Endgames Picture Quiz

Shoulder injury

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e3172 (Published 03 August 2012) Cite this as: BMJ 2012;345:e3172
  1. S S Jing, foundation year 2 trainee in trauma and orthopaedics ,
  2. S D S Newman, specialist trainee year 3 in trauma and orthopaedics ,
  3. D P S Baghla, consultant in trauma and orthopaedics
  1. 1Department of Trauma and Orthopaedic Surgery, Ealing Hospital, Southall UB1 3HW, UK
  1. Correspondence to: S S Jing shanshan.jing{at}gmail.com

A 57 year old right hand dominant woman presented to the emergency department with left shoulder pain one day after a low energy fall from standing height onto her outstretched arm. On clinical examination, she was haemodynamically stable with a swollen and bruised left shoulder. Palpation of the shoulder showed maximal tenderness over the proximal humerus, with global restriction of shoulder movement because of pain. No distal neurovascular deficit was noted. She was a non-smoker, had a body mass index of 28, and was otherwise fit and well with no risk factors for osteoporosis. Plain shoulder radiographs were obtained (figs 1 and 2).

Fig 1 Anterioposterior radiograph of left shoulder

Fig 2 Scapular Y view of the left shoulder joint


  • 1 What abnormality do the radiographs show?

  • 2 What further imaging should be considered?

  • 3 Which neurovascular structures are at risk?

  • 4 What are the options for managing this patient?


1 What abnormality do the radiographs show?

Short answer

The shoulder radiographs show a valgus impacted fracture of the left proximal humerus. It is multifragmentary, affecting the surgical neck, lesser tuberosity, and greater tuberosity.

Long answer

Radiographic evaluation is essential to allow diagnosis, fracture classification, and planning of treatment. Imaging of fractures of the proximal humerus should include three views: an anterioposterior, axillary, and scapular Y view. The shoulder radiographs show a displaced intra-articular fracture of the left proximal humerus. It is multifragmentary, involving the surgical neck and greater and lesser tuberosities. The humeral head articular fragment is rotated and impacted in a valgus position. This is unusual given the forces involved in the injury. More commonly, a two part fracture is sustained.

Proximal humerus fractures account for about 5% of all fractures.1 Most are caused by direct impact onto a shoulder, although they can occur through the transmission of force from a fall onto an outstretched …

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