Name: Shoulder injury — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Most shoulder injuries are dislocations, fractures, and cuff tears that are straightforward — except the posterior dislocation that's normal on the AP film, the fracture-dislocation, the axillary nerve injury, and the "shoulder pain" that's actually the heart, the aorta, or the diaphragm. The defensible chart documents the neurovascular exam, the adequate views (including an axillary/Y view), and the post-reduction recheck.

01What's at stake

A posterior dislocation — from a seizure, electrocution, or fall — is famously missed because the AP radiograph can look normal; it needs an axillary or scapular-Y view. A fracture-dislocation can be converted or displaced by an unwary reduction. The axillary nerve can be injured before or by reduction, so the deltoid/lateral-shoulder exam belongs in the chart before and after. And non-traumatic shoulder pain can be referred from an MI, aortic dissection, or diaphragmatic irritation.

02Can't-miss diagnoses

Posterior dislocation — seizure/electrocution/fall, arm held internally rotated/adducted, can't externally rotate; AP may look normal → axillary/scapular-Y view. → axillary view
Fracture-dislocation — surgical-neck/greater-tuberosity fracture with dislocation; identify before reduction. → pre-reduction films
Neurovascular injury — axillary nerve (deltoid/lateral-shoulder sensation), rarely axillary artery/brachial plexus.
Referred / non-orthopedic pain — acute coronary syndrome, aortic dissection, diaphragmatic/abdominal (splenic, biliary) irritation, PE.
Rotator-cuff tear (acute, weakness), AC separation / clavicle fracture (skin tenting, neurovascular threat).

03History & exam

Mechanism (FOOSH, seizure, electrocution, atraumatic); for atraumatic or risk-factor patients, screen for cardiac/aortic/PE sources.
Neurovascular exam before and after reduction — axillary nerve (deltoid contraction, lateral-shoulder sensation), distal pulses, radial/median/ulnar function. → before & after
Adequate radiographs — AP plus an axillary or scapular-Y view to catch posterior dislocation and characterize fractures.
Post-reduction films to confirm relocation and exclude an iatrogenic fracture. → post-reduction films

Skip the typing

Work the case in the Shoulder Injury Workup — it records the axillary view, the axillary-nerve exam, and the post-reduction films, and assembles an MDM that documents the posterior dislocation and fracture-dislocation were addressed.

04Workup & management

Anterior dislocation: document neurovascular status, reduce with adequate analgesia/sedation, confirm with post-reduction films, immobilize, orthopedic follow-up.
Posterior dislocation: confirm with axillary/Y view; reduction often needs orthopedics, especially with a reverse Hill-Sachs/fracture.
Fracture-dislocation: do not force reduction — involve orthopedics.
Referred pain: when the story or risk fits, ECG/troponin, and aortic/PE evaluation before an orthopedic label.
Cuff tear / AC injury / clavicle: sling, analgesia, follow-up; urgent referral for open/tenting/neurovascular-threat injuries.

05What to document

▼ weak

"Shoulder dislocation, reduced, sling. Neurovascularly intact. Discharged."

▲ defensible

"FOOSH; arm in slight abduction/external rotation. Before reduction — axillary nerve intact (deltoid contraction, lateral-shoulder sensation), distal pulses 2+, hand sensorimotor intact. AP and axillary views: anterior dislocation, no fracture (posterior dislocation excluded on axillary view). Procedural sedation; reduced. After reduction — neurovascular exam unchanged; post-reduction films confirm relocation, no iatrogenic fracture. Sling, orthopedic follow-up; return precautions for numbness, weakness, a cold hand, or recurrent dislocation. (Atraumatic onset would prompt cardiac/aortic/PE consideration.)"

06Where charts fail

Missing a posterior dislocation — relying on a normal-looking AP without an axillary/Y view.
Reducing a fracture-dislocation without recognizing the fracture (no pre-reduction films).
"Neurovascularly intact" without the specific axillary-nerve exam, or no post-reduction recheck.
No post-reduction films to confirm relocation/exclude iatrogenic fracture.
Anchoring on "shoulder pain" and missing referred MI, aortic dissection, or diaphragmatic disease.

07Sources

Cunningham NJ. Techniques for reduction of anteroinferior shoulder dislocation. Emerg Med Australas. 2005;17(5-6):463-471.
Gottlieb M. Shoulder dislocations in the emergency department: a comprehensive review. J Emerg Med. 2020;58(4):647-666.
Rouleau DM, Hebert-Davies J. Incidence of associated injury in posterior shoulder dislocation. J Orthop Trauma. 2012;26(4):246-251.
Hasebroock AW, Brinkman J, Foster L, Bowens JP. Management of primary anterior shoulder dislocations: a narrative review. Sports Med Open. 2019;5(1):31.

Shoulder injury: documentation that holds up