Luxatio Erecta

Written by: Kristen Kobayashi, DO; Edited by: Timothy Khowong, MD, MSEd

 
 

Case:

A 40 year old male presents to the Emergency Department after falling off his tractor. He tried to grab on as he was falling off and now his arm is stuck, abducted and positioned over his head. He did not hit his head and has minor abrasions otherwise.

The image on the right is what you see:

Goals:

  1. Review clinical signs and management of inferior shoulder dislocations.

  2. Review reduction techniques to manage inferior shoulder dislocations.

Epidemiology:

Inferior shoulder dislocations, also known as luxatio erecta, are the least common type of shoulder dislocations, occurring in about 0.5% of all shoulder dislocations [2].

Inferior shoulder dislocation (luxatio erecta)

Pathophysiology:

  1. Mechanism of Injury:

    Forceful, high energy hyperabduction. The humeral head and proximal humerus hyperabducts against the acromion which in turn pushes it down, tearing the inferior glenoid capsule and rotator cuff muscles [1].

  2. Clinical Signs and Symptoms:

    a. Affected shoulder pain

    b. Shoulder hyperabduction, unable to adduct

    c. Disrupted neurovascular exam distal to shoulder if complications

  3. Complications:

    a. Can occur in up to 60% of inferior dislocations [3]

    b. Neurovascular injuries:

    1. Brachial Plexus: most commonly axillary nerve injury: decreased sensation over lateral shoulder

    2. Axillary Artery

    c. Humeral Head/proximal humerus fractures

    d. Glenohumeral capsule and labral tears

    e. Rotator cuff tears

Brachial Plexus (Top)

Vascular supply to shoulder and arm (bottom)

Imaging:

Top: Shoulder Anatomy on XR. AP views (left) and scapular Y/lateral views (right) should be ordered for diagnosis [3]

Reduction:

  1. Typically indicated and successful: Consult orthopedics prior to reduction for vascular compromise, fracture-dislocations, subacute (7-10 days)/chronic dislocations [6].

  2. Pain control:

    1. Intra-articular lidocaine

    2. Procedural sedation

  3. Techniques:

    a. Traction-Countertraction:

    1. Wrap sheet around patient’s upper shoulder and chest to allow for countertraction

    2. Pull traction outward in line with the hyperabducted arm

    b. Traction Only: EMRAP video [4] (https://www.youtube.com/watch?v=k_ORI51luFI&ab_channel=EM%3ARAPProductions)

    1. Pull traction on affected arm while pushing humeral head anteriorly (up and over glenoid rim)

    c. Two-Step Technique:

    1. Push laterally on humerus (one hand) while pulling superiorly on medial epicondyle (other hand) to convert to anterior shoulder dislocation

    2. Reduce with an anterior shoulder reduction technique

  4. Apply sling or shoulder immobilizer

Traction-Countertraction Technique (Left)

Traction Only Technique (Right)

Disposition:

  • Follow up with orthopedics in 1 week.

  • Sling typically has to be used for 3 weeks with gentle exercises followed by physical therapy.

  • Given the high incidence of complications, it is recommended to obtain an MRI post-reduction to assess for ligamentous and muscular injuries.

 

References

  1. Stanislavsky A, Lustosa L, Ranchod A, et al. Inferior shoulder dislocation. Reference article, Radiopaedia.org (Accessed on 19 Dec 2023) https://doi.org/10.53347/rID-12342

  2. Frank, R., & Lin, A. (n.d.). Luxatio erecta (inferior glenohumeral joint dislocation). Orthobullets. https://www.orthobullets.com/shoulder-and-elbow/3132/luxatio-erecta-inferior-glenohumeral-joint-dislocation 

  3. Ameh V, Crane S. Nerve injury following shoulder dislocation: the emergency physician's perspective. Eur J Emerg Med. 2006 Aug;13(4):233-5. doi: 10.1097/01.mej.0000206190.62201.ad. PMID: 16816589.

  4. Walker Anne, Somers David. Shoulder Dislocations. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recwR47OSHvTQhST4/Shoulder-Dislocations#h.64z9jawhzcyf. Updated December 6, 2023. Accessed December 19, 2023.

  5. Chan, W., & Huang, V. (2021, December 9). Splinter series: My arm is stuck like this. ALiEM. https://www.aliem.com/splinter-series-my-arm-is-stuck-like-this/

  6. Sherman, S. (n.d.). Shoulder dislocation and reduction. UpToDate. https://www.uptodate.com/contents/shoulder-dislocation-and-reduction?search=inferior+shoulder+dislocation&source=search_result&selectedTitle=1~2&usage_type=default&display_rank=1#H21

 
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