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Anteroposterior view of the right shoulder joint in an adult patient. The right humeral head is dislocated in- feriorly (Case 1).
Source publication
Inferior shoulder dislocation, also referred to as luxatio erecta, is a rare type of shoulder dislocation. Its incidence is about 1 in 200 (0.5%) among all shoulder dislocations. The objective of this study was to review six cases of inferior shoulder dislocation, including their clinical and radiological presentation, management, and final outcome...
Context in source publication
Context 1
... shoulder joint is the joint where dislocations occur most frequently. [1] Multi-directional mobility of the shoulder joint, its anatomic structure and frequent exposition to traumas result in the more frequent oc- currence of dislocations. [2] Forward and backward dislocations are observed at rates of 95% and 4-5%, respectively, in patients with shoulder dislocations. [1,3] Downward dislocation (luxatio erecta - LE), with an occurrence rate of 0.5% among all shoulder dislo- cations, on the other hand, is a traumatic case that is observed quite rarely, which generally occurs during hyperabduction type trauma of the arm. In such cases, it is usually observed that the inferior capsule of the joint is torn. [4,5] For the formation of the LE, a great amount of force is required; thus, many other injuries can be seen together. [6] The current study presents six cases of downward dislocation of the glenohumeral joint that were treated with closed reduction. Four males and two females, a total of six pa- tients, with the diagnosis of inferior shoulder dislo- cation were treated between 2007 and 2010 (Table 1). Causes of the trauma included fall from a height (n=2), fall down stairs (n=2), motorcycle accident (n=1), and in-vehicle traffic accident (n=1). All six cases were admitted to the emergency service. Three of these patients had right shoulder trauma and the other three had left shoulder trauma; all stated that they had pain and could not bring their arm from ab- duction to neutral position. In their the clinical ex- amination, it was observed that the shoulders of the patients were painful and were locked in the abduc- tion position. In one of the patients, brachial plexus paralysis was diagnosed. Peripheral pulses were open in all patients. Radiologic examination revealed that the humerus head had been dislocated downwards in all patients (Fig. 1), and in one patient, tuberculum majus fracture accompanied the dislocation (Fig. 2 a, b). Closed reduction was applied to all six patients under anesthesia. The mean follow-up duration of the patients was 32 months and the mean age was 45 (range, 22-75). Con- stant shoulder scoring system was used for the clinical examination as pain, position, daily activities, range of motion, and strength were noted. The mean shoul- der score was 94 points (range, 86-100 points). In one of the patients, glenoid anterior wall fracture was di- agnosed by computed tomography (Fig. 3). Presence of neurologic and vascular injury was followed after reduction. In one of the patients, it was observed dur- ing the six-month follow-up that complete recovery of the brachial plexus lesion was achieved with the reha- bilitation program. During the follow-up examination of all patients, it was observed that anatomic relation of the joint was achieved and the fracture had been reduced. Luxatio erecta is the inferior dislocation of the gle- nohumeral joint, which was defined by Middeldorpf and Scharm. [7] The classical view, which is also char- acteristic, is the hyper-adduction of the affected arm, flexion of the elbow, and the hand positioned over or behind the head. [5,7,8] The unaffected hand supports the arm in order to stabilize the affected arm and alleviate the pain. On physical examination, the glenoid cavity is empty and the head of the dislocated humerus can be palpated in the axilla or over the chest wall. Before the reduction procedure, conventional scapular X-ray films should be obtained in all patients in order to confirm the diagnosis and demonstrate any concomi- tant fractures. Transscapular Y-graphy, computed to- mography and magnetic resonance imaging would be helpful in the diagnosis and treatment. [1,2,9] The early diagnosis of LE is of critical importance. Inferior dis- location occurs mostly due to indirect injury. In the in- direct mechanism, inferior dislocation of the shoulder develops due to the lever arm effect of the proximal humerus when a strong hyper-abduction force is ap- plied to the arm. Because of the pulling effect of the pectoralis major, the arm stays in the erected position. [7,10] There may be severe soft-tissue injury due to the avulsion of the supraspinatus, infraspinatus and teres minor muscles. There are some complications of LE. Tsuchida et al. [10] found axillary nerve palsy in 60%, fracture of the humerus in 37% and rotator-cuff tear in 12% of the patients. Adhesive capsulitis and recurrent subluxation or dislocation can be seen as late compli- cations. [9,11,12] In our series, we found rotator-cuff tear in one patient and hypoesthesia of the axillary sensory area of the lateral shoulder in another. Early reduction should be done to prevent compli- cations. [3,6] Adequate