Shoulder and clavicle fractures

Written by the X-Ray Atlas editorial team from the sources listed below · Medical review pending · Updated 24 October 2026 · Level: Beginner

The shoulder girdle is a chain: the humerus articulates with the scapula, the scapula hangs from the clavicle at the acromioclavicular (AC) joint, and the clavicle connects to the sternum. Injury to any link can look subtle on a single film. Older people fracture the proximal humerus after a simple fall; younger people more often break the clavicle or disrupt the AC joint; and a scapular fracture is a marker of high-energy trauma. This guide covers how to look, the classifications you will hear, the normal measurements and the traps.

1. How to look at a shoulder film

Use two orthogonal views, usually an AP and a scapular Y-view or axial view (see shoulder dislocation for the views in detail). Then work round the girdle in the same order every time:

1. Glenohumeral joint: is the head congruent with the glenoid on both views?
2. Proximal humerus: trace the cortex of the head, the anatomical neck, the greater and lesser tuberosities and the surgical neck.
3. Scapula: the glenoid rim, neck, body, coracoid, acromion and spine.
4. AC joint: the inferior borders of the acromion and the clavicle should be level.
5. Clavicle: trace it from end to end, including the medial third, which is often near the edge of the film.
6. Ribs and lung apex: a rib fracture or a pneumothorax may be the most important finding on the film.

Describe any fracture with the standard language: site, pattern, displacement and angulation, joint involvement. See how to describe a fracture.

2. Proximal humerus fractures

These are common in older adults, often with osteoporotic bone, after a fall onto the outstretched hand or directly onto the shoulder. The commonest site is the surgical neck, the narrowing just below the tuberosities. Fractures of the anatomical neck, at the margin of the articular surface, are much less common but carry a higher risk of avascular necrosis of the head, because the blood supply can be cut off.

The Neer classification

Neer divides the proximal humerus into four parts: the articular head, the greater tuberosity, the lesser tuberosity and the shaft. A part is counted as displaced if it is separated by more than about 1 cm or angulated by more than about 45°. A fracture is then described as one-part (no part meets the displacement criteria, however many lines there are), two-part, three-part or four-part. Most proximal humerus fractures are minimally displaced and are managed without surgery. In practice CT is often used when surgery is being considered, and interobserver agreement on plain films is known to be modest.

What to report

• Which parts are involved, and whether any are displaced or angulated.
• Whether the head is still in the glenoid (a fracture-dislocation changes management).
• An isolated greater tuberosity fracture, which may be subtle and is common with anterior dislocation.
• An isolated lesser tuberosity fracture, which is rare and should prompt a look for a posterior dislocation.

3. Clavicle fractures

The clavicle is one of the most commonly fractured bones, typically after a fall onto the shoulder. About 80% of fractures are in the middle third. Most of the rest are in the lateral third, and medial-third fractures are uncommon. This three-way split is the Allman grouping; the Robinson classification is a more detailed alternative used in orthopaedic practice.

• Middle-third fractures: the medial fragment is often pulled upwards by sternocleidomastoid, and the lateral fragment drops with the weight of the arm. Note shortening, displacement by more than a bone width, and comminution, because these features influence whether surgery is discussed.
• Lateral-third fractures: these can involve the coracoclavicular (CC) ligaments. If the ligaments are torn, the medial fragment rides up and the fracture is effectively unstable.
• Medial-third fractures: often missed because they overlap the spine and mediastinum. CT is often needed.

A dedicated clavicle view usually includes an AP and an AP with cephalic (upward) tilt, which projects the clavicle clear of the ribs.

4. AC joint injury

AC joint injuries follow a fall onto the point of the shoulder. They are graded with the Rockwood classification (types I to VI), which depends on the degree and direction of displacement of the clavicle relative to the acromion and on whether the CC ligaments are torn. On the film:

• Look for a step between the inferior borders of the acromion and the clavicle.
• Measure the AC joint width and the coracoclavicular distance (the gap between the top of the coracoid and the undersurface of the clavicle).
• Compare with the other side if a comparison view has been taken.

A type I injury (sprain) has a normal film. Type II shows widening of the AC joint with a normal CC distance. Type III and above show the clavicle displaced above the acromion with an increased CC distance. Types IV (posterior) and VI (inferior) are rare, and posterior displacement is easier to see on an axial view.

5. Scapula and sternoclavicular injuries

Scapula

The scapula is surrounded by thick muscle and needs considerable force to break. A scapular fracture should therefore make you look hard for associated injuries: rib fractures, pneumothorax, pulmonary contusion, and injuries to the spine and great vessels. Scapular fractures are often first seen on a trauma chest film, and CT is the usual next step. See chest trauma.

Glenoid

Glenoid rim fractures (the bony Bankart) accompany anterior dislocation. Larger glenoid fractures are intra-articular and usually need CT.

Sternoclavicular joint

Posterior sternoclavicular dislocation is rare but dangerous: the medial clavicle can press on the great vessels, trachea or oesophagus [esophagus]. Plain films are hard to interpret (a "serendipity" view with cranial tilt is described), and CT is the test if this injury is suspected.

6. Pitfalls and mimics

• Pseudosubluxation: a proximal humerus fracture with haemarthrosis lets the head sag inferiorly. It mimics an inferior dislocation, but the head remains aligned with the glenoid on the Y-view. It resolves as the haemarthrosis settles.
• The physis in adolescents: the proximal humeral growth plate is wavy and can look like a fracture line. It is smooth, bilateral and in a predictable position. See Salter-Harris fractures.
• A lesser tuberosity fracture or a "trough" line suggests a posterior dislocation has occurred. See shoulder dislocation.
• Pathological fracture: a fracture through a lytic area after minimal trauma should prompt a search for metastasis or myeloma. See bone tumours.
• A normal AC joint film does not exclude a type I sprain, which is a clinical diagnosis.
• The edges of the film: the medial clavicle and the upper ribs are easily ignored.

Red flags: act now

What to focus on, by role

Role	Priorities
Medical student	Surgical neck fracture in older people, middle-third clavicle fracture, and AC joint step. Know the Neer "four parts".
Nurse / ENP	Recognise the common fractures, check the skin over a clavicle fracture, and check distal pulses and sensation.
Junior doctor	Distinguish a fracture-dislocation from a simple fracture, recognise pseudosubluxation, and think of the chest in high-energy injuries.
Radiographer	Cephalic tilt clavicle view, Y-view or axial for every trauma shoulder, and make sure the AC joint and medial clavicle are included.
Advanced / FRCR	Neer part counting, Rockwood grading, glenoid fractures and posterior SC dislocation.

Practise on real upper limb X-rays →

References

1. Radiology Masterclass. Shoulder X-ray gallery. radiologymasterclass.co.uk
2. Radiopaedia. Posterior shoulder dislocation. radiopaedia.org
3. Neer CS. Displaced proximal humeral fractures. Part I. Classification and evaluation. J Bone Joint Surg Am 1970;52(6):1077–89.
4. British Orthopaedic Association. BOAST guidelines. boa.ac.uk
5. NICE NG38. Fractures (non-complex): assessment and management. nice.org.uk
6. Royal College of Radiologists. iRefer. irefer.org.uk

For education only. Not a substitute for a formal report, senior review or your local policy. Never use this page to make decisions about a real patient.