Shoulder Pain- Trampoline

Abstract

HISTORY: A 10 year old female presented with left shoulder pain 1 week after she fell while attempting a handstand on a trampoline. She was seen in the ED on the day of injury where x-rays of her c-spine and entire left upper extremity were normal. She was diagnosed with a shoulder contusion and placed into a sling. Despite Motrin and Tylenol, she continued to complain of ongoing pain and was unable to raise her arm out of the sling. She denied numbness or weakness in the extremity but mom mentioned that her hand occasionally appeared mottled. PHYSICAL EXAM: Ecchymosis to the posterior aspect of her upper arm. Tender to palpate over the glenohumeral joint line. ROM diminished in all planes due to pain. Strength 5/5 IR, 4/5 ER. Absent radial pulse. Sensation intact. AIN/PIN intact. Normal exam of her c-spine, elbow and wrist. Her hand was pink and well perfused. DIFFERENTIAL DIAGNOSIS: 1) Arterial compromise 2) Fracture 3) MDI of shoulder4) Rotator cuff injury TESTS & RESULTS: MRI Left Shoulder: 1. High grade tear of the latissimus dorsi and teres major with avulsion of the teres major/latissimus dorsi tendon 2. Brachial artery cut off at the level of the humeral neck 3. Tear of IGHL 4. Myotendinous junction tear of the infraspinatous tendon with intrasubstance tear of the distal tendon 5. Humeral head contusion CTA: Abrupt cutoff of the brachial artery at the level of the proximal humerus. Appearance consistent with arterial injury with resultant thrombosis. FINAL/WORKING DIAGNOSIS: 1) Brachial artery thrombosis 2) Latissimus dorsi/teres major tendon tear. Tear of IGHL. TREATMENT & OUTCOMES: 1) Admitted to Hematology service for initiation of anticoagulation therapy- Enoxaparin 1 mg/kg BID for 3 months followed by ASA 81 mg for 9 months. 2) Serial US with Doppler of her LUE monitored monthly until resolution of her thrombus3) Managed non-operatively with close follow up with orthopedics, IR, hematology and plastic surgery services. 4) MRI shoulder with arthrogram completed 3 months following injury revealed healing of her IGHL tear without extravasation of contrast. Interval healing of previously seen teres major/latissimus dorsi tears. 5) Continues to progress in PT working to improve strength and motion.