Differential Diagnoses for Post-Traumatic Shoulder Pain in Roller Derby

Bony Injuries

• Clavicle fractures are among the most common traumatic shoulder injuries, particularly in young adults sustaining direct trauma or falls during contact sports 1, 2
• Scapular fractures are less common but should be considered with high-energy blunt trauma 1
• Unstable or significantly displaced fractures require acute surgical management 1, 2

Joint Injuries

• AC dislocations can be missed on standard AP views, making axillary or scapula-Y views essential 3, 1

Soft Tissue Injuries

• Acute rotator cuff tears are frequently underreported because patients may not seek immediate treatment 1, 2
• Most rotator cuff tears can undergo conservative management before considering surgery 1, 2
• Labral tears (including Bankart and SLAP lesions) occur with traumatic dislocations or direct trauma 1, 2
• Labroligamentous complex injuries are common soft-tissue injuries requiring evaluation 1, 2

Initial Diagnostic Approach

• Obtain upright radiographs with minimum three views: AP in internal rotation, AP in external rotation, and axillary or scapula-Y view 3, 1, 2
• The axillary or scapula-Y view is absolutely critical as AC and glenohumeral dislocations are frequently misclassified on AP views alone 3, 1

Advanced Imaging Indications

• MRI without contrast is effective for diagnosing most traumatic soft-tissue pathology including rotator cuff tears, labral tears, and assessing bone loss 3, 1
• CT is superior to radiography for characterizing complex fracture patterns when surgical planning is needed 3, 1
• CT angiography is the preferred study if vascular compromise is suspected (diminished pulses, expanding hematoma, signs of ischemia) 5

Management Algorithm

• Any signs of vascular compromise require immediate surgical referral 5
• Open fractures require immediate surgical referral 5
• Most rotator cuff tears initially can be managed conservatively 1, 2
• Labral tears without instability can be managed conservatively 1, 2

Critical Pitfalls to Avoid

• Failing to obtain axillary or scapula-Y views, which leads to missed dislocations 3, 1
• Inadequate neurovascular examination documentation, particularly in high-energy trauma 4
• Performing supine rather than upright radiographs, which underrepresents malalignment 3, 1
• Underestimating the severity of AC joint injuries based on AP views alone 3, 1