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 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]

Clinical Features
  • 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
  • Plain film X-ray in at least 2 views

Management

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 dislocaiton
  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

Complications
    • Axillary nerve palsy in 60% (usually rapidly resolves after reduction[2]
    • Humerus fracture in 37%
    • Rotator cuff tear in 12%

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

See Also

References
  1. 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. 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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