CT and MRI Manifestations of Luxatio Erecta Humeri, and a review of the literature Elmira Hassanzadeh, Connie Y Chang, Ambrose J Huang, Khalid Shaqdan, Mohammad Mansouri, Shima Aran, Hani H. Abujudeh PII: DOI: Reference:
S0899-7071(15)00101-1 doi: 10.1016/j.clinimag.2015.04.009 JCT 7816
To appear in:
Journal of Clinical Imaging
Received date: Revised date: Accepted date:
20 February 2015 9 April 2015 17 April 2015
Please cite this article as: Hassanzadeh Elmira, Chang Connie Y, Huang Ambrose J, Shaqdan Khalid, Mansouri Mohammad, Aran Shima, Abujudeh Hani H., CT and MRI Manifestations of Luxatio Erecta Humeri, and a review of the literature, Journal of Clinical Imaging (2015), doi: 10.1016/j.clinimag.2015.04.009
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title CT and MRI Manifestations of Luxatio Erecta Humeri, and a review of the literature
CE
PT
ED
MA
NU
SC
RI P
T
Authors: Elmira Hassanzadeh, MD.1, Connie Y Chang, MD.2 , Ambrose J Huang, MD.3 , Khalid Shaqdan, MD.4, Mohammad Mansouri, MD.5, Shima Aran, MD.6, Hani H. Abujudeh, MD.,MBA.7 1. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected] , Phone: 617-726-3050, Fax: 617-726-3634 2. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected] , Phone: 617-726-3050, Fax: 617-726-3634 3. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected] , Phone: 617-726-3050, Fax: 617-726-3634 4. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected] , Phone: 617-726-3050, Fax: 617-726-3634 5. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected], Phone: 617-726-3050, Fax: 617-726-3634 6. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected] , Phone: 617-726-3050, Fax: 617-726-3634 7. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected] , Phone: 617-726-3050, Fax: 617-726-3634
AC
Corresponding author: Hani H. Abujudeh, MD. , MBA Department of Radiology, Massachusetts General Hospital, Harvard Medical School 55 Fruit Street, Boston, MA 02114 Email: [email protected] Phone: 617-726-3050 Fax: 617-726-3634 Conflict of interest The authors claim no conflict of interest IRB Statement Institutional Review Board approved this study
1
ACCEPTED MANUSCRIPT Abstract
T
Aim
RI P
We aimed to study luxatio erecta humeri, using advanced imaging modalities.
SC
Method
NU
Patients with luxatio erecta humeri and a subsequent MRI and/or CT scan were included in this study.
MA
Results
ED
Among ten identified cases, we detected 2 rotator cuff, 4 labral, and 2 inferior glenohumeral ligament tears as well as 2 glenohumeral cartilage defects. We observed 6 comminuted
AC
Conclusion
CE
fractures of humeral head.
PT
displaced greater tuberosity fractures, 4 anterior inferior glenoid fractures, and 4 impaction
This study provides detailed radiologic findings associated with luxatio erecta humeri, using magnetic resonance and computed tomography.
Keywords Luxatio erecta humeri, inferior shoulder dislocation, MRI, CT arthrogram, MR arthrogram, CT scan
2
ACCEPTED MANUSCRIPT 1. Introduction Luxatio erecta humeri (LEH) is the least common type of shoulder dislocation, and accounts
RI P
T
for less than 1% of all shoulder dislocations[1]. It is due to either direct or indirect loading stress to the shoulder. A direct dislocation results from an axial loading to a fully abducted arm. An
SC
indirect dislocation, which is more common, is the result of a forceful hyperabduction of the
NU
arm, and usually happens when the patient tries to grasp an object above the head while falling[2, 3]. The distinctive clinical presentation is a hyperabducted arm positioned over the
MA
head, an externally rotated shoulder, and a flexed elbow. The shoulder is locked with complete restriction of movements[4]. This type of dislocation is frequently associated with
ED
neurovascular and musculoskeletal injuries [1, 5, 6]. Mallon et al observed that 12% of the
PT
patients who had associated musculoskeletal injuries had rotator cuff tears [1]. Bone injuries were also prevalent in their review, with the greater tuberosity avulsion fracture being the
CE
most common type of fracture [1]. Although less frequent, fractures of the glenoid, the
AC
acromion, the humeral head, and the body of the scapula have also been reported[1, 7]. Radiographs may demonstrate the classic presentation of the dislocation, i.e. the humeral shaft parallel to the scapular spine, and the humeral head at or below the inferior rim of glenoid[5]. Radiographs may also show the possible fractures of the greater tuberosity, the acromion, coracoid, humeral head, clavicle and the glenoid rim[4, 7]. However, computed tomography is a better tool to evaluate associated fine fractures [8], and magnetic resonance imaging better reveals the injuries to the rotator cuff, the labrum, and the ligaments [5].
