Do I need to rule out dislocation in a patient with painful overhead flexion after a fall, despite no visible deformity?

Ruling Out Shoulder Dislocation After Bike Fall

In a patient with painful overhead flexion after a bike fall but no visible deformity, radiographic imaging is still necessary to rule out shoulder dislocation.

Initial Assessment for Suspected Shoulder Dislocation

• Radiography is the initial imaging modality of choice for evaluating traumatic joint pain, even when no deformity is visible 1
• The absence of visible deformity does not exclude dislocation, as some dislocations may spontaneously reduce but still cause significant pain with movement 1
• Pain with overhead flexion after trauma is a concerning sign that warrants proper imaging evaluation 1

Recommended Imaging Approach

• Standard radiographic views should include:
  • Anteroposterior (AP) view
  • Lateral view of the affected shoulder 1
• Many institutions also include comparison views of the unaffected shoulder to assess for symmetry 1

Importance of Proper Imaging

• Hip fractures and dislocations cannot be diagnosed or excluded definitively via physical examination alone, and the same principle applies to shoulder injuries 1
• Delays in diagnosis of joint dislocations are associated with increased complications and poorer outcomes 1
• Even if a dislocation has spontaneously reduced, radiographs can detect associated injuries such as Hill-Sachs lesions or bony Bankart lesions that indicate a previous dislocation event 1

Common Pitfalls to Avoid

• Relying solely on the absence of visible deformity to rule out dislocation is dangerous, as up to 15% of injuries may be missed on clinical examination alone 1
• Failing to obtain proper imaging after trauma can lead to missed diagnoses of subtle fractures or reduced dislocations that still require treatment 1
• Patients with painful range of motion after trauma should be considered to have a structural injury until proven otherwise 1

Special Considerations

• If standard radiographs are negative but clinical suspicion remains high, additional imaging such as CT may be warranted to detect subtle injuries 1
• In patients with persistent pain despite normal radiographs, MRI may be necessary to evaluate for soft tissue injuries such as rotator cuff tears or labral injuries 1

Follow-up Recommendations

• Even if initial radiographs are negative, patients with persistent pain and limited range of motion should be re-evaluated 1
• Patients should be instructed to avoid activities that exacerbate pain until a definitive diagnosis is established 2