The most expeditious way to diagnose this complication is to obtain a Doppler ultrasound of the injured extremity. If surgery is indicated, saphenous vein graft has been reported as a successful treatment.3
Fractures are another complication to watch for. The most common fractures are of the greater tuberosity, although fractures to the glenoid, humeral head, acromion, and scapular body have also been reported.8 Fracture management depends on the characteristics of the fracture, including displacement, size of the fragment, and joint stability.
Treatment involves traction and countertraction
Luxatio erecta is normally treated by closed reduction using the traction-countertraction technique. In this maneuver, the shoulder is reduced with direct traction, while countertraction is applied with a sheet wrapped over the clavicle on the affected side and pulled down and across the chest toward the unaffected side. The affected arm is pulled in a cephalad direction and further abducted until the humeral head is reduced within the glenoid fossa. After reduction, the arm is gradually moved downwards toward the patient’s side and splinted in the adducted position.8
Special care should be taken with patients who are at risk of cervical spine injuries. Postreduction radiographs should be obtained to verify proper humeral placement and to assess for any associated fractures. While closed reduction is the definitive treatment, patients run the risk of recurrent instability that may necessitate capsular reconstruction.1
Our patient recovered well
Our patient was sedated with fentanyl and midazolam, and his shoulder was reduced with the traction-countertraction technique described earlier. Postreduction radiographs revealed satisfactory alignment of the right glenohumeral joint and that the greater tuberosity was reduced to within a centimeter of its normal position. No additional fractures were identified.
After the reduction, a head CT scan was done; it revealed a small intracerebral hemorrhage. The patient was admitted overnight and discharged the following day with a sling and swathe and instructions to follow up with orthopedics.
CORRESPONDENCE
Casey Z. MacVane, MD, MPH, Department of Emergency Medicine, Maine Medical Center, 47 Bramhall Street, Portland, ME 04102; macvac1@mmc.org