Inferior shoulder dislocation

Background

Inferior dislocation with fracture of the greater tuberosity. Note how the humerus is abducted.
  • Also known as "Luxatio Erecta" due to the presentation of arm held in full abduction
  • Accounts for ~0.5% of all shoulder dislocations[1]
  • Mechanism: typically hyperabduction force which levers the humeral neck against the acromion
    • Can also be secondary to high-energy force applied directly to shoulder from above[2]
  • Frequently associated with significant soft tissue injury or fracture[1]
    • Axillary nerve palsy in 60% (usually rapidly resolves after reduction[2]
    • Humerus fracture in 37%
    • Rotator cuff tear in 12%

Clinical Features

  • Patient presents with humerus fully abducted with hand on or behind the head
  • Humeral head can be palpated on axilla or lateral chest wall[1]

Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

  • Plain film X-ray in at least 2 views

Management

Luxatio erecta.jpg
  • Closed reduction
    • 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[3]
    • Alternatively, use the Two step reduction- convert inferior dislocation into anterior, then reduce anterior dislocation
      • Push with one hand on the lateral mid-shaft of the humerus to move humeral head from inferior to anterior dislocation. Simultaneously, other hand is on medial epicondyle of elbow pulling superiorly/cephalic [4] [5]
      • Reduce the now anterior dislocation
  • Apply sling with arm in adduction and internal rotation.
  • Post-reduction X-ray
  • 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
  • Ortho follow-up

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.