Intended for healthcare professionals

Endgames Picture Quiz

More than just a simple fracture

BMJ 2014; 349 doi: (Published 22 July 2014) Cite this as: BMJ 2014;349:g4600
  1. Mohammed Monem, foundation year 2 doctor1,
  2. Alex Trompeter, consultant orthopaedic trauma surgeon2
  1. 1Kingston Hospital, Kingston upon Thames, UK
  2. 2St George’s Healthcare NHS Trust, London SW17 0QT, UK
  1. Correspondence to: A Trompeter alex_trompeter{at}

A 10 year old white girl presented to our emergency department after falling on to her left arm while cart wheeling in her garden. After the fall, she had pain and was reluctant to move her arm. She had no symptoms before the fall and no other injuries at the time. She was otherwise fit and well with no medical history of note.

On examination, she had mild swelling of her left upper arm, which was tender. The skin was intact with no bruising or other external signs of injury. No deformity of the upper limb was noted, and her distal neurological and vascular status was normal on examination. This was an isolated injury. Basic observations including heart rate, blood pressure, and temperature were all normal. She was otherwise well.

Plain anterioposterior (fig 1) and lateral radiographs of the left shoulder were requested.


  • 1. What does the radiograph show?

  • 2. What in this case suggests that this is an atypical injury?

  • 3. What is the differential diagnosis?

  • 4. How would you confirm the diagnosis?

  • 5. How would you manage patients with this condition?


1 What does the radiograph show?

Short answer

This anterioposterior radiograph of the left proximal humerus shows a fracture in the proximal metaphysis. Minimal displacement is seen and there is no intra-articular involvement. However the bone has a lytic appearance. This is a pathological fracture.

Long answer

In patients who have experienced trauma to the humerus, it is important to request both anterioposterior and lateral radiographs. The anterioposterior radiograph shows an underlying expansile metaphyseal lytic “bubble” lesion (fig 2), which is spreading distally to the diaphysis and is accompanied by cortical thinning. This lesion abuts but does not affect the physis (growth plate), and no periosteal reaction is seen. There is no associated soft tissue lesion. The zone of transition from normal to pathological bone …

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