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Traumatic inferior shoulder dislocation: A case report with a comprehensive review of acute care and post-reduction management strategies
, Thabang Thomo Rachoeneb, Happy Ngwako Masipab, Nkosiphendule Lindani Mzayiyac
⁎Corresponding author: Pududu Archie Rachuene. pududu.rachuene@up.ac.za
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Traumatic inferior shoulder dislocation is a rare kind of shoulder dislocation that accounts for less than 5 % of all shoulder dislocations. It usually occurs after a fall with the arms lifted. After observing three cases at our hospital, we decided to perform a literature analysis to assess the associated and concomitant injuries that occur with luxatio erecta humeri (LEH), as well as the clinical outcomes.
We present case studies of traumatic LEH in male patients. Cases 1 and 2 both had concomitant lower limb injuries, whereas Case 3 had a brachial plexus injury. In all cases, traction-countertraction was used to successfully execute emergent closed reduction. At 18 months of follow-up, Case 2 reported instability and persistent pain. Case 1 had a greater tuberosity fracture that was successfully treated non-surgically.
Although inferior shoulder dislocations are rare, concomitant and associated injuries are not uncommon. Following a closed reduction and a brief period of immobility, the outcomes are generally favourable. However, concomitant injuries requiring referral for orthopaedic care are reported in literature.
In patients presenting with inferior shoulder dislocation, clinicians should have high index of suspicion for concomitant intrinsic shoulder injuries, requiring advanced imaging and referral to orthopaedic surgeons.
Keywords
Inferior shoulder dislocation
Luxatio erecta
Associated injuries
Instability
Advanced imaging
1 Introduction
Traumatic inferior shoulder dislocation is extremely rare, estimated to represent <1 % of all shoulder dislocations.1,2 It is also referred to as luxatio erecta humeri (LEH). Axial compression of a fully abducted arm and forceful hyperabduction of the arm is the most common mechanisms of injury following high energy trauma.1,2 Initial evaluation involve a careful neurovascular assessment. These cases are commonly managed by the emergency unit practitioners and there may be an assumption that there is no role for orthopaedic surgeons in majority of the cases once the reduction is achieved. Following our experience with these three patients, we compiled this manuscript to summarize current literature on emergency care of these patients and the circumstances that necessitate need for a referral to orthopaedic surgeons for evaluation. This manuscript provides insights on the clinical approach to this injury, associated intrinsic shoulder injuries, need for advanced imaging and indications for surgery.
2 Case report
2.1 Case 1
A 34-year-old male was brought to casualty by emergency medical services. He was involved in a motor vehicle accident (MVA) as a driver. He presented with right shoulder pain and loss of function and left knee pain. He had no known comorbid conditions, and he denied history of epilepsy or previous shoulder dislocation. On examination, he was lying supine with his arm elevated and unable to bring it down. His elbow was flexed, forearm pronated and handheld in front of the forehead (Fig. 1a). Neurovascular assessment was normal. Plain x-rays revealed left LEH with associated greater tuberosity fracture (Fig. 2a & b). Knee CT-scan revealed left tibial plateau undisplaced fracture. He underwent left shoulder emergency reduction under general anaesthesia using traction-countertraction method followed by immobilization for 3 weeks in a shoulder brace. At 18 months follow-up he had normal shoulder function and strength with healed greater tuberosity fracture (Fig. 3a–d)
2.2 Case 2
A 27-year-old male presented to emergency unit with right shoulder pain and left ankle sprain following history of assault on the 22 July 2017. He reported his arm was pulled forcefully by an assailant, who was standing in front of him, he fell onto the ground. He had typical clinical presentation and neurovascular examination was normal. X-rays showed simple LEH. He underwent emergency closed reduction under general anaesthesia using a traction-countertraction followed by 4 weeks immobilization in an arm sling. He reported atraumatic dislocation at three months after the index injury and he managed to reduce it at home. At 12 months post injury he had anterior shoulder instability with positive anterior apprehension and re.location tests. He did not have clinical features of joint hypermobility, and his left shoulder examination was normal. He opted for non-surgical treatment.
