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X-ray to Physical Exam: Shoulder
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Doctor’s Arun, Matt, and Mike sit down to discuss how to approach shoulder x-rays and what to look out for with specific injuries. They review common injuries including shoulder dislocations, rotator cuff tears, and fractures.
- Many serious conditions can cause visceral or neuropathic referred pain to the shoulder.
- A screening of shoulder XR is reasonable even for patients with shoulder pain because it can identify unexpected bony lesions.
- Internal & external AP views and Scapular Y views are the 3 required views to assess post-traumatic shoulder pain.
- Suspect posterior shoulder dislocation if the humerus cannot externally rotate after trauma.
- It is safe to attempt closed reduction with isolated Hill-Sachs, Bankart, or greater tuberosity fractures. Shoulder reduction should not be attempted with more significant humeral fractures.
Shoulder pain can be intrinsic or referred from visceral etiologies (e.g. ACS, ruptured ectopic pregnancy, biliary colic) or neck pathology (e.g. cervical radiculopathy).
- Consider referred pain when palpation and range of motion of the shoulder do not reproduce the pain.
- For the assessment of intrinsic/musculoskeletal shoulder pain, several brief historical elements are critical:
Is the pain acute or chronic?
Was there direct trauma? Overuse? Atraumatic?
Which is their dominant hand?
Do they have a history of prior issues with the shoulder?
- It is important to expose and inspect the entire shoulder.
- Consider the possibility of a septic shoulder with severe, atraumatic shoulder pain – especially if the patient is immunocompromised – which may also minimize the common signs associated with septic joints (e.g. redness, warmth, swelling).
- Obtaining a plain film/x-ray is reasonable in most patients, even without a history of trauma, to screen for unexpected osseous pathology.
Metastases can occur to the shoulder in patients with cancer, especially in cancers that have a tendency to metastasize to the bone (e.g. lung, breast).
- It is important to know the musculoskeletal shoulder issues that will have normal XRs:
- Posterior shoulder dislocation
Posterior dislocation most commonly occurs after a fall with the arm abducted.
- Posterior dislocation can occur with the “3 E’s” - Epilepsy, Ethanol, Electricity – all related to the pattern of muscle activation during a generalized seizure.
- Posterior dislocations will be locked in internal humeral rotation and are generally more subtle on the physical exam than an anterior dislocation.
- You may see a “light bulb” sign on XR where the humeral head looks oddly symmetric, like a light bulb.
- Rotator cuff tendinopathies and tears
Rotator cuff tears often require surgery, especially in younger patients (ie: <60 years).
The classic mechanism for a rotator cuff tear is falling on an outstretched arm.
- Calcific tendonitis can present with acute, atraumatic shoulder pain and is common in middle-aged women.
It can be identified by calcium deposits superolateral to the humeral head on the supraspinatus tendon.
Calcific tendonitis typically responds well to subacromial steroid injections.
- The 3 recommended XR views for evaluating trauma are AP in internal rotation, AP in external rotation, and a scapular Y-view.
- An axillary view is the best view to evaluate for dislocation and can be added if dislocation cannot be ruled out with the above views.
- Anterior shoulder dislocation is usually clinically obvious on inspection, but comparing the appearance of the shoulder with the contralateral side can be useful if uncertain.
- Getting an XR before attempts at a reduction is useful to identify any associated bony injury and proves that any bony injuries were not caused by reduction attempts.
Greater tuberosity avulsion fractures are common in patients >50 years, who present with shoulder dislocation.
If there is a greater tuberosity avulsion fracture, it is still appropriate to attempt reduction.
If there is a humeral neck fracture or other fracture associated with the dislocation, a closed reduction attempt may worsen the injury.
- Hill-Sachs humeral fractures are indentation fractures from the humeral head hitting the glenoid rim and should not affect the decision to attempt reduction.
- Bony Bankart lesions are fractures of the glenoid which occur when traction from the labrum results in an avulsion fracture of the scapula.
- Bankart lesions often require surgery in younger patients to prevent excessive shoulder instability.
- Hendey G. Managing Anterior Shoulder Dislocation. Ann Emerg Med. 2016;67(1):76-80. PMID: 26277437
- Orloski J, et. al. Do all patients with shoulder dislocations need pre reduction x-rays?. Am J Emerg Med. 2011;29(6):609-612. PMID: 20825841
- Beaudreuil J, et al. Contribution of clinical tests to the diagnosis of rotator cuff disease: a systematic literature review. Joint Bone Spine. 2009;76(1):15-19. PMID: 19059801