Orthopedics

Case Report

A 25-year-old right-hand-dominant man was brought by ambulance to our Level I trauma center after being involved in a motor vehicle accident in which his motorcycle was struck by another vehicle. He was thrown from the motorcycle and landed on an outstretched hyperabducted arm. The patient was unable to give any additional history about the mechanism of his injury.

On initial examination, his humeral head was visualized in the posterior aspect of his axillary fold (Figures 1A, B). There was gross contamination of the wound, which measured 6 cm² (Figures 1A, C). All of his rotator cuff tendons and glenohumeral ligaments appeared avulsed from the proximal humerus (Figure 1D). No obvious fractures or chondral injuries were visualized on initial examination. The patient had intact radial and ulnar pulses; his neurologic examination showed decreased sensation in the axillary and lateral antebrachial cutaneous distributions. His strength was 4/5 with elbow flexion/extension. Shoulder strength was unable to be tested due to gross deformity and pain.

Figure 1: Preoperative photographs of the patient prior to initial irrigation and debridement. Gross debris is visualized around the open wound (A). The eposed humeral head through a small-appearing posterior wound (B). The extent of the external wound (C). The degloving of the proximal humerus (D).

Radiographs and computed tomography revealed complete open posterior-inferior shoulder dislocation with no evidence of proximal humeral or scapular fracture (Figures 2A, B). The patient also had multiple rib fractures, nonoperative thoracic spine fractures, and bilateral pulmonary contusions. He was stabilized according to Advanced Trauma Life Support protocol and taken emergently to the operating room for irrigation and debridement and reduction of the glenohumeral joint.

Figure 2: Preoperative radiograph (A) and axial computed tomography (B) showing the humerus dislocated posteriorly and inferiorly. Postoperative radiograph after the initial irrigation, debridement, and reduction (C). The closed axillary wound after the index procedure (D).

At the initial procedure, the patient was found to have avulsed all of the rotator cuff tendons, the capsule, the glenohumeral ligaments, the long head of the biceps, and the pectoralis major tendon (Figure 1D). The gross debris was cleared, all non-viable tissue was removed, and the wound was copiously irrigated with pulse lavage. The humeral head was reduced, the wound closed over a drain, and the shoulder immobilized (Figure 2C, D). The patient was continued on intravenous antibiotics for 72 hours postoperatively and was evaluated by our shoulder service for glenohumeral joint reconstruction.

Two days after his initial irrigation and debridement, the patient’s wound was clean and dry; no recurrent deformity was appreciated. The patient had dense numbness in his axillary nerve distribution and moderate decreased sensation in his lateral antebrachial cutaneous distribution. The patient’s motor examination was limited by pain and fear of gross instability. At that point, plans were made to perform a repeat irrigation and debridement and glenohumeral reconstruction 3 days after the initial procedure.

The patient was placed in the beach-chair position. An extended anterior approach to the shoulder was undertaken, and once through the deltopectoral interval, the shoulder was grossly unstable (Figure 3). Obvious avulsions of all 4 of the rotator cuff tendons were evident. The glenohumeral ligaments and capsule were avulsed off the humerus, along with the long head of the biceps tendon and pectoralis major tendon. The shoulder was again irrigated copiously with pulse lavage.

Figure 3: The skeletonized proximal humerus viewed through the deltopectoral interval at the time of final reconstruction.

The glenohumeral joint was reconstructed in step-wise fashion. Multiple 3-mm bioabsorbable anchors were placed along the rim of the humeral head. Sutures were then passed through the glenohumeral ligaments and capsule and then tagged. The 4 avulsed rotator cuff tendons were identified and mobilized. A bed of bleeding bone was established at the articular margin, and multiple bioabsorbable suture anchors were placed. The accompanying sutures were passed using a free needle in mattress fashion (Figure 4).

Figure 4: Suture management was a crucial step in reconstructing the avulsed proximal humeral soft tissue envelope (A). The final reconstruction of the humerus, with the capsule, rotator cuff, biceps tendon, and pectoralis major repaired (B). Final radiographs after the reconstruction was complete (C, D).

Once all sutures had been passed, suture management was performed, and the capsular and glenohumeral ligament sutures were tied in standard fashion. The rotator cuff sutures were then tied at the articular margin, and a second row of anchors was used more laterally, creating a double-row repair, thus optimizing cuff compression. Once the capsule and rotator cuff were repaired, a biceps tenodesis was performed in the bicipital groove, and the pectoralis major was repaired back to its native bed using bioabsorbable suture anchors (Figure 4B).

The shoulder was then taken through a range of motion (ROM) and noted to be stable. The wound was again copiously irrigated and suctioned dry. A single hemovac drain was placed deep in the wound, and the wound was closed in layers. The patient was immobilized and taken to recovery in stable condition.

