Luxatio Erecta: Evaluation and Management

The Problem

An inferior dislocation is commonly referred to as luxatio erecta (Latin for “erect dislocation”), deriving its name from the classical presentation of an arm that is elevated and abducted and held overhead, unable to be lowered. Shoulder dislocations comprise about 50% of all large joint dislocations and inferior dislocations account for about 0.5% of them. Inferior shoulder dislocations may be associated with proximal humerus fractures as well as vascular, neurologic, tendinous, and ligamentous injuries.

Up to 80% of patients sustain a greater tuberosity fracture or rotator cuff tear and as many as 60% of patients have some degree of neurologic compromise, with an axillary nerve palsy being the most common. Luxatio erecta occurs more frequently in men with reported rates of 10:1, male:female. These injuries are almost always treated successfully by closed reduction with low rates of recurrent instability and an overall good long term prognosis.

Clinical Presentation

Patients will typically present after a high energy mechanism such as a fall from height, pedestrian struck accident, or motor vehicle collision. However, low energy falls causing inferior dislocations have been reported as well. Dislocation usually occurs indirectly as a hyperabduction force levers the proximal humerus against the acromion and ultimately out of the glenoid leaving the head to settle in the infraglenoid region, held in place by the pectoralis major. Less commonly, a direct axial load to an abducted extremity causes the humeral head to be driven through the inferior capsule leading to dislocation.

Patients will present with their arm abducted at the shoulder (about 130 degrees), flexed at the elbow (about 90 degrees), pronated at the forearm, and their hand usually resting behind or on their head. The shoulder is fixed in this position and any attempts at movement will elicit complaints of pain. Patients may complain of paresthesias and less frequently, inability to move the wrist or hand in addition to their shoulder, possibly representing a brachial plexopathy.

Diagnostic Workup

Classic Physical Exam Findings

Patients with luxatio erecta have a classic appearance: an abducted shoulder with a flexed elbow and pronated forearm, leaving the arm held overhead. The deformity of the shoulder is described as a “squared appearance” as the acromion is prominent with a subacromial sulcus laterally. The skin must always be examined as there have been case reports of open injuries. On exam, the humeral head is palpable in the axilla. Depending on neurologic involvement, there may be decreased sensation over the axillary, radial, ulnar, musculocutaneous nerve distributions, or more globally, reflecting a brachial plexus type of injury.

Infrequently, if there is vascular compromise, distal pulses may be diminished or even absent and the skin may be cool or mottled. If after closed reduction, vascular insufficiency is suspected, a Doppler exam should be performed. If still inconclusive, arteriography may be indicated.

Imaging Findings

Imaging begins first with plain films and should include a shoulder trauma series including anteroposterior (AP), scapular-Y lateral, and axillary views of the affected shoulder. On AP, the humeral head will be inferior to the glenoid and the humeral shaft is pointing upward parallel with the scapular spine (Figure 1). On the axillary view, the humeral head and glenoid will be seen overlapping. When fractures are evident on plain films, a CT may be indicated to further assess fracture morphology

Figure 1.

Special diagnostic tests

MRIs performed post-reduction have shown several common findings including: rotator cuff tears, injuries to the glenoid labrum (tears of the anteroinferior, posterior, and/or superior labrum), injuries to both the anterior and posterior bands of the inferior glenohumeral ligament (IGHL), and bone bruises or impaction fractures at the superolateral aspect of the humeral head.

Non–Operative Management

The vast majority of cases of luxatio erecta will be successfully managed with closed reduction and post-reduction immobilization. Prior to reduction, a thorough and documented neurovascular exam is essential. Two methods of reduction have been described: A) traction-countertraction and B) the two-step maneuver. All reductions should be performed after the patient is adequately sedated. In contrast to reductions of anterior dislocations, the reduction maneuver often requires heavy sedation and narcotic analgesia.

The traction/counter-traction method is performed as follows:

• Wrap a sheet around the patient’s upper torso, and have an assistant pull on it, such that the force is directed opposite to the direction of traction.

• Straighten the elbow and with the arm still fully abducted, the reducer then pulls in line with the humeral shaft. An assistant may apply a cephalad and laterally-directed force to the humeral head.

