Tag: Shoulder Dislocation

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Case 63:  Point-of-Care Ultrasound in Inferior Glenohumeral Dislocation (Luxatio Erecta) 

Makhlouf Bannoud, Colleen Campbell

 A 22-year-old male with no significant past medical history presented to the emergency department with right shoulder pain and visible deformity after a surfing injury. He reported that a wave forcefully pulled his surfboard while he was holding on, followed by an audible “pop.” He denied head trauma, distal numbness, weakness, or additional injuries. 

Vitals: BP 151/81 | HR 104 | RR 27 | Temp 97.8°F (36.6°C) | SpO₂ 93% 

On exam, the patient was in acute discomfort but alert and oriented. The right upper extremity was held in abduction with visible deformity and inferior displacement of the humeral head. Distal neurovascular exam demonstrated 2+ radial pulse, intact sensation in the axillary, median, radial, and ulnar distributions, and full motor strength in the hand. 

Point-of-care ultrasound (POCUS) of the right shoulder was performed prior to radiography to evaluate the glenohumeral joint. Ultrasound demonstrated inferior displacement of the humeral head relative to the glenoid fossa, consistent with inferior glenohumeral dislocation (Figure 1). No obvious joint effusion or cortical step-offsuggestive of displaced fracture was visualized. 

Figure 1: Inferior shoulder dislocation with humerus outside the glenoid fossa.

 Ultrasound guidance was then used to perform an intra-articular anesthetic injection for analgesia prior to reduction (Figure 2).

Figure 2: Ultrasound-guided joint injection.

Moderate procedural sedation with propofol was subsequently administered. Closed reduction was performed successfully. 

Post-reduction POCUS demonstrated restoration of normal alignment between the humeral head and glenoid (Figure 3). 

Figure 2: Post-reduction ultrasound.

Follow-up radiographs confirmed interval reduction and revealed a Hill-Sachs deformity without definitive osseous Bankart lesion. Repeat neurovascular examination remained intact. The patient was placed in a sling and discharged with close orthopedic follow-up. 

Discussion 

Inferior glenohumeral dislocation, or luxatio erecta, accounts for less than 1% of shoulder dislocations [1]. The classic mechanism involves hyperabduction, driving the humeral head inferior to the glenoid fossa. Patients typically present with the arm fixed in abduction and inability to adduct the limb. 

Although radiographs remain standard for definitive diagnosis, point-of-care ultrasound has emerged as a reliable adjunct for rapid diagnosis of shoulder dislocation. Multiple studies have demonstrated high sensitivity and specificity approaching 100% for identifying glenohumeral dislocation [2]. Ultrasound allows dynamic assessment without radiation and can expedite care in high-volume emergency settings. 

The posterior transverse view is most commonly used, with the probe placed over the scapular spine to visualize the glenoid and humeral head relationship. In normal alignment, the humeral head appears centered over the glenoid. In inferior dislocation, the humeral head is displaced caudally relative to the glenoid, as demonstrated in this case. 

POCUS also facilitates ultrasound-guided intra-articular anesthetic injection. Compared to landmark-based techniques, ultrasound guidance improves accuracy of joint entry and reduces complications [3]. Intra-articular lidocaine has been shown to be comparable to intravenous sedation in facilitating reduction, with shorter ED length of stay and fewer adverse events [4].

In this case, ultrasound-guided anesthetic injection was used as adjunctive analgesia prior to procedural sedation. Vascular injury, although rare, may involve the axillary artery. For this reason, careful pre- and post-reduction neurovascular examination is essential. 

Associated injuries are common and include Hill-Sachs deformity, greater tuberosity fracture, rotator cuffinjury, and labral tears. [5] Post-reduction imaging in this case demonstrated a Hill-Sachs lesion, which may predispose young active patients to recurrent instability depending on lesion size and engagement. 

This case highlights the expanding role of point-of-care ultrasound in musculoskeletal emergencies. POCUS enabled rapid confirmation of inferior glenohumeral dislocation, guided intra-articular anesthetic injection, and verified successful reduction prior to radiographic confirmation. When integrated thoughtfully into clinical workflow, ultrasound enhances procedural safety, diagnostic efficiency, and patient comfort in the management of shoulder dislocation. 

References: 

[1] StatPearls. (2023). Inferior shoulder dislocations. In StatPearls [Internet]. StatPearls Publishing. Retrieved October 2025, from https://www.ncbi.nlm.nih.gov/books/NBK448196/ 

[2] Gottlieb, M., Holladay, D., & Peksa, G. D. (2019). Point-of-care ultrasound for the diagnosis of shoulder dislocation: a systematic review and meta-analysis. The American Journal of Emergency Medicine, 37(4), 757-761. 

[3] Aly, A. R., Rajasekaran, S., & Ashworth, N. (2015). Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. British journal of sports medicine, 49(16), 1042-1049. 

[4] Sithamparapillai, A., Grewal, K., Thompson, C., Walsh, C., & McLeod, S. (2022). Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis. Canadian Journal of Emergency Medicine, 24(8), 809-819. 

[5] Ostermann, R. C., Joestl, J., Hofbauer, M., Fialka, C., Schanda, J. E., Gruber, M., ... & Tiefenboeck, T. M. (2022). Associated pathologies following luxatio erecta humeri: a retrospective analysis of 38 cases. Journal of Clinical Medicine, 11(2), 453. 

[6] Flinders, A., & Seif, D. (2016). Point-of-Care Ultrasound in Diagnosis and Treatment of Luxatio Erecta (Inferior Shoulder Dislocation). Journal of Medical Ultrasound, 24(2), 70-73 

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Case # 14: Whirlpool swirling, twisting and turning

A 13-year-old male presents to the emergency department with right testicular pain for one-hour duration. The pain began while having a bowel movement. He had no nausea or vomiting. His exam is notable for a high riding right testicle and tenderness to palpation over the right testicle.

