(aspects of trauma • a case report)

Bilateral Luxatio Erecta Humeri and Bilateral Dislocations in the Same Patient Abdul Foad, MD, and Robert F. LaPrade, MD, PhD

Abstract is also a rare injury, with bilateral of the lower Bilateral knee dislocations seldom injuries being even more uncom- extremities revealed a neurovascu- occur, and fewer than a dozen cases mon.2 However, no other known case larly intact right lower extremity of bilateral luxatio erecta humeri report illustrates bilateral luxatio with gross ligamentous instability. (erect dislocation of the ) erecta humeri and complete bilateral A Lachman test at 20° of knee flex- have been reported. Here we pre- dislocation of the in the same ion resulted in a complete anterior sent the case of a patient who sus- tained bilateral knee dislocations patient. In addition to sustaining this dislocation (grade 4). The posterior and bilateral luxatio erecta humeri extraordinary extremity trauma, the was grade 3. Varus stress in a motorcycle accident. Transient patient also developed severe hypo- test at 0° and 30° was also grade 3. neurologic compromise resolved thermia, with a markedly depressed Valgus stress testing at 0° was grade with closed reduction of the bilateral core body temperature. 1 and at 30° was grade 3. The left shoulder and left knee dislocations. lower extremity had an anterior sub- To our knowledge, this is the first Case Report cutaneous depression just proximal case report of a patient with this A man in his early 40s, brought to the to the knee, with prominent femo- combination of injuries. emergency department by helicopter, ral condyles posteriorly. The left presented on a backboard wearing a was cyanotic and cold. There rect dislocation of the Philadelphia collar and with fixed eleva- were no pedal pulses by Doppler shoulder (luxatio erecta tion of above head, bent, . Neurologic examination humeri) is a rare type of and cold left leg and foot. He had been revealed complete motor and sen- glenohumeral dislocation. thrown from his motorcycle approxi- sory deficits in the left and ELuxatio erecta occurs in fewer than mately 100 feet, and approximately 8 foot for both the tibial and peroneal 1% of glenohumeral dislocations.1 hours had passed before he was discov- nerve distribution. Even more rare is a bilateral presen- ered. The well-developed patient had no Radiographic examination con- tation in the same patient (fewer than past medical history of musculoskeletal firmed the clinical diagnosis of bilat- a dozen cases have been reported). diseases or injuries. On physical exami- eral erect dislocations (both subgle- Complete dislocation of the knee nation, his core body temperature was noid) of the glenohumeral and 29°C. He was awake, oriented to person an unreduced anterior dislocation of and place, and complained of numbness the left knee (Figures 1-3). The right Dr. Foad is Co–Medical Director, Quality of both hands and left foot. shoulder x-ray also showed a dis- Care Center and Surgery Center, Clinton, Examination of the upper extremi- placed greater tuberosity fracture. The Iowa. ties revealed that the patient’s arms superolateral aspects of the humeral Dr. LaPrade is Professor, Sports Medicine and Shoulder Divisions, Department were abducted approximately 130° at heads were impacted beneath the infe- of Orthopaedic Surgery, University of the , flexed at the elbows, rior glenoid rims, with the humeral Minnesota, Minneapolis, Minnesota. and pronated at the . He had shafts parallel to the spines of the bilateral shoulder sulcus signs with scapulae. Alignment of the right knee Requests for reprints: Robert F. LaPrade, palpable humeral heads in the axillae. was grossly normal, but the gross MD, PhD, Sports Medicine and Shoulder Divisions, Department of Orthopaedic He could move all his fingers on ver- degree of instability revealed that the Surgery, University of Minnesota, 2450 bal command. Sensation was intact right knee had also been dislocated Riverside Ave, R200, Minneapolis, MN in the radial, median, and ulnar nerve and had spontaneously reduced. 55454 (tel, 612-273-8000; fax, 612-263- distributions. Vascular examination With use of intravenous morphine 7959; e-mail, [email protected]). revealed distal radial and ulnar pulses sedation, closed reduction of the left Am J Orthop. 2007;36(11):611-613. (detectable only by Doppler), but knee was performed by longitudi- Copyright Quadrant HealthCom Inc. 2007. capillary refill in the nail beds of the nal distal traction; an audible clunk All rights reserved. fingers took fewer than 2 seconds. occurred with knee reduction. Closed

November 2007 611 Bilateral Luxatio Erecta Humeri and Bilateral Knee Dislocations