3
ACCEPTED MANUSCRIPT There is scant amount of information regarding the MRI and CT scan findings of LEH in radiologic literature. Thus far, only 2 LEH MR arthrograms, 3 LEH MRIs (5 in total) and 3 LEH CT
RI P
T
scans have been described in the literature [5, 8-11]; to our knowledge, no CT arthrogram findings of LEH has been reported. This study adds 10 patients diagnosed with LEH, with 8 CT
SC
scans ( 2 out of 8 are CT arthrograms) and 4 MRIs (2 out of 4 are MR arthrograms), to the
NU
literature. 2. Materials and methods
MA
Institutional Review Board approved this study and waived the requirement of informed
ED
consent. We retrospectively searched our institutional electronic medical data to collect patients with a LEH diagnosis and a subsequent MRI and/or CT scan imaging. We identified 10
PT
patients, with 6 CT scans, 2 MRIs, 2 CT arthrograms, and 2 MR arthrograms; four women and 6
CE
men, with the mean age of 49.5 years (age range: 23-81 years) constitute the study population (Table 1).The mechanism of injury was fall in 8 patients, motor vehicle accident in one patient,
AC
and throwing a punch in one patient. Seven patients were treated by closed reduction, while 3 patients underwent open reduction and internal fixation. Out of our 10 cases, 2 CT scans were obtained pre-reduction due to the clinical judgment of the emergency department physician. One CT scan has been obtained after an unsuccessful reduction attempt (Fig. 4). All other images have been obtained post-reduction.
4
ACCEPTED MANUSCRIPT Our shoulder MR protocol was: axial MPGR (multiplanar gradient recalled), coronal proton density, coronal T2-weighted fat saturated (FS), sagittal T1- weighted, and sagittal T2- weighted
RI P
T
FS. A slice thickness of 3 mm was used, with a field of view of 16 cm for coronal planes, and 14 cm for sagittal and axial planes. The number of excitations was 1-2 and the echo train length
SC
was 1-13. CT scans were performed with slice thickness of 0.625mm, table speed of 39.38mm/rot, rotation speed of 0.8sec/rot, axial reformation at 2.5mm, and Coronal
NU
and Sagittal reformations at 2mm. Intra-articular contrast solution for MR images was a 1:250
MA
diluted mixture of Gadopentetate Dimeglumine (Magnevist, Bayer, Wayne, NJ), Iopamidol (ISOVUE 300, Bracco Diagnostics Inc., Princeton, NJ) and lidocaine, and for the CT arthrograms
ED
was a mixture of Iopamidol and lidocaine. Twelve mL of these solutions were injected under
PT
fluoroscopic guidance for arthrograms.
Two musculoskeletal fellowship trained radiologists, with 7 and 4 years of subspecialty
CE
experience (post-graduate year13 and 10 respectively), retrospectively reviewed in consensus,
AC
MRI and CT arthrograms to detect the abnormalities of rotator cuff, biceps tendon, glenoid labrum, glenohumeral joint (articular cartilage, joint capsule, ligament, and effusion), acromioclavicular joint, and bony structures. CT scans without intra articular contrast were evaluated for fractures and full thickness rotator cuff and biceps tendon tears.
5
ACCEPTED MANUSCRIPT 3. Results In all 10 available shoulder radiographs at the time of acute injury, the humeral shaft
RI P
T
appeared parallel to the scapular spine and the humeral head was below the inferior rim of glenoid (fig. 1). Table 1 summarizes the imaging findings of our set of patients based on the
SC
modality.
NU
Rotator cuff injuries were reported in MRI and CT arthrograms of two patients including supraspinatus and infraspinatus tears in both (fig. 2 Plane A), and subscapularis tendon tear in
MA
one. None of our patients sustained teres minor tendon injuries. Biceps tendon appeared intact
ED
in all the patients.
Labral tears were visualized in all 4 patients with MRI or CT/MR arthrograms. Anterior inferior
CE
patient.
PT
labral tear was observed in all 4 patients (fig. 3) and superior labral tear was evident in one
AC
Injuries to the inferior glenohumeral ligament (IGHL) were observed in 2 out of 4 patients with either MRI or CT/MR arthrograms, and involved both anterior and posterior bands of inferior glenohumeral ligament (fig. 2 Plane A). Glenohumeral joint cartilage defects appeared in two out of 4 patients with MRI or CT/MR arthrograms (fig. 2 Plane B). Regarding bone injuries, we observed 6 out of 10 patients of comminuted displaced greater tuberosity fracture (fig. 4). Anterior inferior glenoid fracture was observed in 4 out of 10 patients (fig. 3). Four patients sustained impaction fracture of the superolateral aspect of
6
ACCEPTED MANUSCRIPT humeral head (fig. 5). Joint effusion was observed in all the images without intra articular contrast (6 CT scans and 2 MRIs).
