SplintER Series: My Arm Is Stuck Like This

A 70-year-old female presents with right shoulder pain and the inability to adduct her arm after she fell on the sidewalk. You obtain shoulder x-rays and see the following images (Image 1: AP, scapular Y, and axillary views of the right shoulder. Author’s own images).

What is your diagnosis?

Inferior shoulder dislocation aka luxatio erecta.

Pearl: Shoulder dislocation is one of the most common dislocations seen in the Emergency Department, and represents 50% of all major joint dislocations [1,2]. Inferior dislocations are rare and represent only 0.5% of all shoulder dislocations [3].

What are the mechanisms of injury?

Axial loading through a fully abducted arm drives the humeral head through the weaker inferior glenohumeral ligaments [4].
Or
Hyperabduction force to the arm which levers the proximal humerus on the acromion and results in injury to the inferior and middle glenohumeral ligaments [4].

What physical exam findings are expected?

The diagnosis can be made through a physical exam alone: the arm is typically in a fixed, abducted position above the patient’s head with the humeral head palpable in the axilla [4].

Pearl: Maintain a high index of suspicion for neurovascular injury because the brachial plexus and axillary artery run inferiorly to the glenohumeral joint [5].

Figure 2. Patient with an inferior shoulder dislocation and arm in a fixed abduction positive. Courtesy of Mark Hopkins, MD.

Which imaging modalities can be used?

Plain radiographs are used to confirm the diagnosis and look for associated fractures. The humeral head is displaced inferiorly from the glenoid fossa and the humeral head is typically parallel to the spine of the scapula [4].

What reduction maneuvers can be used in the ED?

Traction-countertraction: axial traction is applied in the direction of the abducted humerus and countertraction is provided by a rolled sheet across the top of the shoulder [4,6]. This typically requires procedural sedation [6].
2-step maneuver [7]: The patient lies supine and the provider stands on the affected side next to the head of the patient. Place one hand on the lateral aspect of the midshaft of the humerus and push inferiorly [6,7]. Meanwhile, place the other hand over the medial epicondyle and provide force superiorly [6,7]. This converts the inferior dislocation to an anterior dislocation, and a variety of reduction maneuvers can then be performed [4,6,7].

What is the definitive management of this injury? Do I need to consult Orthopedics?

In most cases, non-operative treatment with sling immobilization for 2-3 weeks followed by physical therapy is appropriate [4]. Orthopedics should be consulted in the Emergency Department if there is neurovascular injury, open dislocation, fracture-dislocation, or irreducible dislocations when the humeral head “buttonholes” through the inferior capsule. Operative management may also be needed for capsular reconstruction and rotator cuff injury [3,4,7].

Resources & References:

Looking to bone up in general? Check out the SplintER archives.

Alkaduhimi H, van der Linde JA, Flipsen M, van Deurzen DF, van den Bekerom MP. A systematic and technical guide on how to reduce a shoulder dislocation. Turk J Emerg Med. 2016 Nov 18;16(4):155-168. PMID: 27995208.
Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2017 emergency department summary tables. National Center for Health Statistics.
Groh GI, Wirth MA, Rockwood CA Jr. Results of treatment of luxatio erecta (inferior shoulder dislocation). J Shoulder Elbow Surg. 2010 Apr;19(3):423-6. PMID: 19836975.
Nambiar M, Owen D, Moore P, Carr A, Thomas M. Traumatic inferior shoulder dislocation: a review of management and outcome. Eur J Trauma Emerg Surg. 2018 Feb;44(1):45-51. Erratum in: Eur J Trauma Emerg Surg. 2017 Nov 20. PMID: 28975397.
Orebaugh SL, Williams BA. Brachial plexus anatomy: normal and variant. ScientificWorldJournal. 2009 Apr 28;9:300-12. PMID: 19412559.
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. PMID: 30238913.
Nho SJ, Dodson CC, Bardzik KF, Brophy RH, Domb BG, MacGillivray JD. The two-step maneuver for closed reduction of inferior glenohumeral dislocation (luxatio erecta to anterior dislocation to reduction). J Orthop Trauma. 2006 May;20(5):354-7. PMID: 16766940.

Author information

William C. Chan, MD

Resident Physician
Department of Emergency Medicine
New York Presbyterian Queens

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