What is the best course of action for an adult patient with a lung injury and a potentially missed shoulder fracture on an initial imaging report?

Management of Potentially Missed Shoulder Fracture on Initial Imaging

If a shoulder fracture is suspected clinically but was missed on the initial imaging report, immediately obtain CT without IV contrast to definitively identify or exclude the fracture, as CT is superior to radiography in detecting subtle nondisplaced fractures and can change clinical management in up to 41% of cases. 1

Immediate Action Steps

Re-evaluate the Original Radiographs

• Have the images formally reviewed by a radiologist or experienced clinician before ordering additional imaging 1
• Ensure the initial radiographic series included the minimum three views: anteroposterior (AP) in internal and external rotation PLUS an axillary or scapula-Y view 1, 2, 3
• Missing orthogonal views (axillary or scapula-Y) is a common pitfall that leads to missed fractures and dislocations 1, 2, 3
• Oblique apical and lateral views may detect specific injuries missed on AP views alone, including glenohumeral dislocations with fracture and scapular body/coracoid process fractures 4

Clinical Assessment

• Assess for neurovascular compromise immediately, as this requires urgent intervention 2
• Document the mechanism of injury, as high-energy trauma increases the likelihood of complex or occult fractures 3
• Examine for point tenderness, deformity, and range of motion limitations that localize the injury 3

Advanced Imaging Protocol

CT Without IV Contrast (First-Line Advanced Imaging)

CT is the most appropriate next imaging study when radiographs are indeterminate or a fracture is clinically suspected but not visualized 1

• CT identifies subtle nondisplaced fractures that are radiographically occult 1
• CT characterizes complex fracture morphology, particularly for comminuted proximal humeral fractures and scapular fractures 1
• Scapular fractures are frequently missed on radiographs, especially when nondisplaced, and CT is the most useful modality for detection 1
• CT findings can alter clinical management in up to 41% of patients with proximal humeral fractures 1

MRI Without IV Contrast (Alternative for Soft Tissue Concerns)

• MRI is indicated if there is concern for associated soft tissue injuries (rotator cuff tears, labral injuries, capsular tears) in addition to potential fracture 1, 2
• MRI is highly sensitive for bone marrow contusion and occult fractures that may not be visible on CT 1
• In the acute posttraumatic setting, MRI without contrast is preferred over MR arthrography because joint effusion from acute injury provides natural contrast 1
• MRI can establish underlying pathology including osseous contusions and acromioclavicular sprains 1

Repeat Radiographs in 10-14 Days (Less Preferred)

• Follow-up radiographs have increased sensitivity compared to initial radiographs due to fracture line resorption and callus formation 1
• However, delaying diagnosis with repeat radiographs risks progression of injury, particularly with subchondral insufficiency fractures where morbidity increases significantly with articular surface collapse 1
• This approach should only be considered for very low clinical suspicion injuries where immediate treatment would not differ 1

Special Considerations for Concurrent Lung Injury

Imaging Coordination

• If the patient has a lung injury requiring chest CT, coordinate to include the shoulder in the same CT examination to avoid additional radiation exposure and delays 5
• Multi-detector CT with multiplanar reconstructions is highly sensitive for both thoracic and shoulder injuries 5

Clinical Context

• Blunt thoracic trauma mechanisms (blast injury, high-energy impact) that cause lung injury frequently cause concurrent shoulder girdle fractures 5
• Pulmonary contusions may distract from shoulder injury evaluation—maintain high clinical suspicion for musculoskeletal injuries in polytrauma patients 5

Critical Pitfalls to Avoid

Imaging Errors

• Failure to obtain axillary or scapula-Y views leads to missed diagnoses of glenohumeral and acromioclavicular dislocations in over 60% of cases 1, 2, 3
• Supine radiographs may underrepresent shoulder malalignment; upright radiographs are preferred 3
• Attempting fracture reduction without adequate imaging confirmation can worsen fracture-dislocations 2, 6

Management Errors

• Delaying treatment of unstable or displaced fractures increases risk of complications including neurovascular compromise 2, 3
• Overlooking associated rotator cuff tears, which are more common in older patients with shoulder trauma, can impact functional outcomes 2
• In patients with proximal humeral fractures involving the surgical neck, reduction should not be attempted under sedation—general anesthesia is required 6

Vascular Assessment

• If vascular compromise is suspected (diminished pulses, expanding hematoma, bruit), obtain CT angiography immediately, as axillary artery injury can occur with proximal humeral fractures and dislocations 2

Disposition and Referral

Urgent Surgical Consultation Required For:

• Unstable or significantly displaced fractures 3
• Open fractures 3
• Neurovascular compromise 2, 3
• Fracture-dislocations, particularly those involving the surgical neck 6

Expedited Orthopedic Referral For:

• Complex comminuted fractures requiring surgical planning 1
• Scapular fractures (frequently require operative management) 1
• Traumatic massive rotator cuff tears (delayed treatment leads to suboptimal functional outcomes) 3

Conservative Management Appropriate For:

• Nondisplaced or minimally displaced fractures without neurovascular compromise 3
• Isolated greater tuberosity fractures (if displacement <5mm) 3