RI P
T
4. Discussion
In our series of 10 patients we observed 2 rotator cuff tears, 6 greater tuberosity fractures, 4
SC
glenoid fractures, and 4 impaction fractures of humeral head. In the 4 patients with either MR
NU
arthrogram or MRI/CT arthrograms, we detected 4 labral tears, 2 IGHL tears, and 2
MA
glenohumeral cartilage defects.
There is a paucity of MRI descriptions of LEH in the literature, and is limited to 2 published
ED
papers with a total of 5 MRI studies. Krug et al, in 2010 presented the MRI findings of 4 patients with prior LEH for the first time in the literature. They reported 3 rotator cuff tears and 2 biceps
PT
tendon tears. All 4 patients of Krug’s study sustained labral injuries: 3 anterior inferior, 2
CE
superior, and 3 posterior labral tears. Inferior glenohumeral ligament tear was common in their
AC
patient series, and appeared in all four patients. In addition, one patient demonstrated glenoid cartilage defect. Regarding bone injuries, they reported 2 cases of contusion or fracture of the humeral head, while the absence of greater tuberosity fracture [5]. In 2014, a pediatric case of LEH with MR arthrogram and confirming arthroscopic features was reported. This patient demonstrated a greater tuberosity fracture, and an avulsion of anterior and posterior bands of inferior glenohumeral ligament. The rotator cuff was reported intact[11]. There are also reports that make reference to the MRI findings without actual depiction; Mohseni reported inferior and superior labral tearing and fraying in a patient with LEH, and Karaoglu et al reported a patient with bilateral LEH and bilateral complete tears of the supraspinatus tendons [12, 13]. 7
ACCEPTED MANUSCRIPT However, the very first evaluation of soft tissue injuries associated with LEH was performed arthroscopically in 1998 ; biceps tendon tearing as well as anterior, superior , and posterior
RI P
T
labral detachment were the findings of that study[14].
Description of CT scans in the literature is even rarer and is limited to only 3 case reports [8-
SC
10]. As far as we know, there is no published CT arthrogram description of LEH. In 1990 Davids
NU
et al described CT scan findings of impaction deformity of humeral head in a case of LEH. They suggested that the impaction fractures of humeral head associated with LEH appear at a more
MA
superior and lateral site than a classic Hill-Sachs deformity due to anterior shoulder dislocation[9]. In 2013 Imerci et al demonstrated the CT scan of a patient with a fracture of the
ED
anterior wall of the glenoid[8]. The same year Ellanti et al published a 3D reconstruction of CT
PT
scan of a case of bilateral LEH with bilateral avulsion of greater tuberosity[10].
CE
Our observations regarding rotator cuff, joint cartilage, labral, and ligamental injuries are consistent with previous reports [5, 11, 13, 15]; however, we didn’t observe any biceps tendon
AC
injury or posterior labral tearing. Further evaluation of medical records of the cases with only CT scans revealed one partial rotator cuff injury among 3 patients who underwent shoulder surgery. Of the remaining patients, two showed significant improvement in regaining glenohumeral joint function with conservative therapy. One patient lost to follow up. Bone injuries were common in our set of patients. The most common fractures were greater tuberosity fracture, followed by anterior inferior glenoid fracture and impaction deformity of humeral head. These findings are consistent with the previous observations[1].The 4 impaction deformities of our patients were located in superior and a more lateral aspect of humeral head.
8
ACCEPTED MANUSCRIPT This finding supports the previous reports of the site of humeral head impaction associated with LEH[5, 9]. None of our patients with greater tuberosity fracture sustained rotator cuff
RI P
T
tears. This observation is consistent with the previous hypothesis that the greater tuberosity fracture spares the rotator cuff tendons from tearing[11, 16].
SC
5. Conclusion
NU
Despite the small size limitation, we believe this study provides detailed radiologic findings associated with luxatio erecta humeri, using magnetic resonance and computed tomography.
MA
Further studies with larger series of patients are warranted to elucidate the radiologic features
AC
CE
PT
ED
of this injury.
9
ACCEPTED MANUSCRIPT References [1]Mallon WJ, Bassett FH, 3rd, Goldner RD. Luxatio erecta: the inferior glenohumeral
RI P
T
dislocation. J Orthop Trauma 1990; 4:19-24.
