Upright dislocation of the humerus or inferior dislocation of the shoulder was first described in 1859 [1]This corresponds to a rare presentation injury in less than 1% of all shoulder dislocations. [2]more common in the elderly population [3]The clinical presentation is unmistakable and the diagnosis is clinical [4]This pathology can very often be associated with bone, soft tissue, and neurovascular injuries. [4]Diagnostic support with imaging is therefore recommended to rule out this type of lesion. [5]Closure reduction is the treatment of choice due to excellent results and favorable prognosis. [4]We present the case of an 83-year-old woman who presented with a right lower shoulder dislocation after a fall. Closure reduction was performed with good progress and subsequent control by the outpatient clinic.
An 83-year-old woman with no noteworthy medical history fell from her height while walking. She then presented to her emergency room because of pain and functional limitation in her right upper extremity, followed by her permanent hyperabduction (approximately 160-degree angle). On her physical examination, the patient was awake, complaining, very painful, but cooperative. Her right upper extremity was hyperabducted with no adduction. No evidence of skin color changes, sensory disturbances, or neurovascular disorders was observed.A radiograph of the right shoulder was performed, revealing an inferior shoulder dislocation without evidence of fracture (Fig. 1).
After lidocaine infiltration without epinephrine, closed reduction was performed with the Milch technique followed by the Hippocrates technique. Simple adduction, hyperextension, and external rotation of the right upper extremity were then achieved. Joint matching and immediate pain relief was obtained.A control radiograph was then taken to confirm successful reduction (Fig. 2).
Finally, brachial, radial, and ulnar pulses were assessed, with no evidence of motor or sensory disturbances. The joint was immobilized in a sling and he was immobilized for four weeks, followed by physical therapy on his right shoulder for six weeks.Controls had evidence of improved range of motion in right shoulder flexion and abduction (Fig. 3, Four).
However, when internal rotation of the right shoulder was performed, a marked limitation of joint range of motion was observed (Fig. Five), therefore magnetic resonance imaging (MRI) of controls was requested. Unfortunately, the patient was not tested for personal reasons. Currently, the patient continues physical therapy. According to evolution, the possibility of surgical management is not ruled out.
The shoulder is the most commonly dislocated joint due to its wide range of motion. [5,6]Shoulder dislocations are more frequent anteriorly 95%, with lower rates posteriorly 4-5% and inferiorly 0.5%. [5]Erector dislocation is a very rare and uncommon injury [2]the predisposing factors for this type of injury are older age and previous instability of the joint in patients with a history of shoulder injury. [4].
The mechanism involved in this type of injury is hyperabduction of the arm due to severe abduction forces. [3]straightens the neck of the humerus against the acromion, causing rupture of the inferior joint capsule (possibly the middle and inferior scapular ligaments) and moving the humeral head down and out of the capsule. [5,7].
Two mechanisms of this lesion have been described. Indirect and direct, both involving excessive abduction of the affected arm, like a fall from height. [4]Indirect mechanism most common (70%) [7,8] There is hyperabduction of the shoulder in contact with the proximal humerus and acromion, which causes rupture of the lower glenohumeral capsule and inferior dislocation of the humeral head. [7,8]The direct mechanism is associated with a high-energy event in which the humeral head is turned downward and the glenohumeral ligament is torn. [6].
Upright dislocation is clinically characterized by presenting a fully abducted arm, an arm supported by an elevated head, a partially flexed elbow, and a pronated forearm. [1,4,5]This position is known as the “Hands Up” position [5,9]in some cases, the hand opposite the lesion is found to hold the affected arm to reduce pain [6]Also, in lean patients you can feel the humeral head slipping down in the axilla [3,4,6,7].
Approximately 80% of these lesions are associated with fractures of the humerus itself or the articular scapular space, soft tissue injuries, and neurovascular disorders. [4,5]Fractures of the proximal humerus and greater tuberosity are the most common, accounting for over 60% of this type of injury. [4]The most common soft tissue injuries are rotator sleeve tears, shoulder capsular abrasions, and destruction of adjacent muscles. [5]More than 75% of these patients have rotator cuff lesions on MRI imaging. [4]Also, the most common long-term complication is adhesive pouchitis. [3]60% of these patients have some form of neurovascular disease. [9,10].
The most commonly affected structures are the axillary or circumflex nerves. [3,4]followed by the brachial plexus, radial nerve, ulnar nerve, and median nerve [3,9] Mostly recovered within 2 weeks to 1 year [3]Of the total, 3.3% of cases had angiopathy, with the axillary and humeral circumflex arteries being most affected. [1,3,5]However, these injuries are mostly mitigated by early reduction of the glenohumeral joint. [5].
A physical examination is essential for diagnosing this condition [8]Radiation therapy is required to confirm the diagnosis and rule out possible complications and associated injuries. [4]Therefore, radiographic assessment prior to reduction is recommended for possible associated fractures. [5] The humeral axis is parallel to the scapular spine and the humeral head is visible at or below the lower edge of the joint space [11,12]In some cases, this injury can be confused with an anterior dislocation of the shoulder. In this case, radiographs show that the humeral shaft is parallel to the chest wall, the deltoid muscle loses its normal contour, and the acromion protrudes. [11,13]Computed tomography (CT scan) is most useful for evaluating microfracture lines. [12]MRI after reduction is recommended to rule out the presence of neurovascular lesions [4]In this case, the absence of normal flow voids in the brachial, axillary, or post-circumflex arteries may represent vascular injury, such as thrombosis or dissection of the same vessel. [4].
Closure reduction by traction contraction techniques with conscious sedation, analgesia, and muscle relaxation is the treatment of choice in most cases and is very often successful. [5,9]This is followed by 3-6 weeks of shoulder immobilization and physical therapy and rehabilitation, depending on medical indications. [6]After reduction, radiographic assessment of correct humeral position and possible associated fractures should be discarded. [9]Immediate reduction reduces neurovascular damage [1]For open dislocations, fractures of the humeral head, or related lesions requiring surgical treatment, open or surgical reduction is indicated. [4,5]The long-term prognosis for this injury after treatment is excellent [4]However, connective tissue structure is subject to vascular and structural changes.Healing capacity and biomechanical function may change as patients age [14].
Humeral erectile dysfunction is a rare injury with characteristic clinical symptoms that must be recognized by medical personnel in order to be treated promptly. Since this type of injury is very often associated with fractures, soft tissue, and neurovascular injuries, it is important to perform imaging studies such as X-rays, CT scans, and MRIs. Reduction should be done early to prevent complications. Prognosis is favorable in most cases, but age may play an important role in the healing process.
