A Collapse that Led to Shoulder Pain

Abstract

HISTORY: A 55 year old female presents for right shoulder pain. She has a history of multiple sclerosis, recent falls complicated by a right 6th rib fracture and a right 4th phalanx fracture, a 35 pack year history of tobacco use, and an unknown fracture of her right shoulder sustained at age 16. Her current shoulder pain began four weeks prior to her visit while reaching behind her back in the shower. She felt like her shoulder popped out of place. She has achy pain, worse when touching her shoulder or using her walker. It improves with lying down and with a sling. Acetaminophen and ibuprofen do not provide relief. Physical therapy as part of her multiple sclerosis treatment has not helped. PHYSICAL EXAMINATION: BP: 122/82, Pulse: 69, Respirations: 16, SpO2: 96%. Shoulder: - No gross abnormality, no step-offs along the clavicle. - Tender over the entire humeral head and anterior shoulder. - No swelling, warmth, or erythema. - ROM: o Right flexion 85 degrees active, 95 degrees passive. o Right abduction 90 degrees active, 100 degrees passive. o Adduction, internal rotation, external rotation and extension were full and equal bilaterally. - 5/5 strength - Special tests: positive empty can, Hawkin’s, O’Brien’s, and Speed’s test. Negative crossed arm adduction, AC compression, and sulcus sign. Unable to perform Neer’s test due to pain. DIFFERENTIAL DIAGNOSIS: Torn rotator cuff Glenohumeral arthritis Humeral head fracture as part of Osteogenesis Imperfecta Avascular necrosis AC joint arthritis Shoulder dislocation/subluxation Elder Abuse TEST AND RESULTS: Shoulder 3 view XR: - Extensive posttraumatic deformity of proximal right humerus with marked irregularity of articular surface. - Possible non-displaced superimposed acute or subacute fracture - Slightly displaced posterolateral right 4th and 5th rib fractures Shoulder MRI: - Marked abnormality of the right humeral head with contour deformity - Progressive collapse of superior articular surface, with focal marrow edema. This may be posttraumatic or relate to avascular necrosis - No rotator cuff tear. FINAL WORKING DIAGNOSIS: Avascular necrosis of the humeral head TREATMENT AND OUTCOMES: - Placed in arm sling for pain control - Referred for surgical replacement of the humeral head - Referred for workup for osteogenesis imperfecta, given multiple fractures