What is the appropriate management for a patient with right shoulder pain after a fall, suspected of having a fracture, dislocation, or soft tissue injury, such as a rotator cuff strain?

Management of Right Shoulder Pain After a Fall

Obtain upright radiographs immediately with three mandatory views: anteroposterior in internal and external rotation plus an axillary or scapular-Y view to exclude fracture and dislocation before proceeding with any other management. 1

Initial Imaging Protocol

• Standard radiography is the required first-line imaging study for all traumatic shoulder pain, as it effectively identifies displaced fractures and shoulder malalignment—the two primary concerns requiring immediate intervention 1, 2

• The three-view series must include:

  • AP view in internal rotation
  • AP view in external rotation
  • Axillary lateral OR scapular-Y view 1, 2

• The axillary or scapular-Y view is absolutely critical and non-negotiable—acromioclavicular and glenohumeral dislocations are frequently misclassified on AP views alone, leading to missed diagnoses 1, 2

• Radiographs must be performed upright rather than supine, as shoulder malalignment can be significantly underrepresented on supine films 1, 2

Physical Examination Priorities

Before imaging, document these specific findings:

• Neurovascular status: Check radial pulse, capillary refill, sensation in axillary nerve distribution (lateral deltoid), and motor function of deltoid and rotator cuff 2, 3

• Deformity or asymmetry: Visual inspection comparing both shoulders for obvious dislocation or displaced fracture 3

• Mechanism of injury: Direct blow versus fall on outstretched hand versus fall directly onto shoulder—this guides differential diagnosis 1, 2

Immediate Surgical Referral Indications

Refer urgently to orthopedics if radiographs show:

• Unstable or significantly displaced fractures (particularly middle-third clavicle fractures in active individuals or displaced proximal humerus fractures) 1, 2, 3
• Any dislocation (glenohumeral or acromioclavicular types IV, V, or VI) 2, 3
• Open fractures 2
• Any signs of vascular compromise (diminished pulses, expanding hematoma, signs of ischemia) 2
• Neurological deficits that don't improve immediately after reduction 2, 4

Management When Radiographs Are Normal

If radiographs show no fracture or dislocation but pain persists:

• MRI without contrast is the next appropriate imaging study for evaluating soft-tissue injuries including rotator cuff tears, labral tears, and bone marrow contusions that are invisible on radiographs 1, 2

• In the acute trauma setting, noncontrast MRI is preferred over MR arthrography because acute injuries typically produce joint effusion that provides natural contrast for assessing intra-articular structures 1

• MRI is superior to CT for diagnosing all soft-tissue injuries (rotator cuff tears, labral tears, ligament injuries) and is equivalent to CT for detecting nondisplaced fractures 1

• Ultrasound can be considered as a screening tool in older patients where rotator cuff tears are more common, but maintain a low threshold for proceeding to MRI if ultrasound is noncontributory, as US is inferior to MRI for labral, osseous, and rotator cuff pathology 1

Conservative Management for Soft-Tissue Injuries

Most soft-tissue shoulder injuries can be managed conservatively initially:

• Rotator cuff tears (even full-thickness tears in many cases) can undergo a period of conservative management before considering surgery 1, 2, 3

• Low-grade acromioclavicular separations (types I and II) are managed conservatively 3

• Labral tears without instability can be managed conservatively 2

Conservative management includes:

• Sling for comfort (typically 1-2 weeks, not prolonged immobilization) 3
• Targeted musculoskeletal rehabilitation program 3
• Pain control with acetaminophen as first-line (650-1000 mg every 6 hours, maximum 4 grams daily) 5

Surgical Considerations for Soft-Tissue Injuries

Surgery may be indicated for:

• Type III acromioclavicular sprains in active individuals (this is controversial; discuss with patient) 3
• First-time glenohumeral dislocation in young athletes (to prevent recurrent instability) 3
• Full-thickness rotator cuff tears with persistent symptoms after conservative management, particularly in older patients where the incidence of rotator cuff tears with shoulder dislocation approaches 100% in those over 70 years 6

Critical Pitfalls to Avoid

• Never rely on AP views alone—you will miss dislocations 1, 2
• Never perform supine radiographs—they underrepresent malalignment 1, 2
• Never skip neurovascular examination documentation, particularly in high-energy trauma 2
• Never order CT as the initial study unless you're characterizing a known fracture for surgical planning—it provides no useful information about soft-tissue injuries and MRI is equivalent for detecting occult fractures 1