Luxatio Erecta: Ultrasonography and Reduction

• Use a linear or curvilenear probe
• Place the probe behind the shoulder, over the scapular spine
• Place probe in transverse position, “rock” laterally as needed until glenoid visualized

Place probe in transverse position on posterior shoulder

Now for a quick review of normal shoulder anatomy on POCUS:

Pay particular attention the position of the glenoid and the humeral head. Photo from: ttp://www.foamem.com/2014/06/05/shoulder-ultrasound-intra-articular-injection-and-reduction-2/

To understand what you might see (or not see) on an inferior shoulder sono, you first have to understand anterior and posterior shoulder dislocation images:

The position of the humeral head relative to the glenoid is what guides you. Photo from www.foamem.com/2014/06/05/shoulder-ultrasound-intra-articular-injection-and-reduction-2/

Remember that your probe is placed on the posterior shoulder. Therefore, the top of the screen represents where the waves first start, and the ultrasound waves first hit the posterior shoulder. The bottom of the screen represents where the ultrasound waves end up – anteriorly with this probe positioning. In other words, the waves travel from posterior (top of screen) to anterior (bottom of screen).

…exactly. In an inferior dislocation you will see an empty glenoid fossa – the humeral head will not be visualized. Image from Flinders, A. Journal of Medical Ultrasound. 2016

Can you picture this in 3D? Why is the humeral head not visualized? Top is posterior, bottom is anterior, so inferior would be “inside the screen” – DEEP to the glenoid. Therefore, you will see an empty glenoid fossa (1). An EM ultrasound faculty member suggested you might see the humeral head if, instead of placing the probe posteriorly, you place the probe on the lateral shoulder and fan down, unfortunately I didn’t think of this, and it appears no one in the internet world did either!

AP. Case courtesy of Mr Andrew Murphy, Radiopaedia.orgFrom the case rID: 39905

Oblique. Case courtesy of Mr Andrew Murphy, Radiopaedia.orgFrom the case rID: 39905

Garth’s. Case courtesy of Mr Andrew Murphy, Radiopaedia.orgFrom the case rID: 39905

He has luxatio erecta humeri, the rarest of the shoulder dislocations (1). It is an inferior glenohumeral dislocation, caused by either direct axial loading on a fully abducted extremity or leverage of the humeral head across the acromion by a hyperabduction force. As you now know, the presentation is quite unique as the affected extremity held above the head in abduction.

You’ve done your fair share of anterior shoulder reductions. You even read one of your fellow resident’s posts about them.

http://blog.clinicalmonster.com/2017/06/bored-popped-locked-hurt-shoulder-dislocation/

Ok, Cunningham, Milch, external rotation, scapular manipulation, good…but they’re not for inferior shoulder dislocation! Oh no! What to do next?

While you order procedural sedation medications for your patient, you do a quick literature of the different reduction techniques for luxatio erecta. You find a few…

• Patient is supine
• Stand on the side of the affected arm by the patient’s head
• Apply axial traction inline with the abducted arm
• At same time, an assistant applies countertraction using a sheet wrapped around the affected shoulder
• During the axial traction, try to increase the degree of abduction and apply cephalad pressure to the displaced humeral head
• Arm should then be held in adduction, supinated, and immobilized for post-reduction radiography

Apply axial traction inline with the abducted arm. At same time, an assistant applies countertraction with a sheet over the affected shoulder

Called the two step maneuver because… wait for it… it has 2 steps: First turn the inferior shoulder dislocation into an anterior dislocation, and then reduce the anterior shoulder dislocation.

Step 1:

• Stand on the affected side of supine patient, next to the head of the patient, facing caudad
• The PUSH hand (adjacent to the patient) should be placed on the lateral aspect of the mid shaft of the humerus
• The PULL hand (opposite) positioned over the medial epicondyle
• With the PUSH hand, the clinician pushes anteriorly with the hand on the mid-humerus
• At the same time with the PULL hand, pull posteriorly with the hand on the medial epicondyle
• This converts the dislocation from inferior to anterior

With the PUSH hand, the clinician pushes anteriorly with the hand on the mid-humerus At the same time with the PULL hand, pull posteriorly with the hand on the medial epicondyle

Step 2:

You can try any of the anterior shoulder dislocation maneuvers at this point – see the above linked post! We will describe the external rotation reduction technique:

• Completely adduct the patient’s arm against their torso
• Now face cephalad
• PUSH on the humerus to keep patient’s arm adducted
• The PULL hand now moves to the patient’s wrist or distal forearm and instead of pulling, use it to externally rotate the shoulder clockwise
• 

Externally rotate the shoulder while the arm is in adduction

This technique also involves moving the humeral head anteriorly, but this is broken down into one step instead of two:

• Stand on side of affected arm facing cephalad
• Your patient is supine but at 30-45 degree angle
• With the one arm at proximal forearm or distal arm, apply traction inline with the abducted arm
• At the sane time with the other hand, push anteriorly against the proximal arm to translate the humeral head anteriorly
• Then push proximal humerus up and over as you bring the arm down in adduction