Ortho Case of the Week – Shoulder ANSWERS

Case 1: A 25-year-old male presents with right shoulder pain after falling off a bicycle.

1. What is your interpretation of the x-ray above?

Comminuted fracture of the mid and distal third of the clavicle, with significant displacement and overlap of the fracture ends.

Allman classification of clavicle fractures:

2. How would you manage this patient? When would you consult orthopedics for this type of injury?

Most patients can be managed with sling immobilization and outpatient orthopedics follow-up. However, this patient has significant displacement and skin tending and requires orthopedic consult in the ED.

Indications for ED Orthopedic consultation include all open fractures, displaced fractures with skin tenting, associated neurovascular injury, pediatric fractures with shortening of >2cm, and floating shoulder.

Case 2: An 18-year-old male presents with left shoulder pain after getting tackled in a football game.

3. What is your interpretation of the x-ray above? What grade of injury is this?

Grade III AC joint injury. There is increased AC joint separation with superior displacement of the clavicle and normal coracoclaviclar distance.

4. How would you manage this patient?

This patient can be placed in a sling for immobilization and follow-up with orthopedics as an outpatient within one week.

• Types I-II: rest, ice, sling with return to activity as tolerated
• Types III-VI: orthopedic evaluation, usually as outpatient unless concern for neurovascular compromise. Types IV-VI are generally operative.

When obtaining shoulder series plain films, consider obtaining contralateral/unaffected shoulder for comparison purposes.

Case 3: A 60-year-old male presents with right shoulder pain after a fall from standing.

Source: Radiopaedia

5. What is your interpretation of the x-rays above?

There is an anterior-inferior dislocation of the glenohumeral joint.

Additionally, there is an engaged Hill-Sach lesion evident on the Garth’s projection (right).

6. What nerve is most commonly injured with this pathology? How would you test it?

Axillary nerve.

Test sensation over the lateral deltoid (military patch distribution).