What clinical signs suggest a shoulder fracture?

Clinical Signs of Shoulder Fracture

Plain radiographs (anteroposterior in internal and external rotation plus axillary or scapular Y view) are mandatory as the first imaging study for any patient with traumatic shoulder pain to identify fractures, as standard AP views alone miss up to 50% of glenohumeral dislocations and associated fractures. 1, 2

Key Clinical Presentations by Fracture Type

Proximal Humerus Fractures

• Elderly patients presenting after low-energy falls (such as ground-level falls) are the classic demographic, as these fractures predominantly occur in osteoporotic bone 3
• Patients hold the affected arm against their body with the contralateral hand and demonstrate marked pain with any attempted shoulder motion 3
• Visible deformity, swelling, and ecchymosis around the shoulder and upper arm are common physical findings 4, 3
• Inability to actively elevate or abduct the arm, even when passive motion may be partially preserved, suggests fracture rather than isolated soft tissue injury 3

Clavicle Fractures

• Clavicle fractures are among the most common acute shoulder injuries, typically occurring in young adults from sports injuries or direct trauma 4, 3
• Visible or palpable deformity along the clavicle shaft with localized tenderness and swelling 4
• Patients support the affected arm at the elbow to minimize movement and reduce pain 4

Fracture-Dislocations

• All posterior shoulder dislocations should be assumed to have an associated fracture until proven otherwise by imaging, as these injuries are frequently missed on initial evaluation 5, 6, 7
• Anterior fracture-dislocations with greater tuberosity fractures present with a palpable humeral head in the axilla or a dimple inferior to the acromion laterally 3
• Locked posterior dislocations create a characteristic "lightbulb sign" on AP radiographs and severe restriction of external rotation 6, 7

Critical Physical Examination Findings

Neurovascular Assessment

• Palpate radial and ulnar arterial pulses bilaterally—absence of a pulse after high-energy trauma or dislocation requires immediate vascular imaging with duplex ultrasound or CT angiography 2
• Test sensation in the axillary nerve distribution (lateral deltoid region) and assess deltoid motor function, as axillary nerve injury accompanies up to 40% of proximal humerus fractures 8, 2

Distinguishing Fracture from Soft Tissue Injury

• Pain severity disproportionate to mechanism of injury in elderly patients suggests occult fracture, even when trauma seems minimal or unrecognized 2
• Crepitus with passive motion or palpation along bony structures indicates fracture 4, 3
• Inability to maintain arm elevation against gravity (positive drop arm sign) may indicate either rotator cuff tear or fracture; imaging is required to differentiate 2, 3

Age-Specific Red Flags

Patients Over 35-40 Years

• Focus examination on proximal humerus fractures and associated rotator cuff tears, which occur in up to 40% of these fractures 8, 2
• Degenerative bone changes make even minimal trauma sufficient to cause fracture 2, 3

Patients Under 35-40 Years

• High-energy mechanisms (contact sports, bicycle accidents, motor vehicle collisions) are typical for fractures in this age group 3
• Fracture-dislocations are more common than isolated fractures in younger patients with traumatic injuries 5, 7

Imaging Protocol

Initial Radiographic Views

• Obtain upright radiographs with three mandatory views: AP in internal rotation, AP in external rotation, and axillary or scapular Y view 1, 2
• Supine positioning underrepresents shoulder malalignment and misses pathology—always image upright when possible 2
• Add a Grashey view (30° posterior oblique) when instability or dislocation is suspected to better profile the glenohumeral joint 2

Advanced Imaging Indications

• CT with three-dimensional reconstruction is the gold standard for characterizing fracture patterns, measuring displacement, and evaluating humeral neck angulation 8
• CT alters the management plan in up to 41% of patients with complex proximal humerus fractures compared to plain radiographs alone 8
• Non-contrast MRI is useful in patients unlikely to undergo surgical fixation to assess rotator cuff integrity, as rotator cuff tears accompany approximately 40% of proximal humerus fractures 8

Common Diagnostic Pitfalls

• Do not assume absence of recalled trauma means absence of fracture—osteoporotic fractures occur with minimal or unrecognized trauma in elderly patients 2
• Posterior dislocations are frequently missed because the humeral head may appear aligned on standard AP views; the axillary view is essential 2, 6
• Ultrasound has limited utility for detecting fractures in acute traumatic shoulder pain, though it can identify proximal humeral fractures in 90% of cases when performed by experienced operators 1, 2