Inferior shoulder dislocation: Difference between revisions

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==Background==
==Background==
*Also known as "Luxatio Erecta" due to the presentation of arm held in full abduction
[[File:Gray326.png|thumb|Left shoulder and acromioclavicular joints with ligaments.]]
*Accounts for ~0.5% of all shoulder dislocations<ref name="Imerci" />
[[File:Shoulder_joint_back-en.png|thumb|Shoulder anatomy, anterior.]]
*Mechanism: typically hyperabduction force which levers the humeral neck against the acromion
[[File:Shoulder joint back 05r4v.png|thumb|Shoulder anatomy, posterior.]]
**Can also be secondary to high-energy force applied directly to shoulder from above<ref name="Grate">Grate I Jr. Luxatio erecta: a rarely seen, but often missed shoulder dislocation. Am J Emerg Med. 2000 May;18(3):317-21.</ref>
*Also known as "Luxatio Erecta" due to the affected arm being held 'erect', in a fully-abducted position
*About 0.5% of shoulder dislocations<ref name="Imerci" />
*Typically caused by hyperabduction
**Levers the humeral neck against the acromion
**Rarely caused by high-energy force applied to shoulder from above<ref name="Grate">Grate I Jr. Luxatio erecta: a rarely seen, but often missed shoulder dislocation. Am J Emerg Med. 2000 May;18(3):317-21.</ref>
*Frequently associated with significant soft tissue injury or fracture<ref name="Imerci" />
*Frequently associated with significant soft tissue injury or fracture<ref name="Imerci" />
**Axillary nerve palsy in 60% (usually rapidly resolves after reduction<ref name="Grate" />
 
**Humerus fracture in 37%
{{Shoulder dislocation types}}
**Rotator cuff tear in 12%


==Clinical Features==
==Clinical Features==
*Patient presents with humerus fully abducted with hand on or behind the head
*Mechanism: forceful hyper-abduction of arm
*Humeral head can be palpated on axilla or lateral chest wall<ref name="Imerci">Imerci A, Gölcük Y, Uğur SG, et al. Inferior glenohumeral dislocation (luxatio erecta humeri): report of six cases and review of the literature. Ulus Travma Acil Cerrahi Derg. 2013 Jan;19(1):41-4.</ref>
*Humerus fully abducted
**Hand on or behind head
*Humeral head palpable in axilla or lateral chest wall<ref name="Imerci">Imerci A, Gölcük Y, Uğur SG, et al. Inferior glenohumeral dislocation (luxatio erecta humeri): report of six cases and review of the literature. Ulus Travma Acil Cerrahi Derg. 2013 Jan;19(1):41-4.</ref>


==Differential Diagnosis==
==Differential Diagnosis==
{{Shoulder DDX}}
{{Shoulder DDX}}


==Diagnosis==
==Evaluation==
[[File:Inferiourdislocation.jpg|thumb|Inferior dislocation with fracture of the greater tuberosity. Note how the humerus is abducted.]]
*Plain film X-ray in at least 2 views
*Plain film X-ray in at least 2 views


==Management==
==Management==
[[File:luxatio erecta.jpg|thumbnail]]
*Closed reduction
*Closed reduction
**Consider [[Procedural sedation]]
**Consider [[procedural sedation]]
**Apply traction in upward and outward direction (along same axis as humerus)
 
**Simultaneously apply counter-traction with sheet on upper shoulder and chest wall<ref>Amanda E. Horn and Jacob W. Ufberg. Management of Common Dislocations. http://clinicalgate.com/management-of-common-dislocations/</ref>
===Single-Step Technique<ref>Amanda E. Horn and Jacob W. Ufberg. Management of Common Dislocations. http://clinicalgate.com/management-of-common-dislocations/</ref>===
*Apply sling with arm in adduction and internal rotation.
#Place sheet over upper shoulder and chest wall
*Post-reduction X-ray
#Have assistant grasp sheet and provide countertraction
[[File:luxatio erecta.jpg|thumbnail]]
#Grasp arm and apply traction upward and outward (along humeral axis)
#Place arm in shoulder immobilizer
#Obtain post-reduction radiographs
 
===Two-Step Technique<ref name="Procedures for orthopedic emergencies">Davenport M. Procedures for orthopedic emergencies. In: Bond M, ed. Orthopedic Emergencies: Expert Management for the Emergency Physician. Cambridge: Cambridge University Press; October 31, 2013.</ref> <ref name="Management of Common Dislocations">Horn A. Management of Common Dislocations. In: Roberts and Hedges' Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014. </ref>===
*Converts inferior dislocation to anterior dislocation to allow reduction
#Place one hand on the lateral mid-shaft of the humerus
#Place second hand on medial epicondyle of elbow
#Use first hand to apply pressure to the mid-shaft of the humerus while the second hand pulls the elbow cephalad
#Perform reduction of the [[anterior shoulder dislocation]]
#Place arm in shoulder immobilizer
#Obtain post-reduction radiographs
 