sedation and analgesia is funda- mental to the procedure, and most of the LE cases can be treated successfully in the emergency room with closed reduction. Opposite-traction technique is the most effective closed reduction method. In this tech- nique, traction and mild abduction are applied to the affected arm in the same direction of the humerus, while opposite-directional traction is performed with a rounded sheet. [1,2,12,13] Neurovascular examination and follow-up radiographs are important to exclude iatro- genic fractures after reduction. Successfully reduced cases should be immobilized by using arm-body ban- dage. If the reduction is unsuccessful, it should be re- peated under anesthesia. The standard closed reduction of LE is contraindicated in neck and shaft fractures of the humerus and in the case of any suspicion of ma- jor vascular injury. In these cases, open reduction with surgery is indicated. [2,9,14] Since LE occurs after high- energy trauma, a complete systemic examination must be done in order not to miss any other organ or system injuries. The prognosis is excellent in most of the non- complicated LE cases. [2,4,7,9,15] Although closed reduction is usually successful without difficulty, failures do occur, usually secondary to entrapment of the humeral head in the torn inferior joint capsule. If this occurs, operative treatment with open reduction is the treatment of choice. [1,7,10] Addi- tionally, if displacement of the tuberculum majus is more than 5 mm after reduction, surgery would be in- dicated. If the fracture involves more than 25% of the glenoid cavity, then surgery would also be indicated as instability may occur. [1] In a study of 16 consecutive patients with 18 shoul- der dislocations, initial treatment of closed reduction failed in four patients, and they were surgically treat- ed; recurrent instability of the injured shoulder devel- oped in six patients, who were treated with a capsular reconstruction. The mean follow-up was nine years. Eighty-three percent of the patients had good to excel- lent treatment outcomes, and none of the associated neurovascular injuries affected final outcomes. [9] In their meta-analysis of 80 cases, Mallon et al. [4] found that 80% of patients sustained a fracture of the greater tuberosity or a rotator cuff tear, and 60% had some degree of neurologic compromise. Typically, however, these injuries resolved within one year. Our study re- sults support those of Groh et al. [9] and Mallon et al. [4] Almost all patients achieved good strength and motion with non¬operative management, and associated neu- rologic and associated injury did not affect the final outcomes. There was no direct association between age and comorbidities sustained during the injuries. None of our patients needed surgical intervention, and 100% of the patients had excellent or good outcome. Post-traumatic frozen shoulder is common and leads to a poor functional result. [16] Post-traumatic frozen shoulder did not develop in any of our patients. In conclusion, in this series, all dislocations were reduced with close reduction technique, and none of the patients developed recurrent instability. LE is a rare form of shoulder dislocation due to its specific occurrence mechanism and clinical presentation. Doc- tors should be familiar with the occurrence of this in- frequent condition and should prevent possible com- plications that might result from early reductions by using correct maneuvers in lieu of ordinary reduction ...
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Citations
... This type of shoulder dislocation is primarily caused by an indirect mechanism: when a high-energy hyper-abduction force is applied to the arm, the proximal humerus is dislocated and assumes a lever arm role. This position is sustained in an erect posture due to the strong and constant pulling influence of the pectoralis major [11,12]. Our patient was forcefully ejected from his motorcycle and Hence, inferior shoulder dislocation can be associated with complications. ...
... Early reduction of inferior shoulder dislocation and hip dislocation is recommended to prevent complications [1,4,6,9,18]. Many cases can be successfully treated in the emergency room using an opposite traction with adequate analgesia and sedation [12]. In our case, the reduction of the shoulder was performed successfully and easily in the operating room using simple traction, conducted by one operator. ...
Introduction and importance
Obturator hip dislocation and luxatio erecta humeri are two extremely rare injuries. We are reporting a very rare case that involves the association of these two injuries.
Case presentation
We reported the case of a 34-year-old male who was a victim of a high-energy road accident. Initial examinations showed a right obturator dislocation associated with a left luxatio erecta humeri without vascular-nervous complication. Further examinations have ruled out life-threatening injuries.
A closed reduction for both joints has been performed under general anesthesia less than 6 h following the trauma. Postoperative examination showed two congruent joints. Functional treatment has been implemented. Weight-bearing was permitted after 6 weeks, and physical rehabilitation of the shoulder was initiated 3 weeks after the trauma.
