What is the most appropriate next step for a patient with a shoulder injury, inability to raise their arm, and visible deformity?

X-ray is the Most Appropriate Next Step

For a patient presenting with shoulder injury, inability to raise the arm, and visible deformity, plain radiography (X-ray) is the definitive initial imaging study and should be obtained immediately before any intervention. 1, 2

Why X-ray is the Correct Choice

Primary Diagnostic Concerns

The combination of inability to raise the arm and visible deformity strongly suggests either:

• Fracture (clavicle, proximal humerus, or scapula)
• Dislocation (glenohumeral or acromioclavicular joint)
• Fracture-dislocation (combined injury)

All of these conditions require radiographic confirmation before any treatment intervention. 1, 2

Critical Role of Radiography

• Radiography is the preferred initial study for all traumatic shoulder pain because it effectively delineates shoulder malalignment and most shoulder fractures, which are the two primary concerns in acute management. 1
• Visible deformity on examination is the strongest predictor of therapeutically informative radiographs, correctly identifying significant pathology in 91% of cases. 3
• Attempting reduction or manipulation without radiographic confirmation could worsen fracture-dislocations, potentially causing neurovascular injury or fragment displacement. 2

Essential Technical Requirements

Mandatory Views

You must obtain at least three views: 1, 2

• Anteroposterior (AP) in internal rotation
• Anteroposterior (AP) in external rotation
• Axillary OR scapular-Y view (this third view is non-negotiable)

Critical Pitfall to Avoid

Glenohumeral and acromioclavicular dislocations are misclassified on AP views alone in over 60% of cases, particularly posterior dislocations. 2 The axillary or scapular-Y view is vital for detecting these injuries that would otherwise be missed. 1, 2

Additional Technical Considerations

• Perform radiography with the patient upright when possible, as shoulder malalignment can be underrepresented on supine films. 1
• If the patient cannot abduct or rotate the arm due to pain, modified axial projections can be obtained without arm movement. 4

Why NOT MRI or CT Initially

MRI is Inappropriate as Initial Study

• MRI is indicated after radiographs confirm dislocation and you need to assess soft-tissue injuries (rotator cuff tears, labral injuries, capsular tears). 2
• MRI does not adequately assess for fractures or acute malalignment, which are the immediate management priorities. 1

CT is Inappropriate as Initial Study

• CT is better than radiography at characterizing fracture patterns, but radiography is preferred for initial evaluation because it adequately diagnoses displaced fractures and shoulder malalignment. 1
• CT is reserved for surgical planning when complex fracture patterns need better characterization after initial radiographic diagnosis. 1, 2
• CT should only be performed if symptoms persist or radiographs are equivocal. 2

Clinical Algorithm

1. Obtain three-view shoulder radiographs immediately (AP internal rotation, AP external rotation, axillary or Y-view) 1, 2
2. Assess for neurovascular compromise while awaiting imaging 2
3. Do not attempt reduction until radiographs confirm the diagnosis and exclude fracture-dislocation 2
4. If vascular compromise is suspected, obtain CT angiography after initial radiographs 2
5. Post-reduction radiographs are mandatory to confirm successful reduction and identify fractures that may have been obscured by the dislocation 2, 5