*''Failure of closed reduction may occur secondary to "buttonholing" of humeral through defect in glenohumeral capsule → consult ortho for open reduction''<ref>Lam AC, Shih RD. Luxatio Erecta Complicated By Anterior Shoulder Dislocation During Reduction. Western Journal of Emergency Medicine. 2010;11(1):28-30.</ref>
*''Failure of closed reduction may occur secondary to "buttonholing" of humeral through defect in glenohumeral capsule → consult ortho for open reduction''<ref>Lam AC, Shih RD. Luxatio Erecta Complicated By Anterior Shoulder Dislocation During Reduction. Western Journal of Emergency Medicine. 2010;11(1):28-30.</ref>


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==Disposition==
==Disposition==
*Discharge after successful reduction
*Discharge after successful reduction
*Ortho follow-up
*Outpatient orthopedic surgery follow-up
 
==Complications==
*[[Axillary nerve palsy]] in 60% (usually rapidly resolves after reduction<ref name="Grate" />
*[[Humerus fracture]] in 37%
*[[Rotator cuff tear]] in 12%


==See Also==
==See Also==

Revision as of 20:19, 22 June 2020

Background

Left shoulder and acromioclavicular joints with ligaments.
Shoulder anatomy, anterior.
Shoulder anatomy, posterior.
  • Also known as "Luxatio Erecta" due to the affected arm being held 'erect', in a fully-abducted position
  • About 0.5% of shoulder dislocations[1]
  • Typically caused by hyperabduction
    • Levers the humeral neck against the acromion
    • Rarely caused by high-energy force applied to shoulder from above[2]
  • Frequently associated with significant soft tissue injury or fracture[1]

Shoulder dislocation types

Clinical Features

  • Mechanism: forceful hyper-abduction of arm
  • Humerus fully abducted
    • Hand on or behind head
  • Humeral head palpable in axilla or lateral chest wall[1]

Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

Inferior dislocation with fracture of the greater tuberosity. Note how the humerus is abducted.
  • Plain film X-ray in at least 2 views

Management

Luxatio erecta.jpg

Single-Step Technique[3]

  1. Place sheet over upper shoulder and chest wall
  2. Have assistant grasp sheet and provide countertraction
  3. Grasp arm and apply traction upward and outward (along humeral axis)
  4. Place arm in shoulder immobilizer
  5. Obtain post-reduction radiographs

Two-Step Technique[4] [5]

  • Converts inferior dislocation to anterior dislocation to allow reduction
  1. Place one hand on the lateral mid-shaft of the humerus
  2. Place second hand on medial epicondyle of elbow
  3. Use first hand to apply pressure to the mid-shaft of the humerus while the second hand pulls the elbow cephalad
  4. Perform reduction of the anterior shoulder dislocation
  5. Place arm in shoulder immobilizer
  6. Obtain post-reduction radiographs
  • Failure of closed reduction may occur secondary to "buttonholing" of humeral through defect in glenohumeral capsule → consult ortho for open reduction[6]

Contraindications to closed reduction[1]

  • Humeral neck or shaft fracture
  • Suspected major vascular injury
  • In these cases, open reduction is indicated

Disposition

  • Discharge after successful reduction
  • Outpatient orthopedic surgery follow-up

Complications

See Also

References

  1. ↑ 1.0 1.1 1.2 1.3 Imerci A, Gölcük Y, Uğur SG, et al. Inferior glenohumeral dislocation (luxatio erecta humeri): report of six cases and review of the literature. Ulus Travma Acil Cerrahi Derg. 2013 Jan;19(1):41-4.
  2. ↑ 2.0 2.1 Grate I Jr. Luxatio erecta: a rarely seen, but often missed shoulder dislocation. Am J Emerg Med. 2000 May;18(3):317-21.
  3. ↑ Amanda E. Horn and Jacob W. Ufberg. Management of Common Dislocations. http://clinicalgate.com/management-of-common-dislocations/
  4. ↑ Davenport M. Procedures for orthopedic emergencies. In: Bond M, ed. Orthopedic Emergencies: Expert Management for the Emergency Physician. Cambridge: Cambridge University Press; October 31, 2013.
  5. ↑ Horn A. Management of Common Dislocations. In: Roberts and Hedges' Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014.
  6. ↑ Lam AC, Shih RD. Luxatio Erecta Complicated By Anterior Shoulder Dislocation During Reduction. Western Journal of Emergency Medicine. 2010;11(1):28-30.
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