Last examination (20 months after trauma) showed a painless two-joint with a full range of motion. There was no sign of shoulder instability, and radiographs showed no signs of avascular necrosis of the femoral head.
Clinical discussion
Both injuries are two rare orthopedic emergencies that require prompt diagnosis and immediate reductions.
Conclusions
A good outcome can be expected if functional treatment is applied after prompt closed reduction. Hence, regular monitoring is required to detect complications such as avascular necrosis of the femoral head for the hip and signs of instability for the shoulder.
... LEH is the most likely shoulder dislocation associated with neurovascular compromise. Typically, patients are treated nonoperatively with physical therapy and have full resolutions of complications within three years [3,4,9,10]. This case details an incident of LEH in an 83year-old right-hand dominant female after a ground-level fall with a history of ipsilateral rotator cuff repair greater than 20 years ago. ...
... LEH has an incidence of 0.5%, making it the rarest type of glenohumeral dislocation [1][2][3][4][5][6][7][8][9][10]. Inferior glenohumeral dislocations occur secondary to direct axial loads to an abducted arm or an indirect load caused by rapid hyperabduction to an abducted arm [5,6,8]. ...
... The inferior forces on the humerus, keeping the humeral head in its position below the glenoid, are due to the pull of the teres major and latissimus dorsi [4,5]. Complete shoulder series radiographs are recommended to confirm the diagnosis of LEH, plan reduction maneuvers, and rule out any scapular or proximal humerus fractures [10]. ...
Luxatio erecta humeri is an infrequent type of glenohumeral dislocation. The pathophysiologic mechanism responsible for luxatio erecta humeri is a traumatic incident of direct axial loading or a rapid hyperabduction injury. Patients commonly present with severe shoulder pain and the classic appearance of their arm externally rotated and stuck in abduction overhead. Radiographs help confirm the diagnosis by showing the humeral shaft parallel to the scapular spine and the humeral head inferior to the glenoid. Prompt recognition, neurovascular assessment, and reduction are necessary. This case details an incident of luxatio erecta humeri in an 83-year-old female after a ground-level fall with a history of ipsilateral rotator cuff repair greater than 20 years ago. She had subjective numbness in her fingers that resolved post-reduction. Anesthesia assisted in safely sedating the patient for orthopedics to successfully perform a closed reduction by combining techniques from the two most described maneuvers. The patient was discharged in a shoulder immobilizer for follow-up outpatient and later scheduled for reverse total shoulder arthroplasty.
... This infrequent injury is often due to high-energy trauma and has the highest incidence of concomitant neurovascular injury of all shoulder dislocations [2]. They are often associated with humerus fractures, rotator cuff tears, in addition to vascular and neurological injuries, which can result in significant functional deficits [2][3][4][5]. Patients will typically present with the arm in a pathognomonic abducted and locked overhead position, also known as Luxatio Erecta. In atypical presentations without this distinct arm position, ISD can mimic anterior dislocations leading to initial misdiagnosis and use of improper reduction techniques. ...
... Meticulous assessment of neurovascular status is required in any form of shoulder dislocation both pre-and post-reduction. A recent systematic review noted neurological injury after traumatic ISD in 29% of cases, with the axillary nerve most at risk, and vascular injury in 10%, including axillary arterial injury [4,5]. Most neurological injuries resolve after reduction or within 1 year [6,7]. ...
Case
Inferior shoulder dislocations (ISD) are very rare occurrences estimated to make up only 0.5% of all shoulder dislocations and are typically associated with high-energy trauma and humerus fractures. We present an unusual case of an ISD due to the absence of the pathognomonic arm posture, mimicking an anterior shoulder dislocation. After multiple failed attempts at closed reduction in the Emergency Department, orthopaedics was consulted for further evaluation. Appropriate imaging was ordered, including an axillary radiograph and CT scan, which demonstrated an ISD with an engaging Hill-Sachs lesion and displaced greater tuberosity fracture. The patient was taken to the operating room the same day and underwent a successful closed reduction utilizing intraoperative fluoroscopic imaging.
Conclusion
Early reduction of ISD is critical to preventing complications, such as axillary neuropraxia and brachial plexopathy. However, closed reduction of ISD is often difficult. The two-step maneuver under general anesthesia in the operating room with procedural fluoroscopy is recommended to ensure a safe, adequate, and timely reduction.
... [11] Inferior glenohumeral dislocation is rare, accounting for less than 1% of all shoulder dislocations. [12] On the other hand, the elbow is an inherently stable joint owed to congruous joint surfaces and surrounding capsuloligamentous structures, hence the elbow dislocation is relatively rare. Over 90% of elbow dislocations occur in a posterior or posterolateral direction. ...
