor vehicle accident. He crashed against a wall getting his left arm trapped in hyperabduction against the vehicle's roof.

On initial examination, his left arm was in hyperabduction with external rotation with an apparently clear 7-cm wound near the left armpit where the humeral head protruded with no foreign bodies (Figure 1). The complete rotator cuff and the glenohumeral joint capsule were avulsed from the humeral head. Radial and ulnar pulses were preserved but with neurological impairment. The patient had limited flexo-extension of the elbow and wrist, adduction of the fingers, and limited first finger extension due to brachial plexus neuropraxia. Initial radiographs were performed, and a left open luxatio erecta humeri was confirmed with a greater tuberosity fracture (Figure 2).

Figure 1.

. Open inferior shoulder luxation. Humeral head without skin coverage (arrow).

Figure 2.

Anteroposterior initial x-rays with open inferior shoulder luxation, humeral head inferior to the glenoid joint.

After the patient was stabilized according to ATLS protocol, he was urgently admitted to the operating room. He underwent surgical debridement with profuse irrigation of the wound (approximately 9000 mL of saline solution) and posterior reduction of the glenohumeral joint. The reduction of the left glenohumeral joint was confirmed with a two-position shoulder X-ray (Figure 3).

Figure 3.

A) anteroposterior x-ray after glenohumeral joint reduction; B) lateral scapula view showing the avulsion fracture of the greater tuberosity.

Glenohumeral capsulorrhaphy, brachial plexus exploration and an open transosseous rotator cuff repair were performed. The wound was closed with the placement of a drain and shoulder immobilization. No vascular damage before and after reduction was observed. After surgery, the patient presented complete neurological recovery with all hand movements. The patient received intravenous ceftriaxone 2-g bolus and a maintenance dose of 1 g/12 h associated with gentamycin 80 mg every 8 h administered for five days after surgical reduction. The patient was discharged with a clean wound, a shoulder immobilization bandage for two weeks, and preserved elbow, wrist, and finger movements.

The patient had a 12-month follow-up after the inferior glenohumeral dislocation. During this time, he underwent 20 physical rehabilitation sessions with an important improvement of left shoulder range of motion 14 weeks after surgery. Brachial plexus neuropraxia remitted, and the patient had a fully sensitive and functional elbow, wrist, and left fingers (Figure 4). At his last examination, the patient presented 170° flexion, 170° abduction, 60° external rotation, and internal rotation reaching the D12 vertebrae.

Figure 4.

Twelve-month range of motion after open reduction. A) Abduction 170°; B) flexion 170°; C) Overhead; D) external rotation 60°; E) internal rotation until D12.

Western Ontario Score Index (WOSI) instrument was used to evaluate the clinical functionality of the affected shoulder. The WOSI score is represented by a number from 0 to 2100 (where 0 represents no clinical shoulder deficit and 2100 severe clinical shoulder deficit). The WOSI score in this patient was 295 (14% deficit) with a functional joint and with a deficit that is not important to daily life. ¹¹ At follow-up written consent was obtained for publication.

Discussion

Glenohumeral joint dislocation is the most common of all joint dislocations of the body; however, luxation erecta or inferior dislocation is unusual. Most of these rare cases of inferior dislocation are closed dislocations. Our case, an open inferior dislocation, is particularly special. These lesions are secondary to high trauma injuries and are associated with poor outcomes. We found only three reported cases with complete information following a Pub Med, Scopus and web of science search (table 1).^8–10 There is currently not enough information on the rates of short- and long-term complications in these lesions. ⁵

Table 1.

Comparison of the four cases of open inferior glenohumeral joint dislocation.

Artcle	Age	Mechanism	Associated lesions	Treatment	Immobilization	Range of motion
Lucas et al. 1975	16 years	Farm accident	Fracture of the greater tuberosity; Complete avulsion of the capsule and rotator cuff	Wound debridement + close reduction	4 weeks	Flexion: 70° Abduction: 45° ER: 20° IR: 60°
Davison et al. 1996	36 years	Farm accident	Fracture of the greater tuberosity; Subscapular tendon was ruptured	Manipulation under anesthesia + arthroscopic debridement of shoulder	4 weeks	Flexion:120° Abduction:120° ER: 40° IR: 40°
Garrigues et al. 2011	42 years	Car accident	Avulsion fracture of greater tuberosity; Complete avulsion of the capsule and rotator cuff	Surgical debridement + open repair of rotator cuff and biceps tenodesis	2 weeks	Flexion: 150° Abduction: 115° ER: 45°
Saavedra et al. 2021	39 years	Car accident	Avulsion fracture of greater tuberosity; Complete avulsion of the capsule and rotator cuff	Surgical debridement + open repair of rotator cuff and Glenohumeral capsulorraphy	2 weeks	Flexion: 160° Abduction: 160° ER: 45° IR: 80°

Our patient presented with his left arm in 130-degree hyperabduction with external rotation and with a 7-cm wound in the anterior axillary line. Radiographically, we identified luxatio erecta of the left shoulder where the humeral shaft was parallel to the spine of the scapula; ¹² also, a greater tuberosity fracture was seen on control X-rays of the left shoulder. This is associated in 60% of cases in a previous review article. ⁵

Our patient presented neuropraxia of the brachial plexus compatible with an associated neurologic lesion in 13–60% of cases ¹² with a recovery time from 2 weeks to 1 year. Our patient presented with complete neurologic recovery after surgical reduction. Although inferior luxation cases have the highest incidence of vascular compromise of all humerus luxation cases (3.3%), our patient did not have any vascular compromise. ¹³

Two different mechanisms have been described by Davids et al. In both cases, high-energy trauma is involved. Axial compression in a fully abducted arm displaces the humeral head through the inferior glenohumeral ligaments. The other mechanism involves hyperabduction in an abducted arm, resulting in lesions to the inferior and middle glenohumeral ligaments and the rotator cuff, which is compatible with our case.^5,6 A motor vehicle accident is associated in less than 10% of all the mechanisms.^5,14 The most common cause is related to a fall in 40%. In addition, our patient presented with an avulsion of the greater tuberosity of the humerus. Similar lesions have been reported in previous cases. In two, repair of the rotator cuff was not achieved, leading to weakness and poor range of motion.^8,10 On the other hand, Garrigues et al. reported a good range of motion after complete repair of the rotator cuff without capsulorrhaphy, contrary to our case with complete transosseous rotator cuff reinsertion and capsule repair. In all cases, humeral head avascular necrosis was present. It was hypothesized that complete rotator cuff rupture contributes to a lower humeral head blood supply with a poor outcome.^8–10 Immediate glenohumeral joint reduction with abundant irrigation and surgical debridement was performed to decrease infection risk.

Two previous cases immobilized the shoulder joint for four weeks with poor outcomes. In contrast, we utilized shoulder immobilization for 14 days with prompt range of motion. In this patient, a WOSI score of 295 (14% lower) points was achieved, representing a functional joint for daily activities, and a UCLA shoulder score of 29 points indicating a good clinical outcome. Similar to Garrigues et al. we reported a good short midterm outcome after open inferior glenohumeral dislocation with rotator cuff repair.

In conclusion, an open inferior shoulder dislocation is rare, less than 0.1% of all dislocations, with a high incidence of nerve injury. We suggest prompt surgical treatment with immediate administration of antibiotic therapy, wound debridement, irrigation, open reduction, rotator cuff repair, and focused rehabilitation with early mobilization of the glenohumeral joint as an adequate protocol.