What are the next steps for a 30-year-old male with a right shoulder injury, who felt a tearing sensation and experienced tingling down his arm?

Immediate Management of Traumatic Shoulder Injury with Neurological Symptoms

This patient requires immediate radiographic evaluation with a three-view shoulder series (AP in internal/external rotation plus axillary or scapula-Y view) to rule out fracture or dislocation, followed by urgent orthopedic referral given the combination of tearing sensation and neurological symptoms suggesting possible brachial plexus injury. 1, 2

Initial Diagnostic Imaging

Obtain standard three-view radiographs immediately:

• Anteroposterior views in both internal and external rotation 1
• Axillary or scapula-Y view (critical—dislocations are misclassified on AP views alone in over 60% of cases) 2
• Perform upright if possible, as supine imaging can underrepresent shoulder malalignment 1

The tearing sensation strongly suggests structural injury (rotator cuff tear, labral injury, or dislocation), while the tingling down the arm indicates potential brachial plexus involvement—a combination that warrants urgent evaluation. 3, 4

Critical Assessment for Neurovascular Compromise

Perform immediate neurovascular examination documenting:

• Motor function of deltoid (axillary nerve), biceps, wrist/finger extensors, and intrinsic hand muscles 3, 5
• Sensory testing in axillary nerve distribution (lateral shoulder), median, ulnar, and radial nerve territories 3
• Radial pulse presence and capillary refill 1
• Temperature and color changes suggesting autonomic involvement 3

Neurological complications occur in 5.4-55% of shoulder dislocations, with the axillary nerve most commonly affected, though multiple nerve injuries are more frequent than isolated mononeuropathies. 4 The infraclavicular brachial plexus is the most commonly injured region. 4

Immediate Orthopedic Referral Indications

Refer urgently to orthopedics if radiographs show:

• Any fracture-dislocation (requires reduction under controlled conditions) 1, 6
• Displaced or unstable fractures 1, 6
• Any dislocation (posterior dislocations are frequently missed without proper views) 2

Refer urgently regardless of radiographic findings if:

• Progressive neurological deficits are present 6
• Absent or diminished radial pulse 1
• Complete motor paralysis of any muscle group 4

Advanced Imaging Based on Initial Findings

If radiographs show fracture or dislocation:

• CT without contrast to characterize fracture patterns and confirm reduction success 1
• CT angiography if vascular compromise suspected (absent pulse, expanding hematoma, bruit) 2, 6

If radiographs are normal but symptoms persist:

• MRI without contrast (rated 7/9 appropriateness) or MR arthrography (rated 9/9) for rotator cuff tears, labral injuries, or occult fractures 1, 6
• MRI is superior to CT for all soft-tissue shoulder injuries 1

Neurological Injury Management Timeline

Most brachial plexus injuries from shoulder trauma resolve spontaneously (neurapraxia or axonotmesis predominate), with complete nerve disruption occurring in less than 3% of cases. 4

Conservative management protocol:

• Serial neurological examinations every 2-4 weeks 4
• Electrodiagnostic studies (EMG/NCS) at 3-4 weeks post-injury to establish baseline and differentiate neurapraxia from axonotmesis 5, 7
• Advancing Tinel's sign suggests potential recovery 5

Surgical exploration indicated if:

• No clinical or electrodiagnostic recovery by 3-6 months 7, 4
• Open wound with suspected nerve transection (explore immediately) 7
• Root avulsion suspected on clinical grounds or imaging 7

Only 13-18% of patients with brachial plexus injury from shoulder dislocation ultimately require operative treatment. 4

Critical Pitfalls to Avoid

• Never attempt reduction without radiographic confirmation—fracture-dislocations can be worsened 2
• Failure to obtain axillary or scapula-Y views leads to missed dislocations (especially posterior dislocations) 1, 2
• Delaying reduction increases neurovascular complications—once imaging confirms dislocation without contraindications, reduce promptly 2
• Overlooking vascular injury—brachial plexus compression from traumatic hematoma can cause delayed paralysis (up to 48 hours post-injury) 3
• Premature surgical intervention—most nerve injuries recover spontaneously; wait 3-6 months unless clear indication for earlier surgery 7, 4