UCONN Emergency Medicine Interest Group

EM Images #8

In IMAGES on November 6, 2011 at 7:00 AM

Syndicated from the UCONN EM Residency website; credit to Dr. London for images and text.

These three people all have the same condition, which can be diagnosed bedside. Note all three have extremities that are fixed in the position in which you see them. These arms can not be moved by active or passive range of motion.
The first, an older woman, and the third, a younger man, were pedestrian versus car with outstretched hands at the moment of impact. What do they have and how do you fix it and what special considerations accrue to such a diagnosis? (click below to see answers and explanation)

Luxatio erecta– an unusual inferior subluxation of the shoulder.
Mechanism: usually an already extended abducted arm is hyperabducted leaving the humerous anteriorly and inferiorly locked in an “upright” (erecta) position that is pathognomonic. Bilateral luxatio erecta is rare (less than a dozen cases in literature) but one such (Kumar et al.) is appended. This condition is < 1% of shoulder dislocations BUT has a proportionately higher incidence of rotator cuff tears, vascular and neurologic complications (up to half in some series), necessitating a careful pre- and post-reduction evaluation AND documentation of such possible conditions.

An X-ray demonstrating the radiographic findings is shown below.

The usual reduction technique is as follows:
“The most effective reported reduction technique is the traction-countertraction technique. Upward traction on the extended arm is applied in line with the humeral shaft while an assistant applies countertraction in the opposite direction. Gentle abduction will usually reduce the dislocation and the arm is then brought down into an adducted position” (Yanturali et al., ref 3)

Nho et al. (ref. 1) suggest a different method (from abstract):
“The 2-step closed reduction maneuver was developed to aid in the rarely encountered inferior shoulder dislocation. The maneuver converts the humeral head from an inferior dislocation to an anterior dislocation and then reduces the humeral head into the glenoid. The operator places one hand on the shaft of the humerus and the other hand on the medial condyle. The hand on the shaft initiates an anteriorly directed force rotating the humeral head from an inferior to an anterior position. Once this is accomplished, the humerus is adducted against the body. The humerus is then external rotated reducing the humeral head into the glenoid. Two cases of inferior shoulder dislocation were closed reduced by using the described technique with minimal analgesia and without a change in the postreduction neurovascular status.”

This excellent brief review article can be found here.

References (in descending chronological order):

