Chief Complaint:

Shoulder Pain

HPI:

63 year old female presents after falling while walking down the stairs outside. She notes it was icy on the steps and was using the railing for support with her left hand. She states when she slipped that she tried to catch herself and all of her weight pulled on the left shoulder. Since the fall she has had constant throbbing severe localized pain to the left shoulder and has not been able to move the arm from a position above her head. She denies any numbness or tingling. She denies hitting her head having any loss of consciousness or being on anticoagulation. She states that she has dislocated the shoulder once in the past but was never in a position with her arm stuck above her head like it currently is. She has not done anything to treat her symptoms and was brought in by EMS.
Past medical history, surgical history and social history are otherwise noncontributory.

Pertinent Exam Findings:

General Appearance: Patient is lying in bed with her left arm above her head and mild distress secondary to pain.
Head: No cephalohematoma, no battle sign, no raccoon eyes, no hemotympanum.
Cardiovascular: Radial pulse 2 out of 4 bilaterally
Musculoskeletal: Left arm is abducted above the head. Patient is unable to move it secondary to pain. Patient is able to wiggle fingers
Neurologic: Sensation intact over light touch to radial ulnar median nerves and over deltoid

ED Course:

Conscious sedation was performed with propofol, the shoulder was reduced using direct traction along the axis of the humerus away from the torso along with pressure at the proximal humerus in a posterior to anterior fashion. There was a satisfactory clunk feeling and the shoulder was easily able to be a adducted.

Data Interpretation:

Imaging: Left shoulder with inferior dislocation of the glenohumeral joint trapped underneath the coracoid and glenoid

Figure 2: Reduced L shoulder with Hill-Sachs deformity

DISCUSSION:

Background:

Luxatio Erecta

• The shoulder joint (glenohumeral) is the most frequently dislocated joint, accounting for approximately 50% of major joint dislocations. Most commonly the glenohumeral joint is dislocated anteriorly, however the humeral head can dislodge from the joint in the posterior and inferior directions depending on the mechanism of injury. Luxatio is an inferior dislocation. Translated from latin, luxatio erecta means erect dislocation, an apt name due to this injury’s unique presentation of a raised arm despite the dislocation.

  Luxatio erecta is the least common type of shoulder dislocation, occurring in about 1 in 200 (0.5%) shoulder dislocations. This dislocation is due to a forceful loading on an abducted shoulder or hyperabduction of the joint. Typically the mechanism involves grabbing something overhead while falling. As its name would indicate, this “erect” dislocation is usually obvious, as once the humeral head moves inferiorly the patient will have their arm held in abduction in a raised hand position.

Diagnosis:

Luxatio erecta can often be diagnosed from the doorway. A history and physical exam should help lead to the correct diagnosis. Patients will present in pain with their affected arm held in abduction above their head. History will likely confirm a story of reaching up to grab something overhead while falling. Rotator cuff tears, fractures, neurologic injuries, and vascular injuries can occur as a result of luxatio erecta. Performing a detailed neurovascular examination before and after reduction is necessary to adequately evaluate the extent of the injury.

Management in ED:

Closed reduction of luxatio erecta is the typical management in the emergency department. Like any closed reduction, adequate sedation and analgesia is essential for success. Traction-countertraction is reported to be the most effective method for reduction of this particular dislocation. Traction is applied to the extended arm in line with the humerus while counter-traction is applied in the opposite direction. With traction-countertraction, the arm can either be further abducted for reduction or, as in this case, posterior to anterior pressure can be applied on the proximal humerus to reduce the shoulder. After the shoulder is brought down into the adducted position, post-reduction X-ray images should be obtained to confirm successful reduction and evaluate for iatrogenic fractures. The shoulder should be immobilized and the patient may be discharged with appropriate analgesic medication and orthopedic follow-up.

*Yanturali S, Aksay E, Holliman CJ, Duman O, Ozen YK. Luxatio erecta: clinical presentation and management in the emergency department. J Emerg Med. 2005 Jul;29(1):85-9. doi: 10.1016/j.jemermed.2004.12.016. PMID: 15961015.

Prognosis:

Musculoskeletal and neurovascular injuries can occur as a result of luxatio erecta, though musculoskeletal injuries are far more common. Rotator cuff tear and associated fractures are reported with up to 80% of luxatio erecta cases. The most commonly injured nerve is the axillary nerve injury, with nerve injuries in general occurring in up to 60% of luxatio erecta cases. While the rotator cuff injuries and fractures may necessitate surgery, neurologic injuries typically resolve after reduction of the shoulder. A small subset of cases, 3.3%, report significant vascular injury like axillary artery occlusion as a result of luxatio erecta.

Differential Diagnoses:

• • Anterior Shoulder Dislocation
  • Posterior Shoulder Dislocation
  • Clavicle Fracture
  • Humerus Fracture
  • Scapula Fracture
  • Acromioclavicular joint injury
  • Glenohumeral instability
  • Biceps tendon rupture
  • Triceps tendon rupture
  • Septic joint
  • Rotator cuff tear
  • Impingement Syndrome
  • Neurovascular injury

Clinical Pearls:

• • Although rare, keep an eye out for the dramatic hyperabducted arm of luxation erecta.
  • Traction-counter traction is the most effective method for reduction.
  • Rotator cuff tears and fractures occur in 80% on these cases, remember to give orthopedics follow up.
  • Remember to watch out for associated vascular and neurologi injuries.

References:

1. Kammel KR, Leber EH. Inferior Shoulder Dislocations. [Updated 2020 Aug 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448196/
2. Sherman, S. Shoulder Dislocation and Reduction. UpToDate. 2020. https://www.uptodate.com/contents/shoulder-dislocation-and-reduction?search=luxatio%20erecta&sectionRank=1&usage_type=default&anchor=H10&source=machineLearning&selectedTitle=1~2&display_rank=1#H10
3. Yanturali S, Aksay E, Holliman CJ, Duman O, Ozen YK. Luxatio erecta: clinical presentation and management in the emergency department. J Emerg Med. 2005 Jul;29(1):85-9. doi: 10.1016/j.jemermed.2004.12.016. PMID: 15961015.
   
4. Pirrallo RG, Bridges TP. Luxatio erecta: a missed diagnosis. Am J Emerg Med. 1990 Jul;8(4):315-7. doi: 10.1016/0735-6757(90)90083-c. PMID: 2363754.
5. Mallon WJ, Bassett FH 3rd, Goldner RD. Luxatio erecta: the inferior glenohumeral dislocation. J Orthop Trauma. 1990;4(1):19-24. PMID: 2313425.
6. Gardham JR, Scott JE. Axillary artery occlusion with erect dislocation of the shoulder. Injury. 1979 Nov;11(2):155-8. doi: 10.1016/s0020-1383(79)80014-5. PMID: 521154.

Authors

Aaron Wolfe, DO, FACEP

Jackson Roos, MSIV

John Spartz, MSIII