summary Luxatio Erecta is the specific term for inferior dislocation of the glenohumeral joint trapped underneath the coracoid and glenoid, very commonly associated with neurovascular injury. Diagnosis is made clinically with the presence of the shoulder in a fixed, abducted position and confirmed with radiographs of the shoulder. Treatment is closed reduction and assessment of possible concomitant neurovascular injury. Epidemiology Incidence very rare, only 0.5% of all shoulder dislocations Etiology Pathophysiology pathoanatomy typically a high-energy injury hyperabduction force applied to arm, levering the proximal humerus onto the acromion, injuring inferior capsule/labrum, which subsequently allows for disengagement of HH inferiorly from glenoid commonly involves variable sized tearing of static glenohumeral ligaments Associated conditions (common) neurovascular injury has greatest incidence of neurovascular injury of all types of shoulder dislocations brachial plexopathy axillary artery injuries proximal humerus fractures especially greater tuberosity rotator cuff tears anterior capsule and labral tears Anatomy Static glenohumeral ligaments SGHL restraint to inferior translation at 0° degrees of abduction (neutral rotation) MGHL resist anterior and posterior translation in the midrange of abduction (~45°) in ER IGHL posterior band IGHL most important restraint to posterior subluxation at 90° flexion and IR anterior band IGHL primary restraint to anterior/inferior translation 90° abduction and maximum ER (late cocking phase of throwing) superior band IGHL most important static stabilizer about the joint See complete Glenohumeral anatomy Presentation Symptoms shoulder pain inability to move shoulder - arm is in fixed, abducted, overhead position neurovascular injury neurologic injury up to 60% vascular injury up to 39% Physical exam motion patient presents with the arm in a fixed, abducted position neurovascular exam assessment is important PRE and POST reduction assess for radial and brachial pulse assess neurologic exam including axillary nerve and distal neurologic exam high rate of axillary nerve neuropraxia and branchial plexopathy Imaging Radiographs recommended views complete shoulder series findings inferior glenohumeral dislocation with arm fully abducted MRI indications should be obtained after shoulder is relocated given common occurence of traumatic soft tissue injuries to the shoulder findings may show capsulolabral pathology rotator cuff tears are extremely common Treatment Nonoperative closed reduction and immobilization indications inactive elderly patients may be considered in the absence of acute traumatic rotator cuff tear technique traction-countertraction similar technique as for anterior shoulder dislocations two-step technique converts inferior dislocation to anterior dislocation clinician stands at patient's head, pushes laterally on humerus (one hand) while pulling superiorly on medial epicondyle (other hand), which should rotate HH from inferior to anterior around the glenoid rim when successful, shoulder position will have changed from abduction to adduction against chest wall then use any anterior-dislocation technique to reduce shoulder post-reduction brief period of immobilizer followed by ROM exercises assuming intact rotator cuff physical therapy should focus on periscapular and rotator cuff strengthening Operative arthroscopic or open repair indications active younger patients advantage of arthoroscopic approach allows assessment and addressing multiple concomitant pathologies including capsulolabral damage traumatic rotator cuff tear prompt surgical repair for acute RTC tear typically recommended prolonged non-operative treatment may result in significant retraction and rapid progression to nonrepairable condition technique repair vs reconstruction of shoulder pathology Complications Axillary nerve palsy most common nerve palsy may resolve with reduction of shoulder if persists - EMG may be warranted at 6-12 weeks postinjury for prognosis Brachial plexopathy high energy of injury and displacement of humeral head may result in significant brachial plexopathy will usually resolve following reduction of shoulder and observation Axillary artery thrombosis may occur late Rotator cuff tear common, especially in older patients, but also in young patients as well prompt MRI warranted in young patients following reduction to avoid missed diagnosis/ treatment