What are the signs of shoulder dislocation or fracture on physical exam?

Signs of Shoulder Dislocation/Fracture on Physical Examination

The most reliable physical examination findings for shoulder dislocation include visible deformity, limited range of motion, and pain with specific maneuvers, while fractures typically present with point tenderness, crepitus, and ecchymosis. 1

Key Physical Examination Findings

Shoulder Dislocation Signs

1. Inspection:

   • Visible deformity with anterior dislocations showing a squared-off appearance of the shoulder
   • Prominent acromion with a hollow beneath it
   • Arm held in slight abduction and external rotation (anterior dislocation)
   • Arm held in internal rotation and adduction (posterior dislocation)

2. Palpation:

   • Empty glenoid fossa
   • Humeral head palpable anteriorly (anterior dislocation) or posteriorly (posterior dislocation)
   • Tenderness over the anterior or posterior shoulder

3. Range of Motion:

   • Severely limited active and passive motion
   • Patient reluctant to move the arm due to pain and apprehension

4. Special Tests:

   • Positive apprehension test (patient becomes anxious when the arm is placed in the position of dislocation)
   • Positive relocation test (relief of apprehension when posterior pressure is applied to the humeral head)
   • Sulcus sign (gap between acromion and humeral head when downward traction is applied)

Shoulder Fracture Signs

1. Inspection:

   • Swelling and ecchymosis
   • Visible deformity in severe fractures
   • Arm held in protective position by the patient

2. Palpation:

   • Point tenderness over fracture site
   • Crepitus (grating sensation) with gentle movement
   • Step-off or irregularity along bone contours

3. Range of Motion:

   • Limited and painful active and passive motion
   • Pain exacerbated by specific movements depending on fracture location

4. Special Considerations:

   • Assess for neurovascular compromise, especially with fracture-dislocations 2
   • Check axillary nerve function (sensation over lateral deltoid)
   • Assess distal pulses and capillary refill

Fracture-Dislocation Considerations

Fracture-dislocations present with combined features and require special attention:

• More pronounced deformity
• Greater pain and limitation of movement
• Higher risk of neurovascular compromise 3
• Possible palpable fragments or step-offs
• Increased risk of complications if reduction is attempted under sedation alone 3

Clinical Pitfalls and Caveats

• Posterior dislocations are frequently missed (up to 79% in some series) because the deformity is less obvious than in anterior dislocations 4
• Hill-Sachs lesions (compression fracture of the posterolateral humeral head) are common in anterior dislocations and should be suspected with recurrent instability 1
• Bankart lesions (anterior labral tears) often accompany anterior dislocations and may not be evident on physical exam 1
• Axillary nerve injury should always be assessed by checking sensation over the lateral deltoid
• Vascular compromise requires immediate attention and is more common with proximal humeral fractures, open fractures, and fracture-dislocations 2

Examination Algorithm

1. Initial Assessment:

   • Observe shoulder contour and position of the arm
   • Note any obvious deformity or asymmetry compared to unaffected side

2. Careful Palpation:

   • Systematically palpate bony landmarks (acromion, coracoid, greater/lesser tuberosities)
   • Identify areas of maximum tenderness
   • Feel for crepitus or abnormal movement

3. Gentle Range of Motion:

   • Assess willingness and ability to move (active motion)
   • If tolerated, perform gentle passive motion
   • Document specific limitations

4. Neurovascular Examination:

   • Check distal pulses
   • Assess sensation in all dermatomes
   • Test motor function of key muscle groups
   • Specifically test axillary nerve function

5. Special Tests:

   • Perform apprehension and relocation tests if appropriate
   • Check for sulcus sign
   • Assess for scapular winging

Remember that physical examination findings should guide but not replace appropriate imaging. Plain radiographs are the first-line imaging for all shoulder pain, with specific views for different suspected pathologies 1.