[2]Yamamoto T, Yoshiya S, Kurosaka M, Nagira K, Nabeshima Y. Luxatio erecta (inferior
SC
dislocation of the shoulder): a report of 5 cases and a review of the literature. Am J
NU
Orthop 2003; 32:601-603.
[3]Goldstein JR, Eilbert WP. Locked anterior-inferior shoulder subluxation presenting as luxatio
MA
erecta. J Emerg Med 2004; 27:245-248.
[4]Kelley C, Quimby T, MacVane CZ. Unusual shoulder injury from a motorcycle crash. Luxatio
ED
erecta. J Fam Pract 2013; 62:255-257.
PT
[5]Krug DK, Vinson EN, Helms CA. MRI findings associated with luxatio erecta humeri. Skeletal Radiol 2010; 39:27-33.
CE
[6]Patel DN, Zuckerman JD, Egol KA. Luxatio erecta: case series with review of diagnostic and
AC
management principles. Am J Orthop 2011; 40:566-570. [7]Yanturali S, Aksay E, Holliman CJ, Duman O, Ozen YK. Luxatio erecta: clinical presentation and management in the emergency department. J Emerg Med 2005; 29:85-89. [8]Imerci A, Golcuk Y, Ugur SG, Ursavas HT, Savran A, Surer L. Inferior glenohumeral dislocation (luxatio erecta humeri): report of six cases and review of the literature. Ulus Travma Acil Cerrahi Derg 2013; 19:41-44. [9]Davids JR, Talbott RD. Luxatio erecta humeri. A case report. Clin Orthop Relat Res 1990; 252:144-149.
10
ACCEPTED MANUSCRIPT [10]Ellanti P, Davarinos N, Connolly MJ, Khan HA. Bilateral luxatio erecta humeri with a unilateral brachial plexus injury. J Emerg Trauma Shock 2013; 6:308-310.
RI P
T
[11]Stensby JD, Fox MG. MR arthrogram findings of luxatio erecta in a pediatric patientarthroscopic confirmation and review of the literature. Skeletal Radiol 2014; 3:3.
SC
[12]Karaoglu S, Guney A, Ozturk M, Kekec Z. Bilateral luxatio erecta humeri. Arch Orthop Trauma Surg 2003; 123:308-310.
NU
[13]Mohseni MM. Images in emergency medicine. Luxatio erecta (inferior shoulder dislocation).
MA
Ann Emerg Med 2008; 52:030.
[14]Schai P, Hintermann B. Arthroscopic findings in luxatio erecta of the glenohumeral joint:
ED
case report and review of the literature. Clin J Sport Med 1998; 8:138-141. [15]Groh GI, Wirth MA, Rockwood CA, Jr. Results of treatment of luxatio erecta (inferior
PT
shoulder dislocation). J Shoulder Elbow Surg 2010; 19:423-426.
AC
CE
[16]Freundlich BD. Luxatio erecta. J Trauma 1983; 23:434-436.
11
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
MA
NU
RI P
SC
Fig 1- 49-year-old woman with Luxatio Erecta Humeri
T
Figure captions
12
ACCEPTED MANUSCRIPT Fig. 2A- 49-year-old man with Luxatio Erecta Humeri. Panel A: Coronal T2-weighted fat suppressed image (TR/TE, 3550/44) demonstrates supraspinatus tendon tear (arrow), and the
AC
CE
PT
ED
MA
NU
SC
RI P
T
tearing of inferior glenohumeral ligament (chevron).
