# Orthogonal Radiographs After Shoulder Reduction: Are We Meeting the Standard?

## TL;DR

This study finds that most patients with shoulder dislocations do not receive proper post-treatment X-rays, risking missed injuries and poor care.

## Contribution

The study highlights poor adherence to imaging guidelines and lack of recognition of inadequate radiographs by resident doctors.

## Key findings

- Only 22.7% of patients received adequate post-reduction shoulder imaging.
- Inadequate imaging was rarely recognized or corrected by resident doctors.
- Additional imaging was often required later, but not due to initial imaging failures.

## Abstract

Background

Anterior shoulder dislocation is a common emergency presentation. Post-reduction radiographs are essential to confirm concentric reduction and exclude associated injuries. Guidelines from the British Elbow and Shoulder Society (BESS) and local hospital policy recommend orthogonal views, including anteroposterior and either axillary or scapular Y projections. Failure to obtain adequate imaging risks missed malreduction, overlooked fractures, and unnecessary repeat imaging.

Methods

We conducted a retrospective service evaluation of 22 consecutive patients with anterior shoulder dislocation managed in the emergency department of a single tertiary centre. Radiographic adequacy was defined as the presence of orthogonal post-reduction views in accordance with BESS and local guidance. Data collected included demographics, initial and post-reduction imaging, adequacy of views, whether inadequacies were recognised or acted upon by resident doctors, repeat imaging, and additional investigations.

Results

Only five of 22 patients (22.7%, 95% CI 10.1-43.4) received adequate orthogonal post-reduction radiographs. Inadequate imaging occurred in 17 of 22 patients (77.3%), of which only two cases were recognised by resident doctors (11.8% of documented inadequate cases). No repeat imaging was requested in the emergency department to address inadequate films. Two patients underwent further radiographs later during inpatient admission for social reasons, unrelated to adequacy. Although discharge flow was not interrupted, this reflected a failure to recognise inadequacy at the time of ED care. Additional imaging with MRI, MRI arthrogram, or CT was obtained in several cases as part of subsequent outpatient management.

Conclusion

Compliance with post-reduction imaging standards for shoulder dislocation was poor, and inadequate films were rarely recognised by resident doctors. This represents both a guideline compliance gap and a training issue in radiograph interpretation. Ensuring orthogonal post-reduction views is a basic, low-cost intervention that can improve patient safety and diagnostic certainty. Targeted education and reinforcement of departmental policy, followed by re-audit, are recommended.