This case report presents a 21-year-old male construction worker with ipsilateral inferior shoulder and posterior elbow dislocations, accompanied with other injuries. Such a combination of injury undoubtedly occurs; however, to the best of our knowledge, this is the first reported case. The prompt closed reductions without waiting for anesthesia were accomplished without the help of an assistant using a novel technique. The patient returned to his job with considerable recovery of motion and strength despite his permanent paralysis of the deltoid muscle and he was still employed as a worker after four years. He was abducting his arm by using his accessory muscles, which contribute to abduction when arm is externally rotated. The maneuver described in the report can be used to reduce all inferior shoulder dislocations and it is worth to know that working at a job requiring high level of activity is still possible despite a permanent loss of axillary nerve function.
... Most of the literature so far has emphasized non-operative management of these injuries after closed reduction with either traction-countertraction or two-step techniques [7][8][9][10][11]. Shai at al. [12] first studied the role of arthroscopy in evaluating concomitant shoulder pathology, while Pandey et al. [13] reported 2 cases of inferior shoulder dislocation with associated RC tears that were treated arthroscopically, with good outcomes. ...
Patient: Male, 28-year-old
Final Diagnosis: Luxatio erecta humeri
Symptoms: Pain
Medication: —
Clinical Procedure: Arthoscopy • arthroscopic Bankart repair • arthroscopic fixation of greater tuberosity fracture • arthroscopic rotator cuff repair
Specialty: Orthopedics and Traumatology
Objective
Rare co-existance of disease or pathology
Background
Luxatio erecta humeri (LEH) is a rare injury present in only 0.5% of shoulder dislocations. Much of the relevant literature is focused on the initial management and proper reduction techniques, although the prevalence of associated injuries can reach 80%. A case of LEH associated with greater tuberosity (GT) fracture and rotator cuff (RC) tear in a young laborer managed with closed reduction and arthroscopic repair of the labrum and rotator cuff is presented.
Case Report
A 28-year-old man presented to our hospital with severe pain in his right shoulder after a high-impact motor vehicle accident. Standard anteroposterior radiographs revealed an inferior dislocation (LEH) of the right shoulder and a fracture of the GT. The patient was initially managed with closed reduction under mild intravenous sedation, using a 2-step maneuver followed by arthroscopic evaluation of the joint the next day. During arthroscopic evaluation, an anterior–inferior Bankart lesion, impaction of the humeral head with a minimal displaced GT fracture, and a partial RC tear were identified and successfully treated arthroscopically. The patient had immobilization in a simple sling for 6 weeks and he followed a standard 3-month physiotherapy protocol for rotator cuff, finally regaining almost normal range of shoulder motion at 1 year.
Conclusions
Although very good results of non-operative treatment of LEH have been reported in the literature, the coexistence of intra-articular lesions such as labral and rotator cuff tears makes arthroscopic repair an attractive alternative in individual cases.
... Fractures of the scapula or humeral head may also be seen, particularly of the greater tuberosity as in this case. "However, computed tomography is a better tool to evaluate associated fine fractures [6], and magnetic resonance imaging better reveals the injuries to the rotator cuff, the labrum, and the ligaments [7]. ...
... The vast majority of the literature did not use a standardised outcome score for patients. The Constant score was described for seven patients in two studies [30,31], with an average score of 93.1 (range 86-100). The UCLA score was available for 16 patients from one study [21], with an average score of 93.1 (range 86-100). ...
Introduction:
Traumatic inferior shoulder dislocation (ISD) is rare, estimated to occur in 0.5% of all shoulder dislocations. We describe the demographics, natural history and outcome of this injury.
Hypothesis/aim:
The aim of the study is to provide a summary of the demographics, clinical presentation, management and outcome of patients who suffer ISD METHODS: We conducted a systematic review of the English language literature on ISD using PubMed, Medline, CINHAL, Cochrane Database and Evidence-Based Medicine Reviews. Articles were examined independently by two of the authors and data were extracted using a standard form. Descriptive statistics were performed.