1. Nho, S.J., et al., The two-step maneuver for closed reduction of inferior glenohumeral dislocation (luxatio erecta to anterior dislocation to reduction). J Orthop Trauma, 2006. 20(5): p. 354-7.
2. Garcia, R., et al., Bilateral luxatio erecta complicated by venous thrombosis. J Trauma, 2006. 60(5): p. 1132-4.
3. Begaz, T. and M.B. Mycyk, Luxatio erecta: inferior humeral dislocation. J Emerg Med, 2006. 31(3): p. 303-4.
4. Yanturali, S., et al., Luxatio erecta: clinical presentation and management in the emergency department. J Emerg Med, 2005. 29(1): p. 85-9.
5. Goldstein, J.R. and W.P. Eilbert, Locked anterior-inferior shoulder subluxation presenting as luxatio erecta. J Emerg Med, 2004. 27(3): p. 245-8.
6. Yamamoto, T., et al., Luxatio erecta (inferior dislocation of the shoulder): a report of 5 cases and a review of the literature. Am J Orthop, 2003. 32(12): p. 601-3.
7. Mills, L.D., T. Barrows, and F. Benitez, Bilateral luxatio erecta. J Emerg Med, 2003. 24(1): p. 61-3.
8. Karaoglu, S., et al., Bilateral luxatio erecta humeri. Arch Orthop Trauma Surg, 2003. 123(6): p. 308-10.
9. Tomcovcik, L., et al., [Dislocation of the humerus–diagnosis and the Arlt method of reduction]. Rozhl Chir, 2001. 80(1): p. 38-42.
10. Snyder, B.K., Luxatio erecta. J Emerg Med, 2001. 20(1): p. 83-4.
11. Kumar, K.S., S. O’Rourke, and J.G. Pillay, Hands up: a case of bilateral inferior shoulder dislocation. Emerg Med J, 2001. 18(5): p. 404-5.
12. Grate, I., Jr., Luxatio erecta: a rarely seen, but often missed shoulder dislocation. Am J Emerg Med, 2000. 18(3): p. 317-21.
13. Munk, P.L., Radiology for the surgeon. Musculoskeletal. Case 2: inferior dislocation of the glenohumeral joint (luxatio erecta). Can J Surg, 1999. 42(1): p. 10, 64-5.
14. Schai, P. and B. Hintermann, Arthroscopic findings in luxatio erecta of the glenohumeral joint: case report and review of the literature. Clin J Sport Med, 1998. 8(2): p. 138-41.
15. Habermeyer, P., D. Jung, and T. Ebert, [Treatment strategy in first traumatic anterior dislocation of the shoulder. Plea for a multi-stage concept of preventive initial management]. Unfallchirurg, 1998. 101(5): p. 328-41; discussion 327.
16. Padgham, M. and J.S. Walker, Inferior glenohumeral dislocation (luxatio erecta humeri). J Am Osteopath Assoc, 1996. 96(8): p. 478-81.
17. Mesa, M., P. Carpintero, and J. Carpintero, Bilateral luxatio erecta humeri. Acta Orthop Belg, 1996. 62(2): p. 116-9.
18. Lill, H., et al., [Bilateral luxatio erecta of the shoulder joint–a rare injury. Management and therapy in polytrauma patients]. Unfallchirurg, 1996. 99(10): p. 801-5.
19. Davison, B.L. and J.F. Orwin, Open inferior glenohumeral dislocation. J Orthop Trauma, 1996. 10(7): p. 504-6.
20. Brady, W.J., C.J. Knuth, and R.G. Pirrallo, Bilateral inferior glenohumeral dislocation: luxatio erecta, an unusual presentation of a rare disorder. J Emerg Med, 1995. 13(1): p. 37-42.
21. Tornetta, P., 3rd, et al., Luxatio erecta: persistent displacement of the greater tuberosity after reduction. Orthop Rev, 1993. 22(7): p. 855-8.
22. Wang, K.C., K.Y. Hsu, and C.H. Shih, Brachial plexus injury with erect dislocation of the shoulder. Orthop Rev, 1992. 21(11): p. 1345-7.
23. Naess, P.A., [Luxatio erecta. An uncommon shoulder luxation]. Tidsskr Nor Laegeforen, 1991. 111(9): p. 1113.
24. Daya, M., Radiographic clue to luxatio erecta. Am J Emerg Med, 1991. 9(6): p. 624.
25. Pirrallo, R.G. and T.P. Bridges, Luxatio erecta: a missed diagnosis. Am J Emerg Med, 1990. 8(4): p. 315-7.
26. Mallon, W.J., F.H. Bassett, 3rd, and R.D. Goldner, Luxatio erecta: the inferior glenohumeral dislocation. J Orthop Trauma, 1990. 4(1): p. 19-24.
27. Davids, J.R. and R.D. Talbott, Luxatio erecta humeri. A case report. Clin Orthop Relat Res, 1990(252): p. 144-9.
28. Slawski, D.P., M.M. Rich, and L.A. Gilula, Imaging rounds #99. Luxatio erecta of the left shoulder. Orthop Rev, 1989. 18(4): p. 481-6.
29. Rae, P.J. and B.S. Sylvester, Luxatio erecta–two cases without direct injury. Injury, 1988. 19(5): p. 361-2.
30. Kahn, M.L., H.A. Bade, 3rd, and I. Stein, Body surfing as a cause of luxatio erecta: report of four cases. Orthop Rev, 1987. 16(10): p. 729-33.
31. Fery, A. and J. Sommelet, [Erect dislocation of the shoulder (luxatio erecta humeri). General review apropos of 10 cases]. Int Orthop, 1987. 11(2): p. 95-103.
32. McNeil, E.L., Luxatio erecta. Ann Emerg Med, 1984. 13(6): p. 490-1.
33. Kothari, K., et al., Luxatio erecta. Skeletal Radiol, 1984. 11(1): p. 47-9.
34. Zimmers, T., Luxatio erecta: an uncommon shoulder dislocation. Ann Emerg Med, 1983. 12(11): p. 716-7.
35. Saxena, K. and J. Stavas, Inferior glenohumeral dislocation. Ann Emerg Med, 1983. 12(11): p. 718-20.
36. Freundlich, B.D., Luxatio erecta. J Trauma, 1983. 23(5): p. 434-6.
37. Downey, E.F., Jr., D.J. Curtis, and A.C. Brower, Unusual dislocations of the shoulder. AJR Am J Roentgenol, 1983. 140(6): p. 1207-10.
38. Abad Rico, J.I. and A. Barquet, Luxatio erecta of the hip. A case report and review of the literature. Arch Orthop Trauma Surg, 1982. 99(4): p. 277-9.
39. Gardham, J.R. and J.E. Scott, Axillary artery occlusion with erect dislocation of the shoulder. Injury, 1979. 11(2): p. 155-8.
40. Rao, J.P. and R.B. Read, Luxatio erecta of the hip. An interesting case report. Clin Orthop Relat Res, 1975(110): p. 137-8.
41. Laskin, R.S. and E.D. Sedlin, Luxatio erecta in infancy. Clin Orthop Relat Res, 1971. 80: p. 126-9.
42. Kubin, Z., [Luxatio Erecta of the Humerus. (Case Report Contribution)]. Acta Chir Orthop Traumatol Cech, 1964. 31: p. 565-7.

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