What is the most appropriate initial next step for a patient post Motor Vehicle Accident (MVA) with a shoulder injury, inability to raise their arm, and visible deformity?

Initial Management: Obtain Standard Shoulder Radiographs Before Any Intervention

The most appropriate initial next step is to obtain standard shoulder radiographs including anteroposterior (AP) views in internal and external rotation PLUS an axillary or scapula-Y view before attempting any reduction or manipulation. 1, 2

Why Radiography Must Come First

• Radiography is the preferred initial diagnostic modality to confirm the type of injury (dislocation vs. fracture vs. fracture-dislocation) and identify associated fractures before attempting any intervention. 2
• Attempting reduction without radiographic confirmation could worsen fracture-dislocations, potentially causing catastrophic complications including neurovascular injury. 2
• The visible deformity and inability to raise the arm suggests either a shoulder dislocation, proximal humerus fracture, or both—all of which require different immediate management approaches. 1, 3

Critical Imaging Views Required

• The axillary or scapula-Y view is absolutely vital because glenohumeral and acromioclavicular dislocations can be misclassified on AP views alone—posterior dislocations are missed in over 60% of cases when only AP views are obtained. 1, 2
• Radiographs should be performed upright when possible, as shoulder malalignment can be underrepresented on supine imaging. 1, 4
• These three views (AP internal rotation, AP external rotation, and axillary/Y view) will diagnose displaced fractures and shoulder malalignment, which are the primary concerns requiring immediate decision-making. 1

What Radiographs Will Reveal

The imaging will differentiate between:

• Anterior dislocation (most common—80% of shoulder dislocations): humeral head displaced anteriorly and inferiorly, possible Hill-Sachs deformity or bony Bankart lesion 2, 5
• Posterior dislocation: frequently missed without proper orthogonal views, humeral head displaced posteriorly 2
• Proximal humerus fracture: can be managed nonoperatively in 85% of cases but requires identification first 5
• Fracture-dislocation: requires different management than isolated dislocation 2
• Clavicle fracture: over 80% managed conservatively 5

Immediate Clinical Assessment While Arranging Imaging

While obtaining radiographs, perform:

• Neurovascular assessment: document axillary nerve function (sensation over lateral deltoid), radial pulse, and distal motor/sensory function, as axillary artery injury can occur especially with proximal humeral fractures. 2
• Note the mechanism of injury and patient age, as age under 30 years significantly predicts recurrence after dislocation. 6

Common Pitfalls to Avoid

• Never attempt reduction without radiographic confirmation—you risk converting a simple fracture into a displaced fracture or worsening a fracture-dislocation. 2
• Do not rely on AP views alone—this is the most common cause of missed posterior dislocations. 2
• Delaying reduction after radiographic confirmation increases risk of neurovascular compromise, so once imaging excludes contraindications, proceed promptly. 2

Next Steps After Radiography

• If dislocation without fracture is confirmed: proceed with closed reduction using appropriate technique and analgesia/sedation 3
• If fracture is identified: management depends on fracture pattern, displacement, and patient factors 5, 3
• Post-reduction radiographs are mandatory to confirm successful reduction and evaluate for fractures that may have been obscured by the dislocation 2, 4