The patient was immobilized for 3 weeks, with only gentle active ROM of the elbow, wrist, and hand allowed. This was done to protect the integrity of the reconstruction and in favor of stability over motion. He then began gentle passive ROM exercises of the shoulder for 3 weeks, focusing mostly on forward elevation (limit 120°) and external rotation (limit 30°). Active-assisted exercises then began for 3 weeks, followed by active ROM for 3 additional weeks. Finally, at the 12-week mark, he began strengthening exercises.

The patient’s progress with physical therapy was slow; most of his limitations revolved around residual weakness and limitations of active motion. At his 4-month postoperative examination, he was doing well with activities of daily living and was back working on light-duty status. He reported no residual instability symptoms and was pleased with his progress. His wounds were all healed with no signs of infection. His active forward elevation was 90°, abduction was 90°, external rotation was 0°, and internal rotation to the L4. His sensory neuropraxia resolved without complication, and he regained full motor function. Radiographically, his glenohumeral joint was concentrically reduced; no early evidence of avascular necrosis was present.

Discussion

Open glenohumeral dislocations are devastating high-energy injuries that threaten the viability and functionality of the involved extremity. Although much has been written about the diagnosis, treatment, and rehabilitation of shoulder dislocations, little has been written about open shoulder dislocations.

In a 1990 review article, Mallon et al⁵ reported 86 cases of luxatio erecta, and found only 2 cases with an open glenohumeral dislocation. Middledorff³ was the first to report on this injury pattern, describing an open luxatio erecta humeri with a large laceration over the deltoid. The patient subsequently died of wound sepsis. At autopsy, it was found that the patient had an inferior glenohumeral dislocation with an associated greater tuberosity avulsion fracture.

In 1977, Lucas and Peterson² reported an open anterior shoulder dislocation. No description of the patient’s soft tissue injury was reported. The patient ultimately developed avascular necrosis of the humeral head and had a poor functional outcome. An unreported patient with an open luxatio erecta was seen by Dr. Rockwood, MD, and Dr. Wirth, MD, at the University of Texas HSC in San Antonio (M. Wirth, oral communication, May 2008)

In 1996, Davison and Orwin¹ reported an open luxatio erecta that occurred as a result of a farm equipment injury. Their patient also had an associated greater tuberosity avulsion fracture, along with an avulsion of the subscapularis tendon, and dislocation of the long head of the biceps tendon. After thorough irrigation and debridement, the glenohumeral joint was reduced. The greater tuberosity fracture was reduced but did not require fixation. The subscapularis was repaired to the lesser tuberosity, and the biceps tendon was reduced and repaired to the bicipital groove. Postoperatively, their patient developed arthrofibrosis that required manipulation under anesthesia. The patient obtained good early post-manipulation motion, but ultimately his motion deteriorated and he required a second manipulation with shoulder arthroscopy and debridement. At 18 months of follow-up, the patient had 120° of active abduction and forward flexion, 40° of internal and external rotation, and nearly full return of rotator cuff strength.

The only reported case of an open shoulder dislocation without associated fracture was reported by Moeller⁴ in 1975. His patient had an isolated skeletonization of the proximal humerus after a motor vehicle accident, similar to our patient. Immediate irrigation and debridement, open reduction, and repair of the tendon avulsions were performed. The patient was immobilized in a shoulder spica cast for approximately 2 months. His recovery was complicated by a transient wound infection that resolved after repeat irrigation and debridement; he also developed avascular necrosis of the humeral head. His functional recovery was limited—to only 70° of abduction—and was believed to be the result of damage to the suprascapular and axillary nerves. He also had residual pain in the shoulder, which was believed to be secondary to avascular necrosis. Our patient also had limited ROM, but he was still in the early stages of his rehabilitation.

Our patient is only the second description of an open glenohumeral dislocation with no associated fractures of the proximal humerus. This skeletonization of the proximal humerus represents a complex soft tissue injury that severely compromises the functional capacity of the shoulder. In this injury, as in other open injuries, early irrigation and debridement and early empiric antibiotic treatment are of utmost importance.

As others¹ have expressed, we feel that early surgical reconstruction followed by early rehabilitation of the involved shoulder provides the best opportunity for a reasonable functional outcome. Using a stepwise approach to reconstruction beginning with the deeper capsule and ligamentous structures and working outward to the rotator cuff, biceps, and pectoralis allows for a more solid reconstruction and offers the patient the best chance for a successful functional outcome. Open dislocations of the glenohumeral joint are rare injuries. Understanding the nature of the injury and the involved structures and maintaining a sound treatment algorithm allow orthopedic surgeons to maximize the patient’s functional outcome.