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X-ray to Physical Exam: Shoulder

Arun Sayal, MD, Mike Weinstock, MD, and Matthew DeLaney, MD
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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.

Pearls:

  • 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. 

 

References: 

  1. Hendey G. Managing Anterior Shoulder Dislocation. Ann Emerg Med. 2016;67(1):76-80. PMID: 26277437
  2. 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
  3. 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

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