Fixed Abduction of Left Shoulder After a Fall • Xray of the Week
80 y.o. female with left shoulder pain and deformity after a fall. What is the diagnosis?
Figure 1. Frontal left shoulder radiograph.
Figure 2. Annotated frontal left shoulder radiograph. The humeral head is dislocated inferiorly (red arrow) and the shaft of the humerus is parallel to the scapular spine (yellow arrows).
Figure 3. CT scan of left shoulder. A. Coronal image. There is inferior dislocation of the humeral head (red arrow) relative to the glenoid (yellow arrow). B. Sagittal image. There is inferior dislocation of the humeral head (red arrow) relative to the glenoid. Also note the well corticated old Bankart fracture of the anterior glenoid (yellow arrow) indicating previous anterior glenohumeral dislocation.
Seen in less than 1% of cases, inferior shoulder dislocation is the rarest type of shoulder dislocation. The mechanism of injury is either sudden forceful arm hyperabduction or direct force on fully abducted arm. Luxatio erecta, refers to the abduction deformity that is a result of the of the humeral head situated inferior to the glenoid resulting in the patient presenting with the arm held upright. This injury has the has highest incidence of neurovascular injury of all types of shoulder dislocations with neurologic injury to the brachial plexus in up to 60% of cases and vascular injury to the axillary artery in up to 39% of cases.
Plain radiographs in cases of inferior shoulder dislocation typically demonstrate the humeral head located inferior to the glenoid. The finding of fixed abduction of the shoulder with the shaft of the humerus parallel to the scapular spine (Figs. 1 and 2) is pathognomonic of luxatio erecta. Due to the high incidence of complications, MRI should be performed after the dislocation has been reduced. Common MRI findings include rotator cuff tears, glenoid labrum tears, and injury to both the anterior and posterior bands of the inferior glenohumeral ligament.
Treatment consists of closed reduction and immobilization; however, surgery may be indicated in active patients who have capsulolabral damage or rotator cuff tear.
• Rarely inferior hip dislocation can present with luxatio erecta as seen on this Global Radiology CME Case: Inferior Hip Dislocation with Luxatio Erecta
1. Yao F, Zhang L, Jing J. Luxatio erecta humeri with humeral greater tuberosity fracture and axillary nerve injury. Am J Emerg Med. 2018 Oct;36(10):1926.e3-1926.e5. https://www.ncbi.nlm.nih.gov/pubmed/30238913
2. Ngam PI, Hallinan JT, Sia DSY. Sequelae of bilateral luxatio erecta in the acute post-reduction period demonstrated by MRI: a case report and literature review. Skeletal Radiol. 2019 Mar;48(3):467-473. https://www.ncbi.nlm.nih.gov/pubmed/30151632
3. Carbone S, Papalia M, Arceri V, Placidi S, Carbone A, Mezzoprete R. Humeral head inferior subluxation in proximal humerus fractures. Int Orthop. 2018 Apr;42(4):901-907. https://www.ncbi.nlm.nih.gov/pubmed/29116358
4. Brady WJ, Knuth CJ, Pirrallo RG (1995) Bilateral inferior glenohumeral dislocation: luxatio erecta, an unusual presentation of a rare disorder. J Emerg Med 13:37–42. https://www.jem-journal.com/article/0736-4679(94)00110-3/pdf
5. Baba AN, Bhat JA, Paljor SD, et. al. Luxatio erecta: inferior glenohumeral dislocation—a case report. International Journal of Shoulder Surgery. 2007(1)3:100–102. https://doi.org/10.4103%2F0973-6042.34026
6. Yamamoto T, Yoshiya S, Kurosaka M, et. al. Luxatio erecta (inferior dislocation of the shoulder): a report of 5 cases and a review of the literature. Am J Orthop (Belle Mead NJ). 2003 Dec;32(12):601-603. https://www.ncbi.nlm.nih.gov/pubmed/14713067
7. Davids JR, Talbott RD (1990) Luxatio erecta humeri. A case report. Clin Orthop 252:144-149. https://www.ncbi.nlm.nih.gov/pubmed/2302879
8. Mallon WJ, Bassett FH, Goldner RD. Luxatio erecta: the inferior glenohumeral dislocation. J Orthop Trauma. 1990;4 (1): 19-24. https://doi.org/10.1097%2F00005131-199003000-00003
9. Camarda L, Martorana U, D'Arienzo M. A case of bilateral luxatio erecta. Journal of Orthopaedics and Traumatology, vol. 10, no. 2, pp. 97–99, 2009. https://doi.org/10.1007%2Fs10195-008-0039-x
10. Matsumoto K, Ohara A, Yamanaka K, Takigami I, Naganawa T. Luxatio erecta (inferior dislocation of the shoulder): a report of two cases and a review of the literature. Injury Extra. 2005;36:450–3. https://www.sciencedirect.com/science/article/pii/S1572346105000644?via%3Dihub
11. Mohseni MM. Images in emergency medicine: luxatio erecta (inferior shoulder dislocation). Ann Emerg Med. 2008;52:203–31. https://www.annemergmed.com/article/S0196-0644(07)01798-2/fulltext
12. Ngam PI, Hallinan JT, Sia DSY. Sequelae of bilateral luxatio erecta in the acute post-reduction period demonstrated by MRI: a case report and literature review. Skeletal Radiol. 2019 Mar;48(3):467-473. doi: 10.1007/s00256-018-3047-9
13. Hassanzadeh E, Chang CY, Huang AJ, et. al. CT and MRI manifestations of luxatio erecta humeri and a review of the literature. Clin Imaging. 2015 Sep-Oct;39(5):876-9. doi: 10.1016/j.clinimag.2015.04.009
14. Krug DK, Vinson EN, Helms CA. MRI findings associated with luxatio erecta humeri. Skeletal radiology. 39 (1): 27-33. doi:10.1007/s00256-009-0786-7
Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chief of Staff of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.
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