What radiographic series should I order for a suspected shoulder injury?

Radiographic Series for Suspected Shoulder Injury

For suspected shoulder injury, order a plain radiograph series consisting of anteroposterior (AP) view, external rotation view, and axillary or scapular Y view as the first-line imaging evaluation. 1

Standard Radiographic Series for Shoulder Injury

The American College of Radiology recommends the following radiographic series for initial evaluation of suspected shoulder injuries:

1. Anteroposterior (AP) view - Most sensitive view, detecting approximately 88% of injuries 2
2. External rotation view - Helps visualize anterior and posterior aspects of the glenohumeral joint
3. Axillary or scapular Y view - Critical for detecting glenohumeral dislocations and glenoid fractures

Importance of Multiple Views

• A single view is insufficient for proper evaluation of shoulder trauma
• The AP view alone will miss important pathology, particularly posterior dislocations
• Complementary views are necessary as they each excel at detecting different types of injuries:
  • Oblique apical views are superior for detecting glenohumeral dislocations and clavicular fractures 2
  • Lateral views better visualize scapular body and coracoid process fractures 2
  • Axillary views are essential for detecting Hill-Sachs lesions and evaluating glenohumeral alignment 3

Clinical Decision Making

When ordering shoulder radiographs, consider the following algorithm:

1. Always start with the three standard views (AP, external rotation, axillary/Y view)
2. Consider additional views based on suspected pathology:
   • If posterior dislocation is suspected: Add apical oblique view (detects 15.2% of lesions missed on standard views) 4
   • If scapular fracture is suspected: Add dedicated lateral view 2
   • If clavicular injury is suspected: Add specific clavicular views

Common Pitfalls to Avoid

• Inadequate imaging: Ordering only an AP view is insufficient and may miss up to 15% of significant injuries 4
• Overlooking posterior dislocations: These are frequently missed on AP views alone
• Patient positioning challenges: The axillary view may be difficult to obtain in acute trauma due to pain
  • In these cases, the scapular Y view is a reasonable alternative with 92% diagnostic agreement with axillary views 3
  • Most patients (81%) report less pain with scapular Y view compared to axillary view 3

Advanced Imaging Considerations

If plain radiographs are negative but clinical suspicion for injury remains high:

• MRI without contrast is the next recommended step for evaluating soft tissue injuries including labral tears 1
• MR arthrography is the gold standard for labral imaging (sensitivity 86-100%) 1
• CT arthrography is an alternative when MRI is contraindicated 1

Remember that plain radiographs should always be obtained first to rule out fractures and bony abnormalities before proceeding to advanced imaging 1.