Discussion Luxatio erecta humeri was described initially by Middeldorpf and Scharm in 1859.3,4 Incidence of this injury is estimated to be less than one half of 1% of all shoulder dislocations.5 Bilateral luxatio erecta humeri is even less common, with less than a dozen known case reports.6 The first case report of bilateral luxatio erec- ta humeri was described in 1920 by Murard.7 Approximately 100 cases of luxatio erecta have been reported in Figure 1. Anteroposterior x-ray of right Figure 2. Anteroposterior x-ray of left shoul- the English-language literature.1 Our shoulder shows subglenoid luxatio erecta gle- der shows subglenoid luxatio erecta glenohu- patient’s case is unique in that it appears nohumeral dislocation and displaced greater meral dislocation. to be the only one in which bilateral tuberosity fracture. luxatio erecta humeri and bilater- al knee dislocations occurred in the reduction by gentle upward axial of the right rotator cuff were performed same patient. traction and abduction using a coun- in 10 days, when the patient was stable The mechanism of injury for erect teraction maneuver across the torso enough to return to the operating room. shoulder dislocations is through a easily reduced both shoulders, and Initial plans were for staged right knee violent abduction force or direct axial they remained reduced. The arms arthroscopic anterior and posterior load on an already abducted upper were then brought down into adduc- cruciate reconstructions with extremity.6 Clinical diagnosis is fairly tion and internal rotation, and strong allografts after the left leg wounds were easy to make because of the patient’s radial pulses immediately returned. healed and showed no evidence of fixed “hands up” position, with the The left foot quickly warmed, and infection. The left knee was not planned shaft of the humerus in at least 120° Doppler posterior tibial and dorsalis to be reconstructed acutely because of of abduction6 and the pro- pedal pulses were obtained. Capillary ongoing infection and the location of nated resting on the head.1 Motion refill took fewer than 2 seconds, and the fasciotomy incisions. The patient is understandably painful and vehe- the foot became pink. Full neuro- remained hospitalized for 3 weeks and mently resisted by the patient, who is logic function recovered within min- underwent extensive rehabilitation. He unable to actively or passively lower utes, and the compartments of the was discharged to a nursing home and his or her arms.1 lower leg were soft. Velpeau-type was subsequently completely lost to Associated neurovascular injuries immobilizers were placed for the follow-up. Multiple attempts to locate are frequent (ie, axillary nerve and arms, and bilateral knee immobilizers him over a 4-year period have proved ) but usually spontaneously were placed for the lower extremities. unsuccessful. resolve with early reduction, as in our Postreduction x-rays showed anatom- ical reductions, with the only frac- ture being the displaced right greater tuberosity fracture. Arteriography of bilateral axillary and popliteal arter- ies showed no arterial injuries. The patient subsequently developed of the left lower leg over the next 4 hours, as it was reperfusing and warming, and 4-com- partment fasciotomies were performed. Several irrigation and débridement pro- cedures were performed for the left leg because of myonecrosis and deep infection secondary to the extent of myonecrosis. Anatomical open recon- struction of the posterolateral right A B knee structures, open reduction and internal fixation of the displaced right Figure 3. Anteroposterior (A) and lateral (B) x-rays of left knee show anterior left greater tuberosity fracture, and repair knee dislocation.

612 The American Journal of Orthopedics® A. Foad and R. F. LaPrade patient’s case, as the compression on injuries) associated with a high-veloc- Authors’ Disclosure neurovascular structures is relieved. ity knee dislocation, as in this case, Statement Recurrent dislocation and instabil- is approximately 33%,10 and nerve The authors report no actual or poten- ity are less common consequences injuries associated with high-velocity tial conflict of interest in relation to of the injury, with development of knee dislocations range from 14% to this article. adhesive capsulitis being the more 35%.8,11,12 For patients with a vascular common pathologic sequelae.1,8 injury secondary to a traumatic knee References Acute bony injuries about the shoul- dislocation that has not been repaired 1. Yamamoto T, Yoshiya S, Kurosaka M, Nagira K, Nabeshima Y. Luxatio erecta (inferior dis- der girdle are common, including within 8 hours, the rate location of the shoulder): a report of 5 cases fractures of the clavicle, acromion, is approximately 85%.9 Although our and a review of the literature. Am J Orthop. coracoid, scapula, and, most com- patient did not sustain a vascular injury 2003;32(12):601-603. 8,9 2. Sisto D, Warren R. Complete knee disloca- monly, the greater tuberosity. This by definition, his vascular perfusion tion. Clin Orthop. 1985;(198):94-101. was apparent in our patient’s case was limited for at least 10 hours before 3. Middeldorpf M, Scharm B. Denova humeri (his right shoulder sustained a dis- presentation, and he sustained a com- luxationis specie. Clinique Europiene. 1859;2:12. placed greater tuberosity fracture). partment syndrome with significant 4. Laskin RS, Sedlin ED. Luxatio erecta in infan- In many of these injuries, soft-tissue myonecrosis and a secondary deep cy. Clin Orthop. 1971;80:126-129. injuries include rotator cuff tears.1 infection secondary to this occurrence. 5. Craig EV. Fractures of the clavicle. In: Rockwood CA Jr, Green DP, eds. Fractures Radiographically, the humeral head Major ligamentous reconstruction is in Adults. 3rd ed. Philadelphia, Pa: Lippincott; may be beneath the inferior rim of recommended within 2 weeks of injury 1996:1109-1161. 6. Newman KJ, Bendall R. Bilateral inferior shoulder dislocation: both subglenoid and subcoracoid types seen in the same patient. “Incidence of lower extremity vascular Injury. 1993;24(10):684-685. 7. Murard J. Un cas de “luxatio erecta” de l’ épaule, double et symétrique. Rev d’ Ortho injuries... associated with a high-velocity Par. 1920;7:423-429. 8. Davids JR, Talbott RD. Luxatio erecta humeria knee dislocation, as in this case, (a case report). Clin Orthop. 1990;(252):144- 149. is approximately 33%.” 9. Peiró A, Ferrandis R, Correa F. Bilateral erect dislocation of the shoulders. Injury. 1975;6(4):294-295. the glenoid (subglenoid type, as in or after vascular repair10,13-15 and should 10. Merrill KD. Knee dislocations with vascular injuries. Orthop Clin North Am.1994;25(4):707- this patient) or in front of the be carried out only if there is no con- 713. of the scapula (subcoracoid type), cern about infection or limb survival. 11. Kennedy JC. Complete dislocation of the knee as described by Newman.1,6 The In the meantime, the knee should be . J Bone Joint Surg Am. 1963;45:899- 904. 10 shaft of the humerus is parallel to immobilized in full extension to pre- 12. Twaddle BC, Bidwell TA, Chapman JR. Knee the scapular spine.1 Treatment is vent posterior of the dislocations: where are the lesions? A pro- often closed reduction using a trac- on the . The current recommenda- spective evaluation of surgical findings in 63 cases. J Orthop Trauma. 2003;17(3):198- tion–countertraction force technique tion is to perform ligamentous repair or 202. under general anesthesia or under reconstructions of the torn ligamentous 13. Leffers D. Dislocations and soft tissue injuries conscious sedation.1,8 structures in order to decrease the pain, of the knee. In: Browner B, Jupiter J, Levine A, et al, eds. Skeletal Trauma. Philadelphia, Pa: Complete dislocation of the knee stiffness, and instability that follow knee Saunders; 1992:1717-1743. is one of the most devastating lower dislocations. Lower extremities with a 14. Richter M, Bosch U, Wippermann B, Hofmann extremity injuries. Knee dislocation peroneal nerve injury generally have a A, Krettek C. Comparison of surgical repair or reconstruction of the cruciate has been defined as a knee with at poorer outcome and poorer knee func- versus nonsurgical treatment in patients with least 3 of the 4 major ligamentous tion.10 No current treatment promises traumatic knee dislocations. Am J Sports complexes torn, usually involving to restore function to a nonfunctioning Med. 2002;30(5):718-727. 15. Liow RY, McNicholas MJ, Keating JF, Nutton tears or avulsions of both cruciate or stretched common peroneal nerve. RW. Ligament repair and reconstruction in ligaments and tears of the medial and/ Therefore, an ankle foot orthosis is used traumatic dislocation of the knee. J Bone Joint or lateral ligamentous complexes.10 to keep the foot in neutral dorsiflexion,10 Surg Br. 2003;85(6):845-851. 16 16. Yeap JS, Birch R, Singh D. Long-term results Incidence of lower extremity vascu- or tendon transfers are performed to of tibialis posterior tendon transfer for drop- lar injuries (usually popliteal artery address the resultant footdrop. foot. Int Orthop. 2001;25(2):114-118.

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