2.3 Case 3
A 67-year-old male presented at early hours of the morning with pain to the right shoulder following a history of a fall while trying to get off a chair. He is a former policeman, with no history of prior injury to the shoulder. He had end-stage congestive cardiac failure, and he was restricted to a wheelchair most of the time. He was lying on a stretcher with his arm hyperabducted and held over his head (Fig. 1b). He reported paraesthesia in his right arm and loss of hand function. His distal pulses were normal. Diagnosis was confirmed on x-rays (Fig. 2c). Closed reduction was attempted in casualty under sedation, using traction-counter traction maneuver and it failed. He was successfully reduced under general anaesthesia. He developed anaesthesia related complications, and he was sent to ICU. Post discharge from ICU he had a flail limb, and he was treated conservatively. He was lost to follow-up during the COVID-19 national lockdown period.
3 Discussion
Luxatio erecta humeri (LEH), though rare, presents unique diagnostic and management challenges, necessitating a thorough understanding of its clinical features and associated injuries. Our series of three cases offers valuable insights into the clinical presentation, treatment strategies, and outcomes of this condition.
3.1 Clinical presentation
Males are commonly affected (75 %) compared to 25 % of cases being females and mean age of 44 years.1 Falls are reported to be the most common cause of injury.1,3 The abduction force causes the proximal humerus to abut against the acromion, which results in humeral head being levered on the inferior rim of the glenoid.4,5 Arm hyperabduction of >125o, elbow flexion and hand on forehead or behind head is a typical presentation. Pectoralis major, teres major and latissimus dorsi are responsible for maintaining this position.1 Appearance of a bruise or a wound in the axilla in association with a hyperabducted arm is said to be pathognomonic for LEH.6 Consistent with the literature, all three of our cases demonstrated the hallmark clinical presentation. Lesions of the brachial plexus are frequently reported in literature.7–9
3.2 Diagnostic imaging
Plain radiographs remain the cornerstone for initial diagnosis, distinctly revealing hyperabduction of the humeral shaft parallel to the scapular spine and the humeral head positioned inferior to the glenoid.1,6 Anteroposterior and axillary views of the shoulder are used to confirm the diagnosis.4 X-ray findings in our cases were distinctive. It is important that these are obtained prior to attempted reduction as these injuries may be complicated by associated fractures, as observed in two patients in this study. Emergency department practitioners must high index of suspicion for associated axillary artery rupture. Even if distal pulses are palpable, the presence of brachial plexus lesions should raise suspicion for associated vascular injury, and angiogram should be considered.1
3.3 Initial treatment
These injuries are managed with emergent closed reduction in the emergency setting. The traction-countertraction technique, as described by Freundlich,10 is the most commonly cited method. It involves applying axial traction to the abducted humerus while an assistant provides countertraction using a sheet placed across the top of the shoulder. Nho et al.5 described a two-step reduction technique with the patient in a supine position. The primary surgeon stands on the affected side at the patient's head, placing one hand on the lateral midshaft of the humerus and the other on the medial epicondyle. The humeral head is gently manipulated from inferior to anterior using the midshaft hand, while the medial epicondyle hand applies upward force. This is followed by adduction of the arm, allowing any standard anterior dislocation reduction technique to complete the process. This method minimizes the risks associated with excessive traction by converting an inferior dislocation into an anterior one through controlled arm rotation. In all three cases, emergency reduction using traction-countertraction was successful, though general anaesthesia was required for Case 3 due to failed attempts under sedation. Post-reduction management typically includes short-term immobilization. Majority of these patients will regain normal function without surgical intervention.8,11
3.4 Post-reduction management
Post reduction immobilization of 3–4 weeks is necessary to allow soft tissue to heal, followed by pendulum exercises.12,13 Outcomes are generally favourable, with patients regaining premorbid function and range of motion. Poor outcomes are associated with open dislocations, delayed presentation, and persistent neurological deficits.1 The below literature summarizes concomitant intrinsic shoulder injuries and the risk of instability, highlighting the importance of post-reduction advanced imaging for comprehensive assessment.