• Once the head jumps over the inferior glenoid and is reduced on the glenoid fossa, there may or may not be an appreciable clunk. Once the humeral head is disengaged, the degree of shoulder abduction is gradually decreased, adducting the arm in the coronal plane towards the body.

The two-step maneuver is predicated on converting an inferior dislocation into an anterior dislocation and then proceeding with a usual reduction of an anterior dislocation. (Figure 2, Figure 3). It is performed as follows:

Figure 3.

• With the patient supine, the surgeon stands on the affected side next to the head of the patient facing towards the patient’s feet.

• Place one hand (closer to patient) (PUSH HAND) on the lateral aspect of the midshaft of the humerus and place the other hand (PULL HAND) on the medial epicondyle of elbow.

• The PUSH hand pushes the humeral head from an inferior location to an anterior location and the PULL hand provides gentle superior directed force at the distal humerus.

• Once this maneuver is completed, there should be a straight contour of the shoulder and prominence of the posterolateral aspect of the acromion.

• The shoulder has now effectively been converted to an anterior dislocation and reduction may proceed using a number of varying maneuvers (e.g. Milch technique, Stimson maneuver, traction-countertraction, scapular manipulation).

• After reduction, the shoulder should be placed in a shoulder immobilizer or sling. A repeat neurovascular exam is imperative and a repeat shoulder trauma series is needed to confirm reduction. Patients should have follow-up arranged with an orthopaedic surgeon in one week.

Indications for Surgery

• Irreducible dislocation

• Open dislocations

• Vascular injury

Though rare, given the high incidence of concurrent injuries, associated injuries may need to be surgically treated. Please refer to the appropriate section of this text regarding those injuries.

Surgical Technique

Cases of an irreducible inferior dislocation in the emergency room setting usually occur secondary to the humeral head buttonholing through the inferior capsule. Reports of other structures such as the biceps tendon and the axillary nerve preventing reduction have also been reported. The patient may be brought to the operating room for general anesthesia and a repeat attempt at closed reduction. If the dislocation is still irreducible, or in cases of open dislocations, an open reduction is indicated. We prefer set-up using a beach chair position, and a reduction utilizing a deltopectoral approach. Alternatively, one can use a strap incision to utilize both the deltopectoral interval, and if necessary, a deltoid-splitting interval.

Set up for beach chair positioning is as follows:

• Place the patient supine on the table with the buttocks and greater trochanter at the main break of the table.

• The table is tilted into Trendelenburg, and the back of the table is elevated to the desired level, we prefer about 45 degrees.

• Place pillows beneath the thighs to facilitate the sitting position, and to avoid the patient sliding down the table.

• Place the head in the head holder and ensure neutral position of the neck in both the coronal and sagittal plane. Ensure that there is no pressure inadvertently placed on the ears, eyes, or lips.

• Place the non-operative upper extremity in an arm holder well padded with foam.

After usual sterile preparation of the operative extremity, a deltopectoral approach is used:

• Make a skin incision between the coracoid process and a point on the humeral shaft 1 in lateral to the axillary fold.

• Carry the incision to the level of the fascia, developing skin flaps. The deltopectoral interval with the cephalic vein can usually be identified by a covering fat stripe.

• Open the interval with Metzenbaum scissors along the medial border of the cephalic vein, taking care not to injure this structure. Use blunt dissection to open the interval, retracting the cephalic vein laterally. The clavipectoral fascia will be visible in the base of this interval.

• Identify the coracoid process, and the conjoined tendon. Incise the fascia along the lateral border of the conjoined tendon and carry superiorly to the level of the coracoacromial ligament. In the setting of an inferior dislocation, significant hematoma and soft tissue injury may be seen.

• A Kolbel self retractor is placed to retract the deltoid laterally and the conjoined tendon medially. The musculocutaneous nerve enters the coracobrachialis muscle as close as 2.5 cm distal to the tip of the coracoid. Excessive retraction of the conjoined tendon should be avoided to avoid potential neuropraxias.

• Expose the proximal humeral and confirm the anatomical landmarks (bicipital groove with the biceps tendon, lesser tuberosity, greater tuberosity, and subscapularis tendon).

• Identify the pectoralis major tendon. The superior border may have to be released to improve the ability to reduce the proximal humerus.

