WIDI - M2) Shoulder pain after fall

M2) Shoulder pain after fall

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with arm pain.
Review the DDx considerations in a patient with arm pain.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with arm pain.

History

An 80-year-old male presents from a nursing home after a fall out of bed. The patient has since complained of severe right shoulder pain.

Physical Exam

BP: 128/78, HR 82, RR 18, Temp 98.7, O2 saturation 99%. General: The patient holds their right arm adducted to their side. MSK: There is ecchymosis and swelling over the right shoulder. Right arm movement causes significant right shoulder pain. There is a slight deformity over the right proximal arm. There is tenderness over the proximal humerus. Sensation is intact over the mid-deltoid. No weakness with abduction or external shoulder rotation initiation. 2+ right radial pulse.

Labs

None.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Right shoulder dislocation

Right proximal humeral fracture

Nerve injury

A or B

All of the above

A right shoulder dislocation or humeral fracture with a displaced fracture fragment are possible in this case. Considering the lack of physical exam findings, an axillary or suprascapular nerve injury is unlikely.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

While the patient’s condition is not immediately life-threatening, they require expedited workup.

First Imaging Study

What is the first imaging study you will order?

Right humerus X-ray

Right humerus CT scan

Right humerus MRI

A right humerus X-ray is an appropriate, cost effective option for identifying and characterizing a fracture.

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Right humerus X-ray

There is a joint dislocation.

Yes

While best evaluated by a scapular Y-view, the provided views do not suggest a shoulder dislocation as the humeral head sits within the glenoid fossa.

There is a fracture.

Yes

There is a transverse, laterally displaced, and impacted fracture of the right humeral neck.

View Report

Watch our video

View the full study if you'd like to take a look yourself.

Launch Dicom

Second Imaging Study

What is the next imaging study you will order?

Right arm CT

Right arm MRI

None

No further imaging is required as the fracture can be appropriately identified and characterized with radiography alone.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Neer one-part fracture

Neer two-part fracture

Neer three-part fracture

Neer four-part fracture

This is a Neer two-part fracture as there is one displaced fragment.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

While the patient’s condition is not immediately life-threatening, they require expedited workup and treatment.

Assessment and Plan

Please provide your assessment and plan for this patient

This is an 80-year-old male presenting with a Neer two-part fracture. For this complex proximal humeral neck fracture, reduction should not be attempted. Instead, he should undergo immobilization with a sling and be referred to an orthopedic surgeon. In the interim, he should undergo immobilization with a sling without attempt for reduction.

Lessons Learned:
- Generally, when a proximal humeral fracture is suspected, a true AP view, axillary view, and scapular Y view (or Velpeau view if a scapular Y view is unobtainable). In this case, an adequate assessment was still possible with the provided views.
- It is important to classify proximal humerus fractures based on the type (transverse, oblique, spiral) and presence of displacement, impaction, or dislocation.
- The Neer classification is as follows: One-part: no displaced fragments; two-part: one displaced fragment; three-part: two-displaced fragments; four-part: 3+ displaced fragments + humeral head dislocation from the glenoid). Patients with Neer one-part fractures usually do well with closed, nonoperative management with a sling.

Socioeconomic Factors: - Proximal humerus fractures are most common in elderly female patients with osteoporosis. Elderly females most often face these fractures from low-energy mechanisms and face the higher mortality than younger males.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator