Unilateral inferior shoulder dislocation (luxatio erecta) is uncommon, accounting for only 0.5% of all shoulder dislocations.1 Bilateral luxatio erecta is extremely rare, having been described fewer than 20 times in the literature. The most common etiology is hyperabduction causing the humerus to lever on the acromion; less common is axial loading onto a fully abducted arm and an extended elbow.2 Hyperabduction can occur when a person grabs an object in an attempt to stop a fall, as occurred in the present case. The patient provided written informed consent for print and electronic publication of this case report.
Case Report
A 58-year-old man with a trauma injury presented to our emergency department. For his open right elbow fracture, emergency medical services had given him fentanyl en route, and when he arrived he was less responsive. As the patient reported, he had been on a scaffold 16 feet high when it began to give way. He jumped for another scaffold, 3 to 4 feet away, but came up short and, in an attempt to stop himself from falling, grabbed onto it with arms extended and above his head. His hands and arms were immediately pulled up in full extension. When both shoulders became dislocated, he could not hold on and fell to the ground, landing on a buttock. He did not lose consciousness.
Physical examination revealed both arms abducted at the shoulder, and elbows extended (Figure 1).
Radiographs confirmed the diagnosis and showed bilateral nondisplaced proximal humeral fractures of the greater tuberosity (Figure 2).
For the shoulder reductions, we administered propofol for conscious sedation and fentanyl for analgesia. Then, a sheet was wrapped supraclavicular and pulled across the torso inferiorly to allow countertraction when pulling the arm superiorly on the axial line. Another countertraction sheet was placed on the opposite side. For each arm, the countertraction was pulled inferiorly when the arm was pulled superiorly, both on the longitudinal plane. The arm was then gently rotated in adduction until reduction was achieved.
The right shoulder reduced relatively easily. The left shoulder reduced into an anterior dislocation—a relatively uncommon outcome in in-line traction attempts.3 (Reduction into anterior dislocation can also be a desired result in a specific technique of 2-step reduction, as described by Nho and colleagues.4) The patient’s anterior dislocation was then easily reduced into anatomical position with use of the Kocher technique of arm adduction with elbow flexion, followed by external rotation, and then finally into anatomical position with internal rotation.5 Both arms were then immobilized in full adduction with bilateral slings. The patient was admitted for further treatment of multiple fractures of the arms and vertebrae.
He was discharged in bilateral shoulder slings to an extended-care facility for physical therapy. One month after discharge, he could not elevate his arms and had minimal use of them. Two weeks later, magnetic resonance imaging showed a “comminuted greater tuberosity fracture with new displacement of fragments involving the attachment of the supraspinatus and infraspinatus; posterior subluxation of the glenohumeral joint with evidence of posterior and anterior labral tears; and large glenohumeral joint effusion.” The patient opted for surgical repair and underwent left shoulder arthroscopy with extensive débridement, open rotator cuff repair, open greater tuberosity reduction and internal fixation, and open biceps tenodesis. He was then discharged back to an extended-care facility to continue rehabilitation. One and a half months after surgery, he started the physical therapy phase of the massive rotator cuff repair protocol. He declined reverse total shoulder arthroplasty (RTSA).
Four and a half months after injury (3 months after surgery), the left shoulder demonstrated 20° of flexion and 70° to 110° of abduction (external rotation not tested), and the right shoulder demonstrated 30° of flexion and 70° to 110° of abduction (external rotation not tested). He had no instability and no lag with good external rotation.
Six months after injury, the patient still could not lift his arms above his head. He likely would not be able to do so without RTSA, which he again declined. He continued physical therapy and clinical follow-ups.