3.5 Intrinsic glenohumeral joint injuries
Advanced studies are usually recommended for patients with persistent pain, instability, or recurrent dislocation.1 MRI has an advantage of diagnosing associated soft tissue injuries and humeral head impaction fractures.1,14 Humeral greater tuberosity fractures and rotator cuff tears are the most common associated injuries, with reported rates ranging from 30 % to 80 %.1,15 In the review of MR imaging studies of 4 cases which had prior luxatio erecta humeri, Krug et al.14 found that all four patients had associated rotator cuff tears, ranging from small to large tears. Injuries to other structures were also demonstrated. Several authors observed associated capsulo-labral injuries or lesions of the long head of biceps in their cases.14,16,17 Ostermann et al.18 reported 31 of the 38 patients in their series to be having GHJ intrinsic pathologies to be more common following inferior dislocation. The commonly observed injuries were greater tuberosity fracture (42 %) and rotator cuff tears (34 %). None of the tuberosity fractures needed fixation. Five patients had Hill-Sachs lesions, and four had bony lesions of the inferior glenoid. In 18 % of the patients, capsule-labral injuries were observed. They are of opinion that advanced (CT scan or Mri) imaging should be done as soon as possible following this injury, due to high rate of associated injuries. However, there was no demonstratable correlation between these injuries and risk of instability or subsequent surgery in this study. Only 5 patients needed surgery, two of which were possibly done for instability. Observantly, the majority of these patients will however regain shoulder function without surgical intervention.8,11
3.6 Shoulder instability and recurrence of dislocation
The risk of instability and recurrent dislocations following this injury is not adequately described in the literature. Groh et al. found instability in six LEH patients (33 % of 16 patients with 18 shoulder dislocations).11 A systematic review found an 11 % instability rate in 21 identified LEH patients.1 Case 2 in our study developed anterior instability of the glenohumeral joint with reported episode of subsequent atraumatic anterior dislocation. He decided against having any more imaging studies or surgery. Capsular repair surgery in those with instability has been reported to be successful, with return to competitive sports.11,19 One patient with ALPSA lesion in Ostermann series was treated with a Latarjet procedure following multiple dislocations.18 Furuhata et al. reported a case of LEH with associated greater tuberosity fracture with multiple episodes of recurrent inferior dislocation which was successfully treated with open tuberosity repair, with no recurrence and restoration of shoulder function at 10 months follow-up. Capsulo-labral injury was absent in this patient.20 Although instability is uncommon, it is evident from these results that anatomical repair surgery is effective for those who develop it.
4 Conclusion
Luxatio erecta humeri, though rare, is often accompanied by significant associated injuries and poses management challenges. Emergency practitioners must recognize its clinical characteristics and initiate appropriate reduction techniques promptly. Referral to an orthopaedic specialist is indicated when there are associated fractures, suspicion of or confirmed associated rotator cuff tear, recurrent instability, neurovascular compromise, or when advanced imaging reveals structural injuries requiring surgical intervention.
Informed consent
Written informed consent was obtained from all the three cases presented in this report. Ethical clearance was obtained from Human Research Committee at Sefako Makgatho Health Sciences University.
Author contributions
Rachuene PA and Mzayiya NL were responsible for the conceptualization of the study. The literature review was conducted by Rachuene PA, Rachoene TT, and Masipa NH. Rachuene PA prepared the first draft of the manuscript. All authors contributed to the review, revisions, and production of the final manuscript.
Financial disclosures
The authors declare that no financial support, funding, or grants were received for the research, authorship, or publication of this work. Additionally, the authors have no relevant financial relationships or conflicts of interest to disclose.
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