What is the appropriate evaluation and management for a patient who has had shoulder pain for two days following a fall?

Obtain shoulder radiographs immediately

For a patient with shoulder pain two days after a fall, you must order standard shoulder radiographs as the initial diagnostic test. This is the definitive first step to rule out fracture and dislocation, which are the primary concerns affecting morbidity and management 1.

Initial Imaging Approach

The radiographic series must include at minimum three views 1:

• Anterior-posterior (AP) views in both internal and external rotation
• Axillary view OR scapular Y-view (critical—dislocations are frequently missed without these lateral views)
• Consider adding a Stryker notch view if you suspect Hill-Sachs lesions from dislocation

Why This Matters

Radiographs identify the two most critical acute issues: fractures and joint malalignment. Missing a dislocation on AP views alone is a common pitfall—the axillary or Y-view is non-negotiable for proper evaluation 1. These images also guide whether surgical versus conservative management is needed for proximal humerus fractures 1.

If Radiographs Are Normal or Indeterminate

Your next step depends on clinical suspicion:

For suspected fracture with negative X-rays:

• Order CT without contrast 1
• CT changes management in up to 41% of proximal humerus fractures by detecting subtle nondisplaced fractures missed on radiographs 1
• CT is essential for scapular fractures, which are frequently occult on plain films 1

For suspected soft tissue injury (rotator cuff, labrum, ligaments):

• Order MRI without contrast 1
• MRI identifies rotator cuff tears, labral injuries, bone contusions, and capsular tears
• Do NOT order MR arthrography in acute trauma—the joint effusion from acute injury provides natural contrast 1

Ultrasound has limited utility:

• Only useful if you have high suspicion for isolated rotator cuff or biceps tendon pathology 1
• Poor for bone evaluation due to acoustic shadowing 1

Management Considerations

While awaiting imaging or if imaging is negative:

• Pain control with acetaminophen or NSAIDs (recommended across all shoulder pain guidelines) 2
• Short-term sling use for comfort only—not prolonged immobilization 3
• Early range-of-motion exercises once fracture is excluded 3

Red Flags Requiring Urgent Action

Look for signs demanding immediate reduction or surgical consultation 3, 4:

• Visible deformity or palpable humeral head in axilla (dislocation)
• Patient holding arm rigidly in contralateral hand with severe pain on any movement
• Dimple inferior to acromion laterally (posterior dislocation sign)
• Neurovascular compromise

Timing Considerations

Traumatic massive rotator cuff tears may require expedited surgical repair to optimize functional outcomes 1. If MRI reveals this, don't delay orthopedic referral for "conservative trial."

Common Pitfalls to Avoid

1. Ordering only AP views—you will miss dislocations 1
2. Ordering MRI before radiographs—this wastes resources and delays fracture diagnosis
3. Using ultrasound as primary imaging—it misses most acute traumatic pathology 1
4. Ordering CT or MRI with contrast—no evidence supports this in acute shoulder trauma 1
5. Prolonged immobilization—leads to adhesive capsulitis; start early motion once stable 3