• In difficult cases, the conjoined tendon may also have to be released. Extreme caution should be used to avoid injury to the neurovascular structures. The tendon is released off the tip of the coracoid and tagged with high strength suture, for later repair.

• The extent of the bony and soft tissue injury will dictate further dissection and exposure. Often significant injury to the rotator cuff, greater tuberosity, and capsule are encountered.

• The subscapularis is separated from the joint capsule, and either split or released off the lesser tuberosity leaving a cuff of tissue for later repair.

• The capsule is incised and inferiorly dissected off the humeral neck. With adequate exposure, the open reduction is performed.

• All necessary repairs to injured structures (i.e. rotator cuff, capsulolabral complex, greater tuberosity fractures) are performed as necessary.

• Closure is performed with meticulous repair of the subscapularis using #2 Ethibond, #1 Vicryl for the deltopectoral interval, #2-O Vicryl for subcutaneous tissue, and skin closure with a running 3-O Prolene.

Pearls and Pitfalls of Technique

Closed reduction

• Ensure adequate relaxation/sedation before proceeding with reduction. The two-step maneuver may require less sedation than the traction-countertraction maneuver.

• For the traction-countertraction maneuver, an assistant applying an upward force of the humeral head in the axilla may facilitate reduction.

• A thorough post-reduction neurologic exam and post reduction radiographs are important to ensure reduction and rule out iatrogenic injury.

• Standard closed reduction is contraindicated in cases of humeral shaft or neck fractures or cases of suspected vascular injuries.

Deltopectoral approach

• Careful deltoid mobilization is critical to expose for open reduction.

• In cases of significant injury and altered anatomy, utilize the course of the biceps to orient oneself.

• Clearly identify and protect the axillary nerve during the course of entire procedure. One can perform the “tug test” by sweeping a finger under the border of the subscapularis and simultaneously feeling for the nerve on the undersurface of the deltoid laterally. Gentle palpation of the nerve in both areas can give one a sense of the nerve’s course through the operative field.

Neurologic injury

• Recovery of deep pressure sensation within 2 months is a good prognostic indicator.

• Indication for further exploration includes failure to recover progressively and no recovery 3-5 months after injury.

• Rehabilitation is paramount to maintain mobility until motor function returns.

Potential Complications

• Recurrent instability: Recurrent inferior shoulder dislocation is very unusual. Generally, the only patients who suffer a recurrent dislocation are those that had a previous dislocation prior to their inferior dislocation.

• Soft tissues injuries: IGHL rupture, superior labrum anterior and posterior (SLAP) tear, rotator cuff (RTC) tear.

• Fractures: These occur in about 40% of cases. Most commonly, an avulsion of the greater tuberosity occurring about 30% of the time. Additionally, there may be other fractures of the humeral head, the clavicle, coracoid, acromion and inferior glenoid.

• Neurologic injury: 60% of cases have some neurological involvement most commonly involving the axillary nerve. These deficits usually resolve in a rapid fashion but can take up to 6 months to completely resolve.

• Vascular injury: True vascular injury has only been reported in about 3% of cases.

• Post-traumatic adhesive capsulitis.

Post–operative Rehabilitation

After closed reduction, the patient should remain in a shoulder immobilizer for a period of 2 weeks. Pendulum exercises are started after the first follow up visit within 7 days of injury. After an open reduction, pendulum exercises are begun on the first post-operative day.

After 2 weeks, physical therapy with passive range of motion exercises is started. After 6 weeks the patient will begin a rotator cuff strengthening program.

Outcomes/Evidence in the Literature

Patel, DN, Zuckerman, JD. “Luxatio erecta: case series with review of diagnostic and management principles”. Am J of Orthopedics. vol. 40. 2011. pp. 566-570. (A Series of 11 patients with luxatio erecta, mean age of 44.8 with a ratio of 10:1 male:female. All cases had at least one concomitant injury and were all reduced under location anesthesia or sedation. All patients reported immediate relief after reduction. Before reduction, 9 out of 11 patients were neurovascularly intact and at final follow-up, all patient reported normal motor and sensation. Motion limitations at final follow up (16.3 months) were in abduction (mean 88 degress) and external rotation (mean 60 degrees).

