Severe Shoulder Pain in a Healthy Adolescent Child

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HISTORY: A 12-year-old child presented to sports medicine clinic with his grandfather for evaluation of 4 days of diffuse left shoulder and upper arm pain. Pain developed hours after holding onto a rope while tubing in a lake. He denies being thrown off the tube or shoulder pain while riding. Pain was 4/10 pain at rest and 9/10 pain with movement. Pain gradually worsened over previous past 4 days. He denied any previous injury to the left arm or shoulder. He denied any numbness, or tingling of the left arm. He denied any changes in vision, headaches, chest pain, shortness of breath, or rashes. Of note, he went to the ED two days prior due to subjective fevers and diagnosed with a viral upper respiratory infection. PHYSICAL EXAM: Vitals signs were normal. He was distressed and tearful. He had no tenderness and full range of motion (ROM) of his cervical spine. There was diffuse left sided tenderness over the sternum, ribs, mid-humerus, biceps, upper trapezius, and rhomboids. Pain with active and passive ROM of the elbow and shoulder. Shoulder strength was limited due to pain. Sensation was intact throughout the left upper extremity. No skin discoloration, breaks, or increased warmth of the left arm or shoulder. DIFFERENTIAL DIAGNOSES: 1. Rotator cuff tendinopathy 2. Shoulder dislocation and/or glenoid labral tear 3. Occult Humerus fracture 4. Infection INITIAL TEST AND RESULTS: Left shoulder and humerus radiographs were normal. Due to the disposition of the patient, the patient and his family were advised to go to the pediatric ER. A work-up revealed a normal WBC count, and an elevated CK and CRP. Urine and blood cultures were positive for MSSA. MRI of the shoulder and elbow revealed osteomyelitis of left scapular body with left periscapular abscess. Pediatric Orthopedic Surgery was then consulted and performed an incision and drainage (I&D) of the left supraspinatus, infraspinatus, and subscapularis abscesses. FINAL DIAGNOSIS: Acute MSSA osteomyelitis of left scapula with left periscapular abscess TREATMENTS AND OUTCOMES: After surgical I&D, the patient clinically improved over a two-week hospital course and discharged after 4 weeks of IV antibiotics. He was then transitioned to oral antibiotics for an additional 8 weeks. At the 8-week clinical follow-up there was a complete resolution of shoulder and upper extremity pain.