Fall, Shoulder Pain, Now What?

Hi Reader

This weeks case review. 16 y.o triathlete falls off their bike, immediate left shoulder pain.

Now before we get into this weeks shoulder X-ray, lets summerise last weeks. How did you get on? Did you manage to spot the most obvious injury?

As a reminder, our 69 year old patient presented with knee pain and a knee and distal femur X-ray were conducted within the emergency department. This case study did not give us much information and posed more questions than it did answers, so how did you fare?

Let’s work back through the questions we set.

1. What is the most obvious injury that I observe on the X-RAY?

Now on first glance and checking the femur for symmetry or any bone irregularity, you’d be hard done by to assume there’s no fracture, and you would be correct.
So then, what else could be causing this patient’s symptoms?

Well within the shaft - the diaphysis - of the femur we can see some small hallow cut outs (see attached images), where the bone looks slightly less dense compared to the rest. This is a major sign of possible metastatic bone disease, infiltrating lytic lesion such as metastases or multiple myeloma. If you’re unfamiliar with how this looks on X-RAY don’t beat yourself up, it can be an easy miss but it’s slightly easier to spot on the lateral view (both highlighted).

Now this is a major red flag and cause for concern, and hopefully should trigger within you the need for urgent discussion with a senior colleague or referral to specialist services.

2. Do I need to ask any further questions to the patient who is sat in front of me to further clarify their symptoms?

A thorough subjective history regarding the patient's past medical history will aid to our hypothesis in this situation. Symptom duration, night pain or sweats, pain that doesn't resolve despite pain relief or laying flat, are symptoms worse at night time? Depending on the response to all of these questions this may lead you to have a very high suspicion of red flags and very low tolerance to flag to a senior colleague for discussion, if you're considering serious pathology.

Now as this patient is over the age of 40 we need to consider immediate risk of red flags and differential diagnosis, such as metastases or multiple myeloma. As a reminder, likely causes of cancer could be from any large organ such as the lungs, liver, kidneys, and other possible sources can include the breast and ovary in women and prostate in men.

Also remember that our patient has come through A&E, they’ll likely need a blood work up and some further imaging/investigations, perhaps further MRI of the femur or whole body CT scan.

3. What are my next steps in this situation to help the person in front of me?

Personally, I would help reassure the patient about their symptoms in an honest and approachable way which gives them the clarity and acceptance to move forward in a positive way. Realistic expectations about what the future may look like and potentially adjust any exercise interventions they currently I have.

I would avoid heavy bouts of load bearing exercise's such as impact or jumping and I would consider more water based exercise's such as aqua aerobics and controlled land based exercise's, such as, goblet squats, glute bridges and weighted step ups to maintain daily functional tasks (stairs, getting on/off the toilet, maintaining walking tolerance)

This weeks case review: 16 y.o triathlete falls off their bike, immediate left shoulder pain.

As we've started the spring Triathlon season lets discuss the next case; a young triathlete riding their bike falls off unexpectedly, landing on the floor after going over the handle bars. Their X-ray is as follows,

I want you think about the following questions:

• What is the most obvious injury that I observe on the X-RAY?
• Do I need to ask any further questions to clarify their symptoms?
• What are my next steps in this situation?
• How would you rehab this patient 6-weeks after their initial accident?

As always, I hope you've found the above useful, I'll be back next week with another weekly case study review and follow up discussion regarding the above case.

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Enjoy your weekend!