What are the next steps for a patient with sharp, shooting right shoulder pain radiating to the neck, limited range of motion (ROM), and a history of a recent fall onto the shoulder?

Acute Traumatic Shoulder Pain Management

Immediate Next Step: Standard Radiography

Begin with standard shoulder radiographs including anteroposterior (AP) views in internal and external rotation PLUS an axillary or scapular Y view to evaluate for fracture, dislocation, and shoulder malalignment. 1, 2, 3

This three-view series is essential because:

• AP views alone miss over 60% of posterior dislocations and can misclassify glenohumeral dislocations 3
• The axillary or scapular Y view is vital for detecting dislocations that appear normal on AP projection 1, 3
• Radiography provides quick, inexpensive evaluation for fracture and dislocation in acute trauma 1

If Radiographs Show Fracture or Dislocation

Immediate Orthopedic Referral Required For:

• Unstable or significantly displaced fractures 2
• Presence of neurological deficits 2
• Shoulder joint instability or confirmed dislocation 2
• Vascular compromise (especially with proximal humeral fractures where axillary artery injury can occur) 3

If Fracture Identified:

• CT shoulder without IV contrast (rating 9/9) is usually appropriate to characterize fracture complexity, displacement, and angulation, especially for surgical planning 1
• Delaying referral for surgical intervention makes stabilization more technically challenging 2

If Dislocation Identified:

• Post-reduction radiographs are necessary to confirm successful reduction and evaluate for fractures obscured by the dislocation 3
• Assess for associated injuries, particularly rotator cuff tears in older patients 3

If Radiographs Are Normal or Nonspecific

The next step depends on clinical suspicion:

For Suspected Occult Fracture:

• CT shoulder without IV contrast (rating 9/9) OR MRI shoulder without IV contrast (rating 9/9) is usually appropriate 1
• CT provides detailed osseous anatomy with high spatial resolution for identifying subtle nondisplaced fractures 1
• MRI demonstrates bone marrow edema from trauma and identifies soft tissue pathology 1

For Suspected Rotator Cuff Tear:

MRI shoulder without IV contrast (rating 9/9) OR ultrasound shoulder (rating 9/9) is usually appropriate 1

These are equivalent alternatives; order only one:

• MRI is preferred with large body habitus, restricted ROM due to acute pain, or suspicion of other intraarticular pathologies like labral tears 1
• Ultrasound may be preferred with previously placed proximal humeral hardware causing MRI artifacts 1

For Suspected Labral Tear or Instability:

MRI shoulder without IV contrast (rating 9/9) is usually appropriate 1

• In acute trauma, posttraumatic joint effusion or hemarthrosis typically provides sufficient visualization without contrast 1
• MR arthrography (rating 9/9) may be appropriate for detailed labral evaluation in subacute/chronic settings when joint effusion is insufficient 1
• CT shoulder without IV contrast may be appropriate when MRI assessment of bone loss is limited 1

Key Clinical Considerations for This Patient

Given the mechanism (fall on shoulder one month ago) with sharp, shooting pain radiating to neck and limited ROM:

Primary Differential Diagnoses:

• Rotator cuff tear (most likely in patients >35-40 years with trauma and limited ROM) 4
• Occult fracture (especially in elderly with minimal trauma) 4
• Labral injury with instability (more common in patients <35 years) 1, 4
• Shoulder dislocation (may have spontaneously reduced) 3

Pain Pattern Analysis:

• Anterior shoulder pain suggests rotator cuff or biceps pathology 4
• Superior shoulder pain indicates acromioclavicular joint disease 4
• Radiation to neck may indicate cervical radiculopathy or referred pain 4

Age-Specific Approach:

• If patient >35-40 years: Focus on rotator cuff disease and degenerative changes as predominant causes 4
• If patient <35 years: Prioritize instability and labral tears 1, 4

Critical Pitfalls to Avoid

• Do not assume absence of visible trauma means absence of fracture, especially in elderly patients where osteoporotic fractures occur with minimal trauma 4
• Failure to obtain axillary or scapular Y views leads to missed dislocations in over 60% of cases 3
• Attempting reduction without radiographic confirmation could worsen fracture-dislocations 3
• Inadequate imaging leads to missed fracture components or underestimation of injury severity 2
• Overlooking associated rotator cuff tears in older patients with dislocation impacts outcomes 3