Results:
199 patients were identified, from 101 articles. Mean age was 44 years (range 13-94 years). All cases were caused by trauma, with falls accounting for 44% of all cases. There were three reported cases (2%) of open dislocations and 29 cases (15%) of bilateral ISD. Proximal humerus and scapular fractures were reported in 39 and 8% of patients, respectively. Neurological injury after dislocation was noted in 58 patients (29%). Vascular injury was noted in 20 patients (10%), which included axillary arterial injury in 19 patients and an upper limb deep vein thrombosis in one patient. Follow-up data were available for 107 patients (54%), with an average duration of 2.7 years (1 week-32 years). Avascular necrosis (AVN) was noted between 8 weeks and 2 years after initial injury in three patients (1.5%).
Conclusion:
Clinical and radiographic assessment of ISD is key to diagnosis and successful reduction. Patients can be treated with shoulder immobilisation for 2-3 weeks. In the setting of ongoing pain or instability, further imaging should be performed. The outcome of ISD is generally favourable.
... Luxatio Erecta is a rare type of shoulder dislocation, accounting for approximately 0.5% of all shoulder dislocations [1]. It is associated with traumatic injuries that hyperabduct the arm, which forces the proximal humerus into the acromion, which allows the humeral head to disengage from the glenoid. ...
... Classically, physical exam will show the affected arm hyperabducted with flexion at the elbow, and hand positioning superior or posterior to the patient's head. The examiner should be able to palpate the humeral head in the patient's axilla, along with an empty glenoid cavity [1]. ...
... Fractures of the scapula or humeral head may also be seen, particularly of the greater tuberosity as in this case. When fractures are evident on plain films, computed tomography may be indicated to evaluate fracture morphology [6], and magnetic resonance imaging better reveals the injuries to the rotator cuff, the labrum, and the ligaments [7]. Gentle closed reduction under anesthesia is the first line of management in such injury. ...
Luxatio erecta is an unusual humeral dislocation. It is frequently associated with neurovascular injuries and concomitant fracture. As such, they require a thorough clinical and imaging evaluation. The vast majority of cases may be treated with closed reduction alone, but infrequently, some may require an open procedure. The authors report a case of luxatio erecta with fracture of greater tuberosity to underline the rarity of this entity, and to describe the mechanism of this injury and the therapeutic modalities.
... Inferior shoulder dislocation (luxatio erecta humeri) is a relatively rare form of glenohumeral dislocation, accounting for only 0.5% of all shoulder dislocations. [4] Case reports published irregularly in emergency medicine and orthopedic literature. The mechanism of this injury involves either direct axial loading on a fully abducted extremity or leverage of the humeral head across the acromion by a hyperabduction force. ...
... In this study, we reviewed the mechanism of injuries of all cases (57 articles) and classified the injuries into seven parts: Falling accidents (25 articles), [3,8,9,10,12,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,54] accidents related to working (5 articles), [12,14,35,36,37,38] sport related injuries (9 articles), [2,19,36,39,40,41,42,43,44,45] traffic accidents (10 articles), [4,13,15,45,46,47,48,49,50,57] alcholism, epilepsy, syncope, seizure and sleeping related injuries (6 articles), [5,8,18,40,51,52] unusual age (infant) with unusual mechanism (1 article), [53] boat accident (1 article) [54] [ Table 1]. Table 1 See the article list which were arrenged according to mechanism of the injury We found 20 articles that reported neurovascular injury at admission time (16 articles reported neuorologic injury-4 articles reported vascular injury) [4,7,8,9,10,11,12,14,34,37,40,42,45,46,47,48,51,54,56,57] [ Table 2]. ...
... In this study, we reviewed the mechanism of injuries of all cases (57 articles) and classified the injuries into seven parts: Falling accidents (25 articles), [3,8,9,10,12,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,54] accidents related to working (5 articles), [12,14,35,36,37,38] sport related injuries (9 articles), [2,19,36,39,40,41,42,43,44,45] traffic accidents (10 articles), [4,13,15,45,46,47,48,49,50,57] alcholism, epilepsy, syncope, seizure and sleeping related injuries (6 articles), [5,8,18,40,51,52] unusual age (infant) with unusual mechanism (1 article), [53] boat accident (1 article) [54] [ Table 1]. Table 1 See the article list which were arrenged according to mechanism of the injury We found 20 articles that reported neurovascular injury at admission time (16 articles reported neuorologic injury-4 articles reported vascular injury) [4,7,8,9,10,11,12,14,34,37,40,42,45,46,47,48,51,54,56,57] [ Table 2]. Table 2 See the list of articles which were arrenged according to neurovascular injury We could not obtain full text of one additional article to the 57 stated above, which reported neurovascular injury in vascular surgery concerned journal. ...
