Page 1 of 4Clinical Challenge
An 11-year-old female with no significant past medical history, presents with a five day history of right shoulder pain. The patient’s mother reports that the patient was “horsing around” with her older brother five days ago. She attempted to slap her brother using her arm when she immediately felt a “popping” sensation in her right shoulder. She was taken to a local emergency department where she was evaluated, imaged, and discharged home with the diagnosis of “shoulder strain”.
On today’s visit, the patient has ongoing right shoulder pain and is not moving her right arm. She notes decreased oral intake secondary to pain complaints and inability to feed herself, as she is right hand dominant. She has had a fever since yesterday. Oral temperature at home was 102˚F. She denies recent cough, coryza, sore throat, vomiting, diarrhea, and urinary symptoms.
Mother denies any known past medical conditions, prior surgeries, significant family history, and the patient’s immunizations are up to date.
On examination, the child is of appropriate stature for her age, well appearing, interactive, and in no acute distress.
Vital Signs: Pulse 124; Temp (Src) 102.6 ˚F (39.2 ˚C) (Oral); Resp 16; Wt 38.5 kg; SpO2 99%
Lung sounds are clear. Abdominal exam is normal. TMs, nares, and oropharynx are clear. The right arm is adducted and held firmly against her torso. The elbow is held in about a 30 degree flexion. A notable asymmetry is evident when comparing her shoulders, with the right shoulder sloping downward. There is tenderness of the humeral head and neck as well as in the deltopectoral groove. Palpation of the clavicle does not reveal any crepitus or obvious fractures. When prompted to range her arm, the patient is tearful, anxious, and in moderate/severe discomfort. She is able to range the elbow and wrist with minimal complaints. She refuses to range the shoulder in any direction and resists passive movement. The shoulder girdle is not warm or erythematous and is without any overlying cellulitis. Symmetric radial and ulnar pulses are present, and the distal neurovascular examination is intact.
What do you suspect?
- Dislocation / Subluxation
- AC Inury
- Septic Arthritis
- Clavicular Fracture
- Humerus Fracture
What do you see? What comes next? Continue to NEXT page