Shoulder radiograph (an approach)

Dr Henry Knipe and Dr Jeremy Jones et al.

Shoulder radiographs are common films to see in the Emergency Department, especially during the weekend after sporting events.

Choosing a search strategy and utilizing it consistently is a helpful method to overcome common errors seen in diagnostic radiology. The order in which you interpret the radiograph is personal preference. A recommended systematic checklist for reviewing musculoskeletal exams is: soft tissue areas, cortical margins, trabecular patterns,bony alignment, joint congruency, and review areas. Review the entire radiograph,regardless of perceived difficulty. Upon identifying an abnormality, do not cease the review, put it to the side and ensure to complete the checklist.  

Assess all soft tissue structure for any associated or incidental soft tissue signs 

  • cortex should be smooth
    • humeral head
    • glenoid fossa
    • clavicle
    • body of scapula
  • look for fracture fragments
  • remember the ribs

Although a majority of your focus may be on the shoulder girdle, be vigilant in inspecting the entire radiograph including the:

  • up to 10% of all fractures
  • predominantly midshaft
  • mostly children and the elderly
  • fall onto outstretched hand or shoulder
  • more: clavicle fracture
  • very common injury
  • range from strain to complete joint disruption
  • direct blow or fall onto shoulder with adducted arm
  • step at AC joint, widening of AC joint and/or increased CC distance
  • more: acromioclavicular joint injury
  • common injury resulting in significant disability
  • elderly females: mean age 65 years
  • fall on an outstretched arm
  • more: proximal humeral fracture
  • less than 5% of glenohumeral dislocations but often overlooked
  • common in adults following a seizure or in the elderly
  • humeral head forced posteriorly in internal rotation whilst arm is abducted
  • classically, the humeral head is rounded on AP - light bulb sign
  • associated with anteromedial fracture of humeral head
  • more: posterior shoulder dislocation
  • usually secondary to trauma
  • an effusion or hemorrhage into the joint displaces the humeral head inferiorly
  • this effusion suggests intra-articular fracture
  • do not confuse with dislocation!
  • more: shoulder pseudosubluxation
  • primary bronchogenic carcinoma arising in lung apex
  • account for up to 5% of all bronchogenic cancers
  • always review lung parenchyma, ribs and supraclavicular fossa in AP shoulder radiographs
  • more: Pancoast tumor
Approaches to radiographs

Article information

rID: 28289
Section: Approach
Synonyms or Alternate Spellings:
  • Shoulder xray
  • Shoulder XR
  • Shoulder x-ray

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Cases and figures

  • Figure 1: Annotated frontal view
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  • Case 1: anterior shoulder dislocation
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  • Case 2: clavcicle fracture
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  • Case 3: acromioclavicular joint injury
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  • Case 4: proximal humeral fracture
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  • Case 5: posterior shoulder dislocation
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  • Case 6: lipohemarthrosis and pseudosubluxation
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  • Case 7: Pancoast tumor
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