13
ACCEPTED MANUSCRIPT Fig 2B: Coronal reformatted image with a bone window from a CT arthrogram demonstrates inferior glenohumeral ligament tear (circle) with leakage of injected intra-articular contrast
AC
CE
PT
ED
MA
NU
SC
RI P
T
through the tear into the axilla, and full thickness glenoid cartilage defect (arrow)
14
ACCEPTED MANUSCRIPT Fig. 3 - 23-year-old man with Luxatio Erecta Humeri. Oblique sagittal T1-weighted fat suppressed image (TR/TE, 694/12) from an MR arthrogram demonstrates anterior inferior
AC
CE
PT
ED
MA
NU
SC
RI P
T
labral tear and anterior inferior glenoid fracture (circle)
15
ACCEPTED MANUSCRIPT Fig. 4 - 43-year-old man with Luxatio Erecta Humeri. Axial CT scan demonstrates comminuted
AC
CE
PT
ED
MA
NU
SC
RI P
T
displaced greater tuberosity fracture of right shoulder (arrow)
16
ACCEPTED MANUSCRIPT Fig. 5 - 33-year-old man with Luxatio Erecta Humeri. Axial T1-weighted fat suppressed image (TR/TE, 565/10) from an MR arthrogram demonstrates impaction fracture of humeral head
AC
CE
PT
ED
MA
NU
SC
RI P
T
(circle)
17
S0899-7071(15)00101-1 doi: 10.1016/j.clinimag.2015.04.009 JCT 7816
To appear in:
Journal of Clinical Imaging
Received date: Revised date: Accepted date:
20 February 2015 9 April 2015 17 April 2015
Please cite this article as: Hassanzadeh Elmira, Chang Connie Y, Huang Ambrose J, Shaqdan Khalid, Mansouri Mohammad, Aran Shima, Abujudeh Hani H., CT and MRI Manifestations of Luxatio Erecta Humeri, and a review of the literature, Journal of Clinical Imaging (2015), doi: 10.1016/j.clinimag.2015.04.009
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title CT and MRI Manifestations of Luxatio Erecta Humeri, and a review of the literature
CE
PT
ED
MA
NU
SC
RI P
T
Authors: Elmira Hassanzadeh, MD.1, Connie Y Chang, MD.2 , Ambrose J Huang, MD.3 , Khalid Shaqdan, MD.4, Mohammad Mansouri, MD.5, Shima Aran, MD.6, Hani H. Abujudeh, MD.,MBA.7 1. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected] , Phone: 617-726-3050, Fax: 617-726-3634 2. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected] , Phone: 617-726-3050, Fax: 617-726-3634 3. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected] , Phone: 617-726-3050, Fax: 617-726-3634 4. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected] , Phone: 617-726-3050, Fax: 617-726-3634 5. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected], Phone: 617-726-3050, Fax: 617-726-3634 6. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected] , Phone: 617-726-3050, Fax: 617-726-3634 7. Department of Radiology, Massachusetts General Hospital, Harvard Medical School. 55 Fruit Street, Boston, MA 02114, [email protected] , Phone: 617-726-3050, Fax: 617-726-3634
AC
Corresponding author: Hani H. Abujudeh, MD. , MBA Department of Radiology, Massachusetts General Hospital, Harvard Medical School 55 Fruit Street, Boston, MA 02114 Email: [email protected] Phone: 617-726-3050 Fax: 617-726-3634 Conflict of interest The authors claim no conflict of interest IRB Statement Institutional Review Board approved this study
1
ACCEPTED MANUSCRIPT Abstract
T
Aim
RI P
We aimed to study luxatio erecta humeri, using advanced imaging modalities.
SC
Method
NU
Patients with luxatio erecta humeri and a subsequent MRI and/or CT scan were included in this study.
MA
Results
ED
Among ten identified cases, we detected 2 rotator cuff, 4 labral, and 2 inferior glenohumeral ligament tears as well as 2 glenohumeral cartilage defects. We observed 6 comminuted
AC
Conclusion
CE
fractures of humeral head.
PT
displaced greater tuberosity fractures, 4 anterior inferior glenoid fractures, and 4 impaction
This study provides detailed radiologic findings associated with luxatio erecta humeri, using magnetic resonance and computed tomography.
Keywords Luxatio erecta humeri, inferior shoulder dislocation, MRI, CT arthrogram, MR arthrogram, CT scan
2
ACCEPTED MANUSCRIPT 1. Introduction Luxatio erecta humeri (LEH) is the least common type of shoulder dislocation, and accounts
RI P
T
for less than 1% of all shoulder dislocations[1]. It is due to either direct or indirect loading stress to the shoulder. A direct dislocation results from an axial loading to a fully abducted arm. An
SC
indirect dislocation, which is more common, is the result of a forceful hyperabduction of the
NU
arm, and usually happens when the patient tries to grasp an object above the head while falling[2, 3]. The distinctive clinical presentation is a hyperabducted arm positioned over the
MA
head, an externally rotated shoulder, and a flexed elbow. The shoulder is locked with complete restriction of movements[4]. This type of dislocation is frequently associated with
ED
neurovascular and musculoskeletal injuries [1, 5, 6]. Mallon et al observed that 12% of the
PT
patients who had associated musculoskeletal injuries had rotator cuff tears [1]. Bone injuries were also prevalent in their review, with the greater tuberosity avulsion fracture being the
CE
most common type of fracture [1]. Although less frequent, fractures of the glenoid, the
AC
acromion, the humeral head, and the body of the scapula have also been reported[1, 7]. Radiographs may demonstrate the classic presentation of the dislocation, i.e. the humeral shaft parallel to the scapular spine, and the humeral head at or below the inferior rim of glenoid[5]. Radiographs may also show the possible fractures of the greater tuberosity, the acromion, coracoid, humeral head, clavicle and the glenoid rim[4, 7]. However, computed tomography is a better tool to evaluate associated fine fractures [8], and magnetic resonance imaging better reveals the injuries to the rotator cuff, the labrum, and the ligaments [5].
