A detailed acquisition of history of shoulder complaints (pain, weakness, active deficit in range of motion (ROM), instability, previous surgery) may provide a first hint to pre-existing rotator cuff pathologies. But in the elderly patient a proper evaluation of pre-traumatic shoulder function might be difficult due to reduced practice of the arm and altered pain perception. According to the increasing prevalence of RCTs with age the patient’s age gives an idea of the overall tear probability [6, 11].

Clinical examination of the acute injured patient is mainly limited due to pain. But a careful inspection of the periscapular muscle status may already reveal an atrophy of the fossa supraspinata and/or infraspinata as a sign of a large chronic RCT (see Fig. 11.2). Significant haematoma or soft tissue swelling complicate this assessment. Traumatic lesions of the suprascapular nerve often combined with high velocity trauma and fractures of the scapula are also difficult to examine clinically. If due to the trauma mechanism a nerve injury is suspected additional neurologic diagnostics are indicated.

Plain radiographs of the shoulder are accepted as basic diagnostics for suspected proximal humeral fractures. For a standardized evaluation at minimum two planes (“true ap” and axial view/Velpeau) are required, an additional “outlet view” gives further information. Due to the inability to be visualized directly on plain radiographs, soft tissue structures have been neglected during initial evaluation of proximal humeral fractures. Nevertheless there are secondary signs of chronic rotator cuff insufficiency that are displayed on plain radiographs. The most obvious changes are seen in advanced cuff arthropathy with changes of the shape of the glenoid and acromion (acetabularisation) [12]. In early stages subchondral sclerosis of the acromion and cystic changes in the footprint of the rotator cuff might be evitable (see Fig. 11.3). An advanced osteoarthritic deformation of the head (fragments) or a posterior osteoarthritic glenoid bone loss gives no evidence of rotator cuff insufficiency.

The validity of the combination fracture pattern/dislocation and rotator cuff tear is discussed controversially. Biomechanically a typical fracture dislocation (greater tuberosity – postero-superior, lesser tuberosity – antero-inferior) concludes intact tension vectors (RC) and might be seen as a sign for functional integrity of the rotator cuff. But smaller rotator cuff tears may not be evident for changes in tension vectors. On the other hand two current studies show a positive correlation between severity/displacement of the fracture and prevalence of RCTs [1, 7]. But these differences might be due to different fracture mechanisms and age of the patients. In massive RCTs especially fracture patterns with compression fractures between acromion and humeral head are described.

In complex fractures a computed tomography (CT) scan enhances the consistency in understanding these fractures [13]. Additionally the fatty infiltration of the rotator cuff muscles can be evaluated in the parasagittal reconstruction according to Goutallier et al. [14]. In the elderly patient a generalized mild fatty infiltration in all parts of the RC is a common finding due to muscle inactivity whereas a localized fatty infiltration degree III/IV according to Goutallier is a certain sign for a biomechanically relevant chronic RCT (see Fig. 11.4a, b).

Besides the muscle structure also the muscle volume especially of the supraspinatus muscle can be estimated in CT according to the Thomazeau MRI classification in the parasagittal reconstruction, but changes in the cross-sectional area due to retraction of the musculo-tendinous junction have to be considered [15].

Additional ultrasonographic examination can give further information about the status of the rotator cuff. In traumatic or degenerative RCTs ultrasonography showed a sensitivity and specificity of 85–91 % regarding a detection of RCTs when compared to MR-arthrograms of the shoulder or arthroscopic findings of the shoulder at time of surgery [16]. But this accuracy is strongly dependent on the experience of the investigator. In fracture cases the examination accuracy is additionally limited due to haematoma and fracture dislocation of the RC insertion so that it cannot be recommended as standard diagnostic tool in dislocated multifragmentary fractures. Besides regarding the evaluation of the continuity of the RC some studies show the possibility of evaluating fatty infiltration but haematoma and investigator’s experience may limit this technique [17, 18].

In daily clinical practice Magnetic resonance Imaging (MRI) diagnostics are performed only in few cases of proximal humeral fracture due to its availability and often misinterpretation of bony defect areas (bone bruise). But non- or minimally-displaced humeral head fractures are often not recognized until MRI reveals the fracture. In current radiological studies MRI showed information on fracture morphology comparable to CT but due to the above mentioned reasons it has not found the way to regular clinical practice yet. But in cases of persisting pain after conservative treatment MRI is accepted as standard diagnostic tool besides x-ray.

Diagnostic arthroscopy may reveal especially intraarticular lesions of the RCT and pathologies of the long head of the biceps tendon. But arthroscopy ahead of open refixation is technically limited to 2-Part fractures or minor dislocated fracture patterns. In comminuted or massive dislocated fractures the joint capsule continuity is completely destroyed so that an intraarticular visualisation cannot be achieved [9, 10]. As disadvantage prolonged arthroscopic diagnostics or treatment can cause massive periarticular swelling due to joint capsule interruption and complicate the open surgery itself. So the extent of arthroscopic diagnostics and treatment should be planned carefully.