What is the appropriate evaluation and management for a patient presenting with pain at the top of the humerus?

Evaluation and Management of Pain at the Top of the Humerus

Start with standard three-view shoulder radiographs (AP in internal rotation, AP in external rotation, and axillary or scapula-Y view) to identify fractures, dislocations, or malalignment—this is the preferred initial diagnostic approach for acute shoulder pain. 1

Initial Imaging Strategy

Radiography First-Line

• Radiographs are the preferred initial diagnostic modality because they effectively delineate shoulder malalignment and most shoulder fractures, which are the two primary concerns in acute traumatic shoulder management. 1
• The standard trauma series must include all three views—never rely on AP views alone, as glenohumeral and acromioclavicular dislocations are routinely misclassified without orthogonal views. 1, 2, 3
• The axillary or scapula-Y view is absolutely vital for accurate diagnosis of dislocations and can detect scapular fractures that are frequently missed on standard AP views, especially when nondisplaced. 1, 3

Common Pitfall to Avoid

• Standard shoulder radiographs are typically cropped at the mid-humerus, potentially missing mid-shaft lesions that can present as shoulder pain. 4 If symptoms don't respond to standard treatment or clinical findings are inconsistent with imaging, obtain a complete humerus radiograph. 4

Advanced Imaging Based on Initial Findings

When Radiographs Show Fracture

• CT without contrast should be obtained for proximal humeral fractures when surgical planning is needed, as CT can affect clinical management in up to 41% of patients by better characterizing fracture morphology, particularly in complex comminuted fractures. 1
• CT is superior to radiography for identifying subtle nondisplaced fractures and is the most useful modality for detecting scapular fractures. 1
• Radiographs alone are sufficient for fracture classification and determining initial management approach (surgical versus nonsurgical) for most proximal humeral fractures. 1

When Radiographs Are Normal or Indeterminate

• MRI without IV contrast is the appropriate next step if radiographs are noncontributory but clinical suspicion remains high for soft tissue pathology. 1
• MRI can establish underlying pathology including rotator cuff tears, osseous contusions, acromioclavicular sprains, and bony abnormalities following glenohumeral joint dislocation. 1
• In the acute posttraumatic setting, MRI without contrast is preferred over MR arthrography. 1

Ultrasound Limitations

• Ultrasound has limited usefulness for pain at the top of the humerus unless the pain can be specifically localized to the rotator cuff or biceps tendon. 1
• While US can diagnose proximal humerus fractures, it is generally limited in evaluating bone due to acoustic shadowing. 1

Specific Clinical Scenarios

Suspected Dislocation

• Obtain pre-reduction radiographs to confirm dislocation and identify associated fractures before attempting reduction. 2
• Post-reduction radiographs are necessary to confirm successful reduction and evaluate for fractures that may have been obscured by the dislocation. 2
• Assess for neurovascular compromise following reduction, as axillary artery injury can occur, especially with associated proximal humeral fractures. 2
• If vascular compromise is suspected, CT angiography is the preferred examination. 2

Greater Tuberosity Fractures

• Surgical fixation is recommended for fractures with >5 mm displacement in the general population or >3 mm displacement in active patients involved in frequent overhead activity. 5
• These fractures may be associated with partial-thickness rotator cuff tears and labral tears, which can cause persistent pain after fracture healing. 5

Nerve Injury Considerations

• Radial nerve injury is the most common nerve complication with humeral shaft fractures. 6
• With proximal humerus fractures, particularly dislocation fractures, axillary nerve lesions and plexus irritation are most frequent. 6
• Primary radial nerve paresis is a relative indication for surgery; secondary radial nerve paresis (developing after initial presentation) is an absolute indication for operation. 6