What is the most appropriate initial management for a patient with a shoulder injury, inability to raise their arm, and visible deformity after a motor vehicle accident?

Acute Shoulder Injury with Visible Deformity Post-MVA

Immediately obtain a three-view radiographic series (AP internal rotation, AP external rotation, and axillary or scapula-Y view) performed upright if the patient's condition permits, as this is the essential first step to identify fracture patterns and confirm or rule out shoulder dislocation before any manipulation or intervention. 1, 2

Initial Assessment and Imaging

• Radiography is the mandatory first imaging modality because it effectively identifies displaced fractures and shoulder malalignment—the two primary concerns driving acute management decisions in trauma. 1, 2

• The three-view series is non-negotiable: You must obtain at minimum an AP view in internal rotation, an AP view in external rotation, and an axillary or scapula-Y view. The axillary or scapula-Y view is critical because glenohumeral dislocations are frequently misclassified on AP views alone, and posterior dislocations are missed in more than 60% of cases without proper orthogonal imaging. 1, 2, 3

• Perform radiographs upright rather than supine whenever possible, as shoulder malalignment can be underrepresented on supine imaging, potentially leading to misdiagnosis. 2, 3

Critical Pre-Imaging Management

• Apply splinting immediately to immobilize the shoulder in the position of comfort before obtaining radiographs. Splinting should be used as soon after musculoskeletal injury as possible to prevent further soft tissue damage, neurovascular compromise, and pain. 4

• Assess neurovascular status thoroughly at initial presentation, documenting pulses, capillary refill, sensation, and motor function. This is essential because axillary artery injury can occur with shoulder trauma and proximal humeral fractures, and delays in recognizing vascular injury significantly worsen outcomes. 3, 5

• Never attempt shoulder manipulation or reduction without radiographic confirmation of the injury pattern, as this could convert a stable fracture into a displaced one or worsen neurovascular compromise. 3

When to Escalate to CT

• Order CT shoulder without contrast if radiographs show complex comminuted fractures requiring surgical planning, or if fracture pattern characterization is inadequate on plain films. CT is advantageous in identifying subtle nondisplaced fractures and can affect clinical management in up to 41% of patients with proximal humeral fractures. 1

• Consider CT angiography urgently if there are any signs of vascular compromise including diminished pulses, expanding hematoma, bruit, or ongoing ischemia, as this is a time-critical emergency requiring joint specialist input from orthopedic and vascular surgeons. 3, 5

Specific Injury Patterns to Consider

• Anterior glenohumeral dislocation (80% of shoulder dislocations) presents with inability to raise the arm and visible deformity with the shoulder appearing "squared off." The axillary view definitively shows the relationship between the humeral head and glenoid. 6

• Posterior dislocation appears deceptively normal on AP views alone and requires the axillary or scapula-Y view for diagnosis. 3

• Proximal humeral fractures are common in trauma and require classification on radiographs to determine surgical versus nonsurgical management. 1

• Acromioclavicular separation presents with visible deformity at the AC joint and is graded on radiographs; types I-II are managed conservatively, types IV-VI surgically. 6

Post-Reduction or Definitive Management

• Following surgical treatment or reduction, range-of-motion exercises including shoulder, elbow, wrist, and hand motion should begin within the first postoperative days. A sling is worn for comfort only and may be discarded as early as pain allows. 1

• Restrict above-chest-level activities until fracture healing is evident, as overly aggressive physical therapy may increase the risk of fixation failure. 1

• In patients over 40 years, maintain high suspicion for associated rotator cuff tears even if the bony injury appears minor, as these are commonly overlooked and impact long-term function. 3

Common Pitfalls

• Missing posterior dislocations by relying on AP views alone—always obtain the axillary or scapula-Y view. 3

• Attempting reduction without imaging—this can catastrophically worsen fracture-dislocations. 3

• Failing to reassess neurovascular status after any intervention or reduction. 3, 5

• Performing supine radiographs when the patient can tolerate upright positioning, potentially missing subtle malalignment. 2, 3