Right Shoulder X-Ray Order
Order a standard three-view shoulder radiograph series including anteroposterior (AP) views in internal and external rotation plus an axillary or scapula-Y view, performed upright when possible. 1
Standard Imaging Protocol
Radiography is the preferred initial imaging study for right shoulder pain or trauma. 1 This modality effectively identifies the two primary concerns requiring immediate management: fractures and shoulder malalignment (dislocations). 1
Required Views
The minimum three-view series must include: 1
Critical Technical Considerations
The axillary or scapula-Y view is non-negotiable because acromioclavicular and glenohumeral dislocations are frequently misclassified on AP views alone—posterior dislocations are missed in over 60% of cases when only AP views are obtained. 2 Without orthogonal views, you risk missing the diagnosis entirely. 2
Perform radiographs upright rather than supine whenever the patient's condition permits, as shoulder malalignment can be underrepresented on supine imaging. 1
Why Radiography First
Radiography provides excellent delineation of bony anatomy to assess for fractures and proper shoulder alignment. 1 While CT better characterizes fracture patterns, radiography adequately diagnoses displaced fractures and shoulder malalignment—the primary concerns driving acute management decisions. 1 Starting with CT would expose patients to unnecessary radiation and cost when plain films suffice for initial assessment. 1
Common Pitfalls to Avoid
Ordering only AP views will result in missed dislocations. 2, 3 The oblique apical view detected 15.2% of lesions missed on standard views in one series, particularly glenohumeral dislocations and glenoid fractures. 4
Do not attempt reduction before obtaining radiographs. 2 Attempting reduction without radiographic confirmation could worsen fracture-dislocations. 2
Obtain post-reduction radiographs to confirm successful reduction and evaluate for fractures that may have been obscured by the dislocation. 2
When to Consider Advanced Imaging
After initial radiographs, consider: 1
- CT if fracture pattern characterization is needed for surgical planning 1
- CT angiography if vascular compromise is suspected, particularly with proximal humeral fractures where axillary artery injury can occur 2
- MRI for persistent symptoms with normal radiographs, as MRI reveals occult lesions including rotator cuff tears, labral injuries, and bone contusions that plain films miss 5
- Ultrasound has limited utility in acute trauma unless rotator cuff pathology is specifically suspected, as it completely overlooks instability and has 0% positive predictive value for detecting dislocations 5