What is the initial management for a shoulder injury?

Initial Management of Shoulder Injury

For traumatic shoulder injuries, radiography is the preferred initial imaging study, followed by appropriate immobilization and conservative management for most cases, while surgical referral is necessary for unstable or significantly displaced fractures and severe joint instability.1

Initial Assessment and Imaging

Radiographic Evaluation

• Standard radiographs should include at least three views:
  • Anteroposterior (AP) views in internal and external rotation
  • Axillary or scapula-Y view (critical for accurate diagnosis)1
• Radiographs should be performed upright as malalignment can be underrepresented on supine imaging1
• These views help identify:
  • Fractures (clavicle, scapula, proximal humerus)
  • Shoulder malalignment
  • Dislocations (glenohumeral or acromioclavicular)

Physical Examination

• Assess for deformity, point tenderness, and range of motion
• Evaluate neurovascular status of the affected limb
• Check for signs of instability (anterior, posterior, or multidirectional)
• Examine for rotator cuff integrity with specific tests

Management Algorithm Based on Injury Type

1. Fractures

• Clavicle fractures:

  • Over 80% can be managed conservatively with a sling2
  • Surgical referral for significantly displaced or comminuted fractures

• Humeral head fractures:

  • 85% can be managed nonoperatively, especially in elderly patients2
  • Immobilization with sling for 2-3 weeks

2. Shoulder Dislocations (80% are anterior)2

• Reduction: Various nonsurgical techniques can be employed
• Post-reduction management:
  • Immobilization in a sling for 3 weeks
  • Note: External rotation bracing shows no significant benefit over traditional internal rotation sling immobilization in preventing recurrence3, 4
  • Recurrence rates remain high (50% overall, up to 88.9% in 14-20 year age group)5

3. Acromioclavicular (AC) Joint Injuries

• Type I and II: Conservative management with sling and pain control2
• Type IV to VI: Surgical referral2
• Type III: Controversial - consider patient factors and activity demands

4. Rotator Cuff Injuries

• Acute tears:
  • Initial conservative management with:
    • Pain control
    • Immobilization for comfort
    • Early gentle range of motion exercises when pain allows
  • Surgical referral for:
    • Young, active patients
    • Complete tears with significant functional deficit

Prevention of Shoulder Pain After Injury

For post-injury management, consider:

• Electrical stimulation to improve shoulder lateral rotation
• Proper shoulder positioning and support
• Avoid overhead pulleys which encourage uncontrolled abduction1
• Range of motion exercises focusing on external rotation and abduction when appropriate

Treatment of Post-Injury Shoulder Pain

• Intra-articular injections (Triamcinolone) for significant pain
• Stretching and mobilization techniques
• Modalities: ice, heat, and soft tissue massage
• Functional electrical stimulation
• Progressive strengthening1

Common Pitfalls to Avoid

1. Inadequate imaging: Failure to obtain axillary or scapula-Y views can lead to missed diagnoses of dislocations1
2. Prolonged immobilization: Extended immobilization does not reduce recurrence rates and may lead to stiffness5
3. Overlooking neurovascular injuries: Always assess neurovascular status
4. Delayed rehabilitation: Early, appropriate rehabilitation is crucial for optimal outcomes
5. Missing associated injuries: Carefully evaluate for concomitant injuries like Bankart lesions or Hill-Sachs defects

The initial management of shoulder injuries requires careful assessment and appropriate treatment selection based on injury type and severity, with the goal of optimizing functional outcomes and minimizing complications.