3
ACCEPTED MANUSCRIPT There is scant amount of information regarding the MRI and CT scan findings of LEH in radiologic literature. Thus far, only 2 LEH MR arthrograms, 3 LEH MRIs (5 in total) and 3 LEH CT
RI P
T
scans have been described in the literature [5, 8-11]; to our knowledge, no CT arthrogram findings of LEH has been reported. This study adds 10 patients diagnosed with LEH, with 8 CT
SC
scans ( 2 out of 8 are CT arthrograms) and 4 MRIs (2 out of 4 are MR arthrograms), to the
NU
literature. 2. Materials and methods
MA
Institutional Review Board approved this study and waived the requirement of informed
ED
consent. We retrospectively searched our institutional electronic medical data to collect patients with a LEH diagnosis and a subsequent MRI and/or CT scan imaging. We identified 10
PT
patients, with 6 CT scans, 2 MRIs, 2 CT arthrograms, and 2 MR arthrograms; four women and 6
CE
men, with the mean age of 49.5 years (age range: 23-81 years) constitute the study population (Table 1).The mechanism of injury was fall in 8 patients, motor vehicle accident in one patient,
AC
and throwing a punch in one patient. Seven patients were treated by closed reduction, while 3 patients underwent open reduction and internal fixation. Out of our 10 cases, 2 CT scans were obtained pre-reduction due to the clinical judgment of the emergency department physician. One CT scan has been obtained after an unsuccessful reduction attempt (Fig. 4). All other images have been obtained post-reduction.
4
ACCEPTED MANUSCRIPT Our shoulder MR protocol was: axial MPGR (multiplanar gradient recalled), coronal proton density, coronal T2-weighted fat saturated (FS), sagittal T1- weighted, and sagittal T2- weighted
RI P
T
FS. A slice thickness of 3 mm was used, with a field of view of 16 cm for coronal planes, and 14 cm for sagittal and axial planes. The number of excitations was 1-2 and the echo train length
SC
was 1-13. CT scans were performed with slice thickness of 0.625mm, table speed of 39.38mm/rot, rotation speed of 0.8sec/rot, axial reformation at 2.5mm, and Coronal
NU
and Sagittal reformations at 2mm. Intra-articular contrast solution for MR images was a 1:250
MA
diluted mixture of Gadopentetate Dimeglumine (Magnevist, Bayer, Wayne, NJ), Iopamidol (ISOVUE 300, Bracco Diagnostics Inc., Princeton, NJ) and lidocaine, and for the CT arthrograms
ED
was a mixture of Iopamidol and lidocaine. Twelve mL of these solutions were injected under
PT
fluoroscopic guidance for arthrograms.
Two musculoskeletal fellowship trained radiologists, with 7 and 4 years of subspecialty
CE
experience (post-graduate year13 and 10 respectively), retrospectively reviewed in consensus,
AC
MRI and CT arthrograms to detect the abnormalities of rotator cuff, biceps tendon, glenoid labrum, glenohumeral joint (articular cartilage, joint capsule, ligament, and effusion), acromioclavicular joint, and bony structures. CT scans without intra articular contrast were evaluated for fractures and full thickness rotator cuff and biceps tendon tears.
5
ACCEPTED MANUSCRIPT 3. Results In all 10 available shoulder radiographs at the time of acute injury, the humeral shaft
RI P
T
appeared parallel to the scapular spine and the humeral head was below the inferior rim of glenoid (fig. 1). Table 1 summarizes the imaging findings of our set of patients based on the
SC
modality.
NU
Rotator cuff injuries were reported in MRI and CT arthrograms of two patients including supraspinatus and infraspinatus tears in both (fig. 2 Plane A), and subscapularis tendon tear in
MA
one. None of our patients sustained teres minor tendon injuries. Biceps tendon appeared intact
ED
in all the patients.
Labral tears were visualized in all 4 patients with MRI or CT/MR arthrograms. Anterior inferior
CE
patient.
PT
labral tear was observed in all 4 patients (fig. 3) and superior labral tear was evident in one
AC
Injuries to the inferior glenohumeral ligament (IGHL) were observed in 2 out of 4 patients with either MRI or CT/MR arthrograms, and involved both anterior and posterior bands of inferior glenohumeral ligament (fig. 2 Plane A). Glenohumeral joint cartilage defects appeared in two out of 4 patients with MRI or CT/MR arthrograms (fig. 2 Plane B). Regarding bone injuries, we observed 6 out of 10 patients of comminuted displaced greater tuberosity fracture (fig. 4). Anterior inferior glenoid fracture was observed in 4 out of 10 patients (fig. 3). Four patients sustained impaction fracture of the superolateral aspect of
6
ACCEPTED MANUSCRIPT humeral head (fig. 5). Joint effusion was observed in all the images without intra articular contrast (6 CT scans and 2 MRIs).
