Management of Fall on Shoulder
Immediate Assessment Priority
Obtain standard three-view shoulder radiographs (AP in internal rotation, AP in external rotation, plus axillary or scapular Y view) before any manipulation to identify fractures and dislocations, as the axillary/Y view is essential because AP views alone miss up to 50% of glenohumeral dislocations. 1
Initial Clinical Evaluation
History Components That Guide Management
Document the exact fall mechanism: height of fall, landing position (direct impact vs. outstretched hand), and whether the patient heard/felt a "pop" or experienced immediate deformity 2
Assess for high-risk features in elderly patients (>65 years): even minor-impact falls represent major trauma mechanisms in geriatrics and warrant comprehensive evaluation for occult injuries including blunt head trauma, spinal fractures, and proximal humerus fractures 3
Determine time spent on ground after fall: prolonged time down suggests loss of consciousness, severe injury, or inability to self-rescue—all requiring broader evaluation 3
Screen for pre-fall symptoms: syncope, near-syncope, orthostasis, chest pain, or palpitations that may indicate the fall was secondary to a medical event rather than purely mechanical 3
Medication review is mandatory: specifically assess for vasodilators, diuretics, antipsychotics, sedative/hypnotics that increase fall risk and may have precipitated the event 3
Physical Examination Sequence
Inspect for deformity, asymmetry, or abnormal shoulder contour suggesting dislocation or displaced fracture; look for muscle atrophy in supraspinatus/infraspinatus fossae indicating chronic rotator cuff pathology 4
Palpate systematically: proximal humerus, clavicle (entire length), acromioclavicular joint, and scapula for focal tenderness or step-off deformities 4
Perform neurovascular assessment BEFORE any reduction attempt: palpate radial and ulnar pulses (absence requires immediate vascular imaging), test axillary nerve sensation over lateral deltoid ("regimental patch"), assess radial nerve function (wrist/finger extension), and document median/ulnar nerve function 2, 5, 6
Test active range of motion only if no obvious deformity: inability to initiate abduction suggests rotator cuff tear or severe pain inhibition; preserved passive motion with painful active motion indicates rotator cuff pathology rather than adhesive capsulitis 2
Imaging Protocol
Mandatory Initial Imaging
Plain radiographs are the first-line study for ALL traumatic shoulder presentations and must include three views minimum: AP internal rotation, AP external rotation, and axillary or scapular Y view 2, 1
The axillary or Y view is non-negotiable: posterior dislocations are missed in over 60% of cases when only AP views are obtained, and acromioclavicular separations are frequently misclassified without orthogonal views 1
Obtain radiographs with patient upright when possible: supine positioning underrepresents malalignment and can lead to missed dislocations 2
Advanced Imaging Indications
CT without contrast is indicated when: radiographs show complex fracture patterns requiring surgical planning (especially scapular, glenoid, or comminuted proximal humerus fractures) 2, 1
CT angiography is the preferred study if vascular compromise is suspected: particularly with proximal humeral fractures or high-energy mechanisms where axillary artery injury may occur 1
MRI without contrast or ultrasound (if local expertise available) for suspected rotator cuff tears: indicated when radiographs are normal but clinical examination suggests significant soft tissue injury, particularly in patients >35 years with weakness or inability to maintain abduction 2, 4
Post-reduction radiographs are mandatory: confirm successful reduction and evaluate for fractures that may have been obscured by the dislocation 1
Management Based on Findings
If Dislocation Identified
Reduction should be performed promptly to minimize risk of neurovascular complications, but only after pre-reduction radiographs and neurovascular documentation 1, 7
Post-reduction protocol: obtain confirmatory radiographs, repeat neurovascular examination, immobilize in sling, and arrange orthopedic follow-up within 3-5 days 1, 7
Older patients (>40 years) with dislocation require assessment for associated rotator cuff tears: these are common and may require MRI evaluation even after successful reduction 1
If Fracture Identified
Unstable or significantly displaced fractures require immediate orthopedic consultation for potential surgical fixation 2
Stable, minimally displaced fractures may be managed conservatively: immobilization in sling, ice, analgesia, and orthopedic follow-up within 5-7 days 2
Clavicle and proximal humerus fractures: plain radiographs are sufficient for initial diagnosis and treatment planning 2
If Radiographs Normal but Significant Pain/Dysfunction
For patients >35-40 years with painful arc (pain during 70-120° abduction) and positive Hawkins/Neer tests: diagnose subacromial impingement or rotator cuff tendinopathy 2
Initial management: complete rest from aggravating activities until pain-free, NSAIDs for acute pain, ice application 2
Refer to physical therapy as first-line treatment: evidence-based conservative care leads to full recovery in approximately 80% of patients within 3-6 months 2
MRI is NOT required initially when clinical findings clearly establish impingement diagnosis; reserve MRI for patients who fail 3-6 months of adequate conservative therapy or when full-thickness tear is suspected 2
For patients <35-40 years: prioritize assessment for instability and labral pathology; if suspected, MR arthrography is the gold-standard imaging modality 2, 4
Fall Risk Assessment and Prevention (Especially for Elderly)
Perform orthostatic blood pressure measurement: check supine and after 1 and 3 minutes standing to identify orthostatic hypotension 3
Assess gait and balance: difficulty with either predicts future falls and requires physical therapy referral 3
Document fall history: falls in the previous year are the strongest predictor of future falls 3
Screen for high-risk comorbidities: dementia, Parkinson's disease, stroke, diabetes, previous hip fracture, depression, visual impairment, and peripheral neuropathy 3
Expedited outpatient follow-up with home safety assessment is recommended for elderly patients discharged from ED after fall; admission should be considered if patient safety cannot be ensured 3
All elderly patients admitted after fall require physical therapy and occupational therapy evaluation during hospitalization 3
Rehabilitation Protocol (Once Acute Injury Managed)
Early mobilization is critical after fracture or surgery: range-of-motion exercises for shoulder, elbow, wrist, and hand should begin within first postoperative days 3
Sling use should be minimized: worn for comfort only and discarded as early as pain allows to prevent adhesive capsulitis 3
Restrict above-chest-level activities until fracture healing evident (typically 6-8 weeks), as overly aggressive therapy increases fixation failure risk 3
For rotator cuff pathology: progress through three phases: (1) complete rest until asymptomatic, (2) stretching/mobilization focusing on external rotation and abduction, (3) rotator cuff and scapular stabilizer strengthening once pain-free motion achieved 2
Avoid overhead pulley exercises: these encourage uncontrolled abduction and can worsen rotator cuff pathology 2
Return to activities requires 1-3 months of functional, progressive, individualized program without symptom recurrence 2
Critical Pitfalls to Avoid
Never attempt reduction without pre-reduction radiographs: attempting reduction of a fracture-dislocation without imaging can worsen the injury 1
Do not assume absence of trauma means absence of fracture in elderly: osteoporotic fractures occur with minimal or unrecognized trauma 2
Failure to obtain axillary or Y view is the most common cause of missed posterior dislocation: this error has significant medicolegal implications 1
Do not overlook neurovascular injury: document baseline neurovascular status before any manipulation, as nerve injuries (particularly axillary, radial, and ulnar nerves) occur in 5-35% of shoulder dislocations depending on mechanism and patient age 5, 6, 8
Delaying reduction increases complication risk: prompt reduction minimizes neurovascular compromise and improves outcomes 1
In elderly patients, do not focus solely on the shoulder injury: assess for multifactorial causes of fall including cardiac, neurologic, and medication-related etiologies 3