Frank, MA, Laratta, JL, Tan, V. “Irreducible luxatio erecta humeri caused by an aberrant position of the axillary nerve”. JSES. vol. 21. 2012. pp. e6-e9. (Study of a 57-year-old man with luxatio erecta, and ipsilateral both bones fracture, and compartment syndrome of the forearm. The patient failed a trial of closed reduction and emergently went to the operating room for decompression of compartment syndrome and both bones forearm fracture open reduction-internal fixation surgery (ORIF). Intra-operatively, it was found that the axillary nerve was preventing reduction of the shoulder and had to be repositioned before adequate reduction was possible. Ultimately, open reduction and repair of a RTC tear and biceps tenodesis was successful. At 9 months, active and passive range of motion were equal although limited and motor strength in axillary distribution was 4+/5.

Imerci, A, Golcuk, Y. “Inferior glenohumeral dislocation (luxatio erecta humeri): reports of six cases and review of the literature”. Turkish Journal of Trauma and Emergency Surgery. vol. 19. 2013. pp. 41-44. (Case series of six patients with luxatio erecta with a mean age of 45 years with a 4:2 male:female ratio. All cases were treated with closed reduction and followed for a mean of 32 months. The mean constant score was 94 (range 86-100) at an average of 2 years post-dislocation.)

Groh, GI, Wirth, MA. “Results of treatment of luxatio erecta”. J Shoulder and Elbow Surg. vol. 19. 2010. pp. 423-426. (Case series of 18 patients (20 shoulders) with luxatio erecta with an average age of 31 years and a 13:3 male:female ratio. Average follow up was 9 years. Eight out of eighteen patients presented with a nerve injury, six involving the axillary nerve. All neurological impairment resolved within 1 day to 6 months. Seven patients presented with vascular changes and all patients had complete resolution of vascular changes after reduction. Three patients underwent arthrography and two out of three of them had RTC tear. Only nine patients were successfully treated with closed reduction alone. The remaining nine patients required additional procedures for recurrent instability or humeral head fractures. Thirteen out of sixteen patients at final follow up had good to excellent University of California Los Angeles (UCLA) scores and overall mean UCLA score was 31 (range 26-35). All patients demonstrated >140 degrees of active elevation and all were satisfied with treatment.)

Garrigues, GE, Nagda, SH. “Open Luxatio erecta: a case report and literature review”. JOT. vol. 25. 2011. pp. e34-e37. (A 42 year old man presented with an open inferior shoulder dislocation who underwent emergent irrigation and debridement and reduction and was placed on antibiotics. After 72 hours, the patient underwent RTC repair and biceps tenodesis, but not capsular repair to minimize the chance of stiffness. At 15 months, his constant score was 90/100 and he had a UCLA score of 34/35 and at 30 months he was pain free with full strength. The patient was found to have avascular necrosis (AVN) at the superolateral aspect of the humeral head which did not seem to influence outcome.)

Nho, SJ, Dodson, C, Bardzik, KF. “The two-step maneuver for closed reduction of inferior glenohumeral dislocation (luxatio erecta to anterior dislocation to reduction)”. JOT. vol. 20. 2006. pp. 354-357. (The two-step maneuver for luxatio erecta attempts to convert an inferior dislocation to an anterior dislocation. The reduction then proceeds as usual with a number of varying techniques for reduction of anterior shoulder dislocation. This technique requires less force than the alternative traction-countertraction maneuver.)

Krug, DK, Vinson, EN, Helms, CA. “MRI findings associated with luxatio erecta humeri”. Skeletal Radio. vol. 39. 2010. pp. 27-33. (Four patients with clinical and radiographical evidence of luxatio erecta underwent MRI post-reduction. All four patients demonstrated pathology of the glenohumeral joint. Three-quarters of patients had RTC tears. All four patients demonstrated injuries to the glenoid labrum and anterior and posterior bands of the IGHL. Three quarters of patients had cartilage abnormalities at the anterior inferior glenoid.)

Summary

Luxatio erecta is a rare type of glenohumeral dislocation. The vast majority of cases may be treated with closed reduction alone, but infrequently, some may require an open procedure. Neurovascular complications may occur but usually resolve by 6 months. Careful clinical and radiographic evaluation and a high index of suspicion for associated injuries is paramount. Despite associated injuries, the long-term results of treatment of luxatio erecta appear to be good.

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