Teen With Acute Shoulder Pain Four Years After A Car Accident.

Abstract

HISTORY: 18yo male with sudden onset, severe right shoulder pain occurring while sitting in class 11 days prior to presentation. He had a history of a posterior shoulder dislocation at age 14 in a car accident, requiring relocation under sedation without known complication. He completed PT at that time, however was unable to return to football or overhead throwing activities. At the start of his new onset pain, he suspected re-dislocation of his shoulder and went to the ED. X-rays were abnormal but with unclear diagnosis. He was referred to sports medicine clinic for further evaluation and treatment. PHYSICAL EXAMINATION: Inspection: Significant atrophy of the supraspinatus and infraspinatus. Right shoulder was held elevated. Intertrigo noted in right axilla. Range of motion of the shoulder: 20 degrees forward flexion, 20 degrees forward flexion, 0 degrees external rotation, and internal rotation to T12. Strength: 4/5 empty can, 4/5 internal rotation, 3+/5 external rotation. Neurovascular: Brisk pulses, 2 second capillary refill, intact motor exam, and sensation intact in all dermatomes. Special tests: Neer’s positive pain with no increased ROM, Speed’s test positive, O’Brien’s test positive, cross over test negative, and Hawkin’s positive. DIFFERENTIAL DIAGNOSIS: Recurrent shoulder dislocationMalignant or benign bony lesionPathologic fracture of proximal humerusRotator cuff tearDisruption of suprascapular nerve TEST AND RESULTS: X-rays of the right shoulder:- Patchy sclerosis and irregular shape of the humeral head. - Decreased joint space of the glenohumeral joint and elevation of the humeral head.- Hill-Sachs deformity with small adjacent osseous fragment. - Curvilinear osseous density superior to the humeral head - likely calcification of the rotator cuff or loose body. MRI with and without contrastiv> FINAL WORKING DIAGNOSIS: Osteonecrosis of the humeral head TREATMENT AND OUTCOMES: Referred to orthopedic shoulder specialist who plans to do a hemiarthroplasty without a stem. Surgery is planned for December 1, 2017. Follow-up will be available by May 2018.