RI P
T
4. Discussion
In our series of 10 patients we observed 2 rotator cuff tears, 6 greater tuberosity fractures, 4
SC
glenoid fractures, and 4 impaction fractures of humeral head. In the 4 patients with either MR
NU
arthrogram or MRI/CT arthrograms, we detected 4 labral tears, 2 IGHL tears, and 2
MA
glenohumeral cartilage defects.
There is a paucity of MRI descriptions of LEH in the literature, and is limited to 2 published
ED
papers with a total of 5 MRI studies. Krug et al, in 2010 presented the MRI findings of 4 patients with prior LEH for the first time in the literature. They reported 3 rotator cuff tears and 2 biceps
PT
tendon tears. All 4 patients of Krug’s study sustained labral injuries: 3 anterior inferior, 2
CE
superior, and 3 posterior labral tears. Inferior glenohumeral ligament tear was common in their
AC
patient series, and appeared in all four patients. In addition, one patient demonstrated glenoid cartilage defect. Regarding bone injuries, they reported 2 cases of contusion or fracture of the humeral head, while the absence of greater tuberosity fracture [5]. In 2014, a pediatric case of LEH with MR arthrogram and confirming arthroscopic features was reported. This patient demonstrated a greater tuberosity fracture, and an avulsion of anterior and posterior bands of inferior glenohumeral ligament. The rotator cuff was reported intact[11]. There are also reports that make reference to the MRI findings without actual depiction; Mohseni reported inferior and superior labral tearing and fraying in a patient with LEH, and Karaoglu et al reported a patient with bilateral LEH and bilateral complete tears of the supraspinatus tendons [12, 13]. 7
ACCEPTED MANUSCRIPT However, the very first evaluation of soft tissue injuries associated with LEH was performed arthroscopically in 1998 ; biceps tendon tearing as well as anterior, superior , and posterior
RI P
T
labral detachment were the findings of that study[14].
Description of CT scans in the literature is even rarer and is limited to only 3 case reports [8-
SC
10]. As far as we know, there is no published CT arthrogram description of LEH. In 1990 Davids
NU
et al described CT scan findings of impaction deformity of humeral head in a case of LEH. They suggested that the impaction fractures of humeral head associated with LEH appear at a more
MA
superior and lateral site than a classic Hill-Sachs deformity due to anterior shoulder dislocation[9]. In 2013 Imerci et al demonstrated the CT scan of a patient with a fracture of the
ED
anterior wall of the glenoid[8]. The same year Ellanti et al published a 3D reconstruction of CT
PT
scan of a case of bilateral LEH with bilateral avulsion of greater tuberosity[10].
CE
Our observations regarding rotator cuff, joint cartilage, labral, and ligamental injuries are consistent with previous reports [5, 11, 13, 15]; however, we didn’t observe any biceps tendon
AC
injury or posterior labral tearing. Further evaluation of medical records of the cases with only CT scans revealed one partial rotator cuff injury among 3 patients who underwent shoulder surgery. Of the remaining patients, two showed significant improvement in regaining glenohumeral joint function with conservative therapy. One patient lost to follow up. Bone injuries were common in our set of patients. The most common fractures were greater tuberosity fracture, followed by anterior inferior glenoid fracture and impaction deformity of humeral head. These findings are consistent with the previous observations[1].The 4 impaction deformities of our patients were located in superior and a more lateral aspect of humeral head.
8
ACCEPTED MANUSCRIPT This finding supports the previous reports of the site of humeral head impaction associated with LEH[5, 9]. None of our patients with greater tuberosity fracture sustained rotator cuff
RI P
T
tears. This observation is consistent with the previous hypothesis that the greater tuberosity fracture spares the rotator cuff tendons from tearing[11, 16].
SC
5. Conclusion
NU
Despite the small size limitation, we believe this study provides detailed radiologic findings associated with luxatio erecta humeri, using magnetic resonance and computed tomography.
MA
Further studies with larger series of patients are warranted to elucidate the radiologic features
AC
CE
PT
ED
of this injury.
9
ACCEPTED MANUSCRIPT References [1]Mallon WJ, Bassett FH, 3rd, Goldner RD. Luxatio erecta: the inferior glenohumeral
RI P
T
dislocation. J Orthop Trauma 1990; 4:19-24.
[2]Yamamoto T, Yoshiya S, Kurosaka M, Nagira K, Nabeshima Y. Luxatio erecta (inferior
SC
dislocation of the shoulder): a report of 5 cases and a review of the literature. Am J
NU
Orthop 2003; 32:601-603.
