Can the X‑ray of an 83‑year‑old patient with a recent left shoulder injury, bruising, stiffness, and limited arm elevation but minimal pain be interpreted to assess for clavicle fracture, proximal humerus fracture, glenohumeral dislocation, or scapular fracture?

X-Ray Interpretation for Acute Shoulder Injury in an 83-Year-Old

Yes, X-ray can and should be interpreted to assess for clavicle fracture, proximal humerus fracture, glenohumeral dislocation, or scapular fracture in this patient—radiography is the appropriate initial imaging modality for acute shoulder trauma. 1

Initial Imaging Approach

Standard shoulder radiographs for trauma must include at minimum three views: anterior-posterior (AP) views in internal and external rotation, plus an axillary or scapula-Y view 1. The axillary or scapula-Y views are vital because acromioclavicular and glenohumeral joint dislocations can be misclassified on AP views alone 1.

What the X-Ray Can Detect

Radiographs effectively delineate:

• Shoulder malalignment (including glenohumeral dislocation)
• Most shoulder fractures including clavicle, proximal humerus, and displaced scapular fractures
• Fracture classification to guide surgical versus nonsurgical management 1

Critical Clinical Context for This Patient

This 83-year-old presents with several concerning features:

• Significant bruising extending to anterior chest—suggests substantial force and possible occult injury
• Inability to lift the arm despite minimal pain—this dissociation between function and pain is atypical and warrants careful evaluation
• Delayed presentation with worsening stiffness—may indicate evolving hematoma or missed injury
• Elderly patient—higher risk of osteoporotic fractures, including subtle nondisplaced fractures

If X-Ray Shows a Fracture

If radiographs are positive for proximal humerus, scapular, or clavicle fracture, CT shoulder without IV contrast is usually appropriate as the next imaging study 1. CT imaging after radiographs can affect clinical management in up to 41% of patients with proximal humeral fractures by better characterizing fracture morphology 1. CT is particularly superior for:

• Scapular fractures (frequently missed on radiographs, especially when nondisplaced) 1
• Intraarticular extension, angulation, and lateral border offset 1
• Complex comminuted fractures where radiographs are indeterminate 1

If X-Ray is Normal or Indeterminate

Given this patient's significant bruising, functional impairment, and mechanism, if radiographs are normal or nonspecific, either CT shoulder without IV contrast or MRI shoulder without IV contrast is usually appropriate 1.

Choose CT when:

• Suspicion for occult fracture (especially scapular or nondisplaced clavicle/proximal humerus fractures)
• CT provides detailed osseous anatomy with high spatial resolution 1

Choose MRI when:

• Suspicion for soft tissue injury (rotator cuff tear, capsular injury, bone marrow edema)
• MRI can demonstrate bone marrow edema from trauma and identify capsuloligamentous pathology 1
• In acute posttraumatic settings, MRI without IV contrast is preferred because acute intraarticular pathology creates joint effusion, facilitating soft tissue assessment 1

Special Considerations for This Case

The extensive bruising extending to the anterior chest is particularly concerning and may indicate:

• Pectoralis major injury (partial detachment or strain)
• Anterior shoulder dislocation with spontaneous reduction (can be missed on initial presentation)
• Occult fracture with significant soft tissue injury

The functional limitation with minimal pain is atypical—elderly patients may have blunted pain response, and this pattern suggests either:

• Significant soft tissue disruption (rotator cuff tear)
• Neurologic injury (though patient denies this)
• Occult fracture with impaction

Common Pitfalls to Avoid

1. Missing glenohumeral dislocation: Ensure axillary or scapula-Y view is obtained—AP views alone can miss dislocations 1
2. Overlooking scapular fractures: These are frequently missed on radiographs, especially when nondisplaced 1
3. Underestimating injury in elderly patients: Osteoporotic bone fractures more easily with less force
4. Dismissing normal radiographs: In elderly patients with significant bruising and functional impairment, consider advanced imaging (CT or MRI) even if X-rays appear normal 2

Specific Imaging Recommendations for This Patient

Given the extensive bruising, functional limitation, elderly age, and delayed presentation, I recommend:

1. Obtain complete shoulder radiograph series (AP internal/external rotation + axillary or scapula-Y view)
2. If fracture identified: Proceed to CT without IV contrast for surgical planning
3. If radiographs normal but high clinical suspicion: Consider MRI without IV contrast given the extensive soft tissue bruising and functional impairment—this will detect occult fractures, rotator cuff tears, bone marrow edema, and capsular injuries that may explain the clinical presentation 1, 2

The research evidence demonstrates that in shoulder trauma with normal radiographs, MRI reveals abnormal signals in essentially all cases and establishes diagnoses that US and clinical examination miss, including shoulder instability and bone contusion 2.