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A 25-year-old man lost his balance while getting onto his bicycle and fell forward, landing on his outstretched right arm. He complained of pain in his right shoulder. There is no other injury. He presents holding his arm as shown in the photograph. He found it painful to move his shoulder from this position. There was no shoulder deformity or localized tenderness.

  • What, if any, abnormalities are present on the shoulder radiograph (Figure 1)?
  • How would you manage this patient’s shoulder injury?

Shoulder Radiographs

When ordering a radiographic study, it is important to know which views are included and whether they have been properly performed. The standard views included in a radiographic study often vary from hospital to hospital. This is especially true of the shoulder. In many hospitals, the standard radiographs of the shoulder are AP views of the patient with the arm (humerus) in external and internal rotation (Figures 2 and 3).

Figure 2

Normal AP views of the shoulder.

(A) AP view in external rotation. The greater tuberosity projects laterally (arrow).

(B) AP view in internal rotation. The greater tuberosity has rotated anteriorly and is seen en-face. The humeral head has a rounded appearance. The lesser tuberosity projects medially (arrowhead).

Figure 3

Shoulder anatomy.

[From Pansky B: Review of Gross Anatomy, 6th ed. McGraw-Hill, 1996.]

In Patient 6, because of his limited range of motion, only one view was obtained.

The standard AP views of the shoulder may not be sufficient to establish a diagnosis in certain situations.

An additional view was obtained in this patient (Figure 4).

  • Which view is this?
  • Are any abnormalities present?
  • When should you order this additional view?

The shoulder is the most frequently dislocated joint owing to the shallowness of the glenoid fossa and the shoulder’s great mobility. The vast majority of shoulder dislocations are anterior (>95%). Posterior dislocations are uncommon because the strong muscular and skeletal support prevents posterior displacement of the humeral head.

Posterior shoulder dislocations are frequently misdiagnosed; up to 50% are missed on initial presentation. They are missed because of a lack of familiarity with this uncommon injury, and a failure to appreciate the findings on the standard AP views ...

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