Bilateral luxatio erecta humeri with a unilateral brachial plexus injury.

Sir,

Luxatio erecta is a rare inferior glenohumeral dislocation accounting for only 0.5% of all shoulder dislocations.[1] Bilateral luxatio erecta is rarer still with only a few cases reported. We present a case of successful closed reduction of bilateral luxatio erecta sustained subsequent to a road traffic accident (RTA).

A 19-year-old male front seat passenger was brought to the Emergency Department (ED) subsequent to a RTA. The ambulance crew noted that the patient held both his arms in an abducted position and any movement of the arms were painful. He was immobilized on a spinal board in this unusual position [Figure 1]. He had an obvious right lower limb injury which was immobilized with a splint.

Figure 1

Photograph of the patient with bilateral inferior shoulder dislocations immobilized on a spinal board. The arms are held in an abducted position with the elbows flexed and forearms pronated. The humeral heads (white arrows) were readily palpable on the lateral chest wall

On clinical examination both arms were abducted, the elbows flexed and forearms pronated. The humeral heads were palpable in the axilla on the lateral chest wall [Figure 1]. Paraesthesia of the left arm along a C6 and C7 dermatomes were present. A right tibial shaft fracture was identified and immobilized appropriately. Computerized tomography scan of the thorax revealed bilateral inferior dislocations associated with avulsion fracture of the greater tuberosity [Figure 2] as well as bilateral pneumothoraxes for which chest drains were sited.

Figure 2

Three-dimensional reconstruction of the computerized tomography scan of the thorax demonstrating bilateral inferior dislocations with associated with avulsion fracture of the greater tuberosity

Closed reduction of the shoulders was performed with traction and counter traction to the abducted arm under a general anesthetic prior to intramedullary nailing of the tibial fracture. The shoulders reduced easily [Figure 3] and were immobilized in a sling with the arms in adduction and internal rotation. Post-operative examination revealed a left wrist drop and loss of finger extension. However, they began to improve by the third post-operative day with full resolution by 2 weeks.

Figure 3

Radiographs demonstrating satisfactory reduction of both shoulder joints

Physiotherapy was commenced at 3 weeks and at the 6 months follow-up, the patient had a good range of motion to both shoulders without neurovascular deficits.

Luxatio erecta has a high incidence of associated injuries with up to 80% having, either a fracture of the greater tuberosity or a rotator cuff tear, up to 60% having a neurological deficit, however vascular injuries are uncommon.[2] Our patient sustained a transient wrist drop, loss of finger extension and paraesthesia, which likely resulted from stretching of the posterior cord of the brachial plexus during the dislocation.

Treatment is generally by closed reduction. Traction to the abducted arm with counter traction is the most commonly used reduction technique.[34] Post-reduction, the shoulder is immobilized for at least 2 weeks with the subsequent commencement of physiotherapy. Long-term prognosis is good in most of these patients.[5]

These dislocations add an additional layer of complexity to managing the poly-traumatized patient in the ED. Satisfactory immobilization of the cervical spine can be difficult due to the abducted arms. Log rolling of the patient while performing the initial and subsequent examinations in our case required additional time and personnel. However, the abducted arms made it easier to site the chest drains.