Everything is MSK

History: Fall/Syncope

EMR: Seizure disorder. Fell from wheelchair. 

What a hazy-gray mess on this sitting acquisition. Patient isn't setting records on inspiration either.  I'm sure all of you are carefully inspecting the anterior junction line, but let's pretend like we've already just given them atelectasis, poooosssibly mild edema and moved on to the bones.   CLAHE?

Ahhhhhh. Much, much better. Do you see it?   How bout we magnify too. 

Scapular fracture!  They mostly worked this fella up for his chronic hydrocephalus and seizure issue.  After a stable HCT, this guy was paperwork away from discharge before we caught this. 

Even extends into the glenoid. Very efficient patient fall. 

Lucky for all of you, this isn't a scapular fracture case.  It's mostly a reminder that, for better or worse, CXRs are also half-assed AP Shoulder XRs. 

Have a plan for how to inspect the shoulder girdle on your CXR.  I look at the upper corners of trauma films first out of habit.  You can look at them last.  Throw it in there somewhere. 

This is my jam. If my eyes travel in this angular path, I can inspect the:

-Sternoclavicular joint alignment and general symmetry.

-Clavicle

-AC and glenohumeral joint alignment 

-Lateral margins of the scapula.   

Then you can find fun stuff like this in this patient s/p Fall:

Not the coracoclavicular pseudoarthrosis. There does seem to be an extra density over the lateral border of the partially visualized scapula.  If it's the humeral head, it's too low and medial...

Follow up Shoulder XR shows an anterior dislocation with gnarly greater tuberosity fracture.

Or this in a patient s/p Fall out of bed onto dumbbell:

If looks like a true AP and the trachea is midline, the medial clavicular head should never project over the airway.  This guy also has very peculiar asymmetry of his shoulder posture with anterior rotation of his right girdle.   Sternoclavicular dislocation? Get a CT.... 

WITH CONTRAST! (I forgot to specify that in my dictation.  Luckily no hematoma or fat stranding)

We can get into sternoclavicular details later. 

Surely there are other ways to inspect the upper chest and shoulders on a trauma CXR, but I've had reasonable success with this     clav  -> scap method.