[3]Goldstein JR, Eilbert WP. Locked anterior-inferior shoulder subluxation presenting as luxatio
MA
erecta. J Emerg Med 2004; 27:245-248.
[4]Kelley C, Quimby T, MacVane CZ. Unusual shoulder injury from a motorcycle crash. Luxatio
ED
erecta. J Fam Pract 2013; 62:255-257.
PT
[5]Krug DK, Vinson EN, Helms CA. MRI findings associated with luxatio erecta humeri. Skeletal Radiol 2010; 39:27-33.
CE
[6]Patel DN, Zuckerman JD, Egol KA. Luxatio erecta: case series with review of diagnostic and
AC
management principles. Am J Orthop 2011; 40:566-570. [7]Yanturali S, Aksay E, Holliman CJ, Duman O, Ozen YK. Luxatio erecta: clinical presentation and management in the emergency department. J Emerg Med 2005; 29:85-89. [8]Imerci A, Golcuk Y, Ugur SG, Ursavas HT, Savran A, Surer L. Inferior glenohumeral dislocation (luxatio erecta humeri): report of six cases and review of the literature. Ulus Travma Acil Cerrahi Derg 2013; 19:41-44. [9]Davids JR, Talbott RD. Luxatio erecta humeri. A case report. Clin Orthop Relat Res 1990; 252:144-149.
10
ACCEPTED MANUSCRIPT [10]Ellanti P, Davarinos N, Connolly MJ, Khan HA. Bilateral luxatio erecta humeri with a unilateral brachial plexus injury. J Emerg Trauma Shock 2013; 6:308-310.
RI P
T
[11]Stensby JD, Fox MG. MR arthrogram findings of luxatio erecta in a pediatric patientarthroscopic confirmation and review of the literature. Skeletal Radiol 2014; 3:3.
SC
[12]Karaoglu S, Guney A, Ozturk M, Kekec Z. Bilateral luxatio erecta humeri. Arch Orthop Trauma Surg 2003; 123:308-310.
NU
[13]Mohseni MM. Images in emergency medicine. Luxatio erecta (inferior shoulder dislocation).
MA
Ann Emerg Med 2008; 52:030.
[14]Schai P, Hintermann B. Arthroscopic findings in luxatio erecta of the glenohumeral joint:
ED
case report and review of the literature. Clin J Sport Med 1998; 8:138-141. [15]Groh GI, Wirth MA, Rockwood CA, Jr. Results of treatment of luxatio erecta (inferior
PT
shoulder dislocation). J Shoulder Elbow Surg 2010; 19:423-426.
AC
CE
[16]Freundlich BD. Luxatio erecta. J Trauma 1983; 23:434-436.
11
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
MA
NU
RI P
SC
Fig 1- 49-year-old woman with Luxatio Erecta Humeri
T
Figure captions
12
ACCEPTED MANUSCRIPT Fig. 2A- 49-year-old man with Luxatio Erecta Humeri. Panel A: Coronal T2-weighted fat suppressed image (TR/TE, 3550/44) demonstrates supraspinatus tendon tear (arrow), and the
AC
CE
PT
ED
MA
NU
SC
RI P
T
tearing of inferior glenohumeral ligament (chevron).
13
ACCEPTED MANUSCRIPT Fig 2B: Coronal reformatted image with a bone window from a CT arthrogram demonstrates inferior glenohumeral ligament tear (circle) with leakage of injected intra-articular contrast
AC
CE
PT
ED
MA
NU
SC
RI P
T
through the tear into the axilla, and full thickness glenoid cartilage defect (arrow)
14
ACCEPTED MANUSCRIPT Fig. 3 - 23-year-old man with Luxatio Erecta Humeri. Oblique sagittal T1-weighted fat suppressed image (TR/TE, 694/12) from an MR arthrogram demonstrates anterior inferior
AC
CE
PT
ED
MA
NU
SC
RI P
T
labral tear and anterior inferior glenoid fracture (circle)
15
ACCEPTED MANUSCRIPT Fig. 4 - 43-year-old man with Luxatio Erecta Humeri. Axial CT scan demonstrates comminuted
AC
CE
PT
ED
MA
NU
SC
RI P
T
displaced greater tuberosity fracture of right shoulder (arrow)
16
ACCEPTED MANUSCRIPT Fig. 5 - 33-year-old man with Luxatio Erecta Humeri. Axial T1-weighted fat suppressed image (TR/TE, 565/10) from an MR arthrogram demonstrates impaction fracture of humeral head
AC
CE
PT
ED
MA
NU
SC
RI P
T
(circle)
17
