What is the initial workup and treatment for a shoulder injury?

Initial Workup and Treatment for Shoulder Injury

For traumatic shoulder injuries, radiography is the most appropriate initial study, followed by targeted advanced imaging based on findings, with treatment determined by the type and severity of injury, ranging from conservative management to surgical intervention.

Initial Assessment and Imaging

Radiography

• Standard radiographs should be the first imaging study for all traumatic shoulder injuries 1
• A complete shoulder trauma radiographic series should include:
  • Anteroposterior (AP) views in internal and external rotation
  • Axillary or scapula-Y view (critical for evaluating dislocations) 1
  • Radiographs should be performed upright as malalignment can be underrepresented on supine imaging 1

Physical Examination

• Focus on examination maneuvers with highest reliability:
  • Abduction range of motion and strength (excellent reliability)
  • External rotation strength (substantial reliability)
  • Note: Hawkins' test and external rotation lag sign have lower reliability in acute trauma 2

Further Imaging Based on Initial Findings

If Radiographs Show Fracture:

• Humeral head/neck fracture: CT without IV contrast for characterizing fracture planes 1
• Scapular fracture: CT without IV contrast to document intra-articular extension and fragment angulation 1

If Radiographs Show Bankart or Hill-Sachs Lesions:

• MRI shoulder without IV contrast or MR arthrography to assess labroligamentous injuries 1

If Radiographs Are Normal but Clinical Suspicion Remains:

• For suspected labral tear/instability: MR arthrography (rated 9/9) or MRI without contrast (rated 7/9) 1, 3
• For nonlocalized shoulder pain: MRI without IV contrast 1
• For suspected rotator cuff pathology: MRI without contrast or ultrasound 1, 4

Treatment Approach

Fractures

• Clavicle fractures: 80% can be managed conservatively 5
• Humeral head fractures: 85% can be managed nonoperatively, especially in elderly patients 5

Soft Tissue Injuries

1. Shoulder Dislocations:

   • 80% are anterior dislocations 5
   • Can typically be reduced using nonsurgical techniques
   • After reduction, brief immobilization followed by rehabilitation

2. Rotator Cuff Tears:

   • Initial management: conservative approach with exercise therapy and NSAIDs 3
   • Physical therapy should include scapular stabilization, rotator cuff and core strengthening 3
   • Consider surgery for:
     • Failure of conservative measures after 3-6 months
     • Significant functional limitations
     • Young, active patients with high physical demands 3

3. Acromioclavicular (AC) Joint Injuries:

   • Graded from types I to VI
   • Types I and II: conservative treatment
   • Types IV to VI: surgical treatment
   • Type III: controversial management, individualized decision 5

4. Shoulder Impingement Syndrome:

   • Mainstay of treatment: physical therapy, anti-inflammatory medications, and injections
   • Surgical treatment reserved for refractory cases 4

Common Pitfalls to Avoid

1. Inadequate imaging: Failure to obtain axillary or scapula-Y views can lead to missed glenohumeral or acromioclavicular dislocations 1

2. Overreliance on less reliable physical examination tests: Tests like Hawkins' and external rotation lag sign have lower reliability in acute trauma settings 2

3. Premature surgical intervention: Most soft tissue injuries (labral tears, rotator cuff tears) can undergo a period of conservative management before considering surgery 1

4. Overlooking associated injuries: Shoulder injuries often involve multiple structures; comprehensive evaluation is essential 6

5. Inadequate follow-up: Recurrence is common with certain treatments, particularly with corticosteroid injections alone 3