CASE 2165 Published on 01.05.2003

Inferior dislocation of shoulder

Section

Musculoskeletal system

Case Type

Clinical Cases

Authors

Dussa C U

Patient

53 years, female

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Clinical History

The patient presented with an inferior dislocation of her right shoulder which was reduced successfully in the casualty department under sedation. Post reduction neurovascular status was normal.

Imaging Findings

Presented to the emergency department for excruciating pain in the right shoulder subsequent to a fall on outstretched hand. On clinical examination, apart from obviously being in distress due to pain, her right arm was abducted with the elbow pointing above the head. Diffuse swelling of the shoulder was noted. The head of the humerus was palpable in the axilla. Distal neuro-vascular status was intact.
X-Ray of the shoulder showed an inferiorly dislocated right shoulder.
The shoulder was manipulated in the emergency department under sedation using morphine by traction in the axis of the upper limb along with manual relocation of head. Post manipulation, the neurological and vascular status was intact. Check X-ray confirmed the relocation of head of humerus.

Discussion

Middeldorpf and Scharm described inferior dislocation in 1859. It is also called "luxatio erecta". It accounts for 0.5 % of the shoulder dislocations(1). The clinical picture is very diagnostic of this injury, where the position of the arm lies abducted with the elbow above the head. The mechanism of injury is hyper-abduction force that causes impingement of the neck of the humerus against the acromion process which levers the head out of the glenoid cavity inferiorly. The humerus is locked in this position with 110 – 160 degrees of abduction. It may be associated with severe soft tissue injury like avulsion of supraspinatus, infraspinatus or teres minor(2). Fractures of proximal humerus may also be associated injuries. High incidence of the brachial plexus injuries has been reported. Occasionally, axillary artery may be thrombosed(3). Traumatic bilateral inferior dislocations are less frequent(1). Very high forces may produce compound inferior dislocation (4). Confirmation of the clinical diagnosis is by X-rays that show the head inferior to the glenoid cavity. Axillary views show the position of the head in relation to the glenoid. Arthroscopy may show superior labral tears(5). Reduction of the dislocation is easy with traction and manual relocation under sedation. Buttonhole of the inferior capsule should be suspected where the dislocation is resistant to relocation.. In such cases open relocation may be necessary.

Differential Diagnosis List

Inferior dislocation of shoulder

Final Diagnosis

Inferior dislocation of shoulder

References

[1] Grate I Jr. Luxatio erecta: a rarely seen, but often missed shoulder dislocation. Am J Emerg Med 2000 May;18(3):317-21. (PMID: 10830689)

[2] Schai P, Hintermann B Arthroscopic findings in luxatio erecta of the glenohumeral joint: case report and review of the literature. Clin J Sport Med 1998 Apr;8(2):138-41. (PMID: 9641446)

[3] Mesa M, Carpintero P, Carpintero J Bilateral luxatio erecta humeri. Acta Orthop Belg 1996 Jun;62(2):116-9. (PMID: 8767163)

[4] Gardham JR, Scott JE. Axillary artery occlusion with erect dislocation of the shoulder. Injury 1979 Nov;11(2):155-8. (PMID: 521154)

[5] Davison BL, Orwin JF. Open inferior glenohumeral dislocation. J Orthop Trauma 1996;10(7):504-6. (PMID: 8892152)

Case information