Vitals: T: 97.8, HR: 106, BP: 135/79, RR: 16, Sat: 96% on RA

A bedside ultrasound of the testicles is performed. What do you see?

Answer and Learning Points

Answer

These ultrasound images demonstrates limited flow into the right testicle suggestive of testicular torsion. Manual detorsion was performed at the bedside using the “open-the-book” maneuver with subsequent ultrasound demonstrating return of flow to the right testicle. Urology was consulted, and the patient was scheduled for an outpatient orchiopexy.

Learning Points

The acute scrotum is a presentation that requires timely evaluation and management by the emergency physician. Of all causes of acute scrotum, testicular torsion is the diagnosis that requires the most emergent action because of the limited time window of testicular salvageability.1 Unfortunately, in many clinical settings including urgent cares, clinics, and rural community emergency rooms, it can be challenging to confirm our clinical suspicion in a timely fashion because of the difficulty in obtaining an official scrotal ultrasound. For this reason, POCUS is an important tool for emergency physicians in the diagnosis of patients with acute scrotum.

Ultrasound findings of testicular torsion:

Loss or reduction of color Doppler flow/Spectral Doppler tracings to affected testicle (Must compare to other testicle)

Affected testicle becomes more heterogeneous than other testicle

Adhikari, S. R. (2008). Small parts - Testicular ultrasound. Retrieved from https://www.acep.org/sonoguide/smparts_testicular.html

Thickened, hypoechoic mediastinum5 

Prando D. Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs. Abdom Imaging. 2009 Sep-Oct;34(5):648-61. doi: 10.1007/s00261-008-9449-8. Review. PubMed PMID: 18709404. 

Whirlpool sign6

Author

Marissa Wolfe, MS4; Amir Aminlari, MD, Emergency Ultrasound Fellowship Director at UCSD

References

  1. Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2017 Sep 25. doi: 10.1097/PEC.0000000000001287. [Epub ahead of print] PubMed PMID: 28953100.
  2. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013 Dec 15;88(12):835-40. Review. PubMed PMID: 24364548.
  3. Wang S, Scoutt L. Testicular torsion and manual detorsion. Ultrasound Q. 2013 Sep;29(3):261-2. doi: 10.1097/RUQ.0b013e3182a2d129. PubMed PMID: 23945494.
  4. Adhikari, S. R. (2008). Small parts - Testicular ultrasound. Retrieved from https://www.acep.org/sonoguide/smparts_testicular.html
  5. Prando D. Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs. Abdom Imaging. 2009 Sep-Oct;34(5):648-61. doi: 10.1007/s00261-008-9449-8. Review. PubMed PMID: 18709404.
  6. Kalfa N, Veyrac C, Lopez M, Lopez C, Maurel A, Kaselas C, Sibai S, Arena F, Vaos G, Bréaud J, Merrot T, Kalfa D, Khochman I, Mironescu A, Minaev S, Avérous M, Galifer RB. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007 Jan;177(1):297-301; discussion 301. PubMed PMID: 17162068.
  7. Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion. J Ultrasound Med. 2006 May;25(5):563-74. PubMed PMID: 16632779.

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Case # 10: A Mechanical Issue

A 32 year old male was carrying a heavy pipe overhead with his right arm and slipped falling forward, onto the right side. He notes pain in the right shoulder, worse with any movement. His right arm is flexed and internally rotated for comfort.

Vitals: T 98.6 HR 95 BP 143/91  RR 14 O2 98% on RA

A bedside ultrasound of the right shoulder is performed, what is the next best step in management?

Screen Shot 2017-11-18 at 11.09.45 AM

Answer and Learning Points

Answer

Shoulder dislocation reduction. The ultrasound image shows anterior displacement of the humeral head with respect to the glenoid fossa consistent with an anterior shoulder dislocation. A hematoma is also noted within the joint space which is very commonly associated with a traumatic shoulder dislocation. 

Ultrasound diagnosis of anterior shoulder dislocation

Learning Points

    • Ultrasound is useful for both the initial diagnosis and reduction confirmation of a shoulder dislocation, as well as for intra-articular injection of local anesthetic; however in a traumatic dislocation, an initial x-ray should be obtained to evaluate for any associated fracture.
    • To perform the exam, a low frequency curvilinear transducer should be used. The operator should stand behind the patient, on the side of the affected shoulder, and place the ultrasound system directly in front of the patient for easy visualization. The probe should be placed on the posterior aspect of the scapula, parallel and just inferior to the scapular spine. This will allow direct visualization of the glenohumeral joint.

  • Proper probe placement for evaluation of glenohumeral joint.

    • In a normal shoulder the glenoid and humeral head articulate nicely and this can be appreciated on ultrasound with internal and external rotation of the patient's arm, however with dislocation, the humeral head and glenoid will not be aligned. In anterior dislocation, the humeral head will be deep to the glenoid, while in a posterior dislocation, the humeral head will be more superficial to the glenoid.

  • Normal glenohumeral ultrasound anatomy

    • Ultrasound is especially useful to confirm successful shoulder relocation and prevent both a prolonged stay in the emergency department waiting for a post reduction x-ray, as well as re-sedation if this was required for a difficult shoulder reduction.
    • Lastly, this same ultrasound view can be used for in-plane needle guidance to provide intra-articular anesthesia using a lateral needle entry approach.
    • For a 5 minute video tutorial on  ultrasound for shoulder dislocation , click here to watch this excellent video at 5 Minute Sono.

In vivo shoulder reduction!

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

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