Test yourself: X-shoulder
Case Study 1
A young man (18 years) falls from his bicycle and hits the pavement with his left shoulder. He indicates that every shoulder movement hurts.
A shoulder x-ray is made (fig. 1).
Figure 1. AP image (a) and a Y image (b) of the left shoulder.
Mid-shaft clavicular fracture. Note: the lucent line and rounded cortical interruption at the humeral head is a not yet fully closed epiphyseal plate (= physiological).
Mid-shaft clavicular fracture.
♦ Figure 1. Answer: mid-shaft clavicular fracture.
Case Study 2
During a rugby game, one of the players says his right shoulder hurts. The symptoms developed following a frontal confrontation with an opponent. Exorotation is particularly painful.
A shoulder x-ray is made (fig. 2).
Figure 2. AP image (a) and a Y image (b) of the left shoulder.
There is abnormal articulation of the glenohumeral joint. The humeral head is dislocated to posterior. Note also the lightbulb sign on the AP image.
Posterior shoulder luxation.
♦ Figure 2. Answer: posterior shoulder luxation.
Case Study 3
A construction worker fell backwards and dropped about 3 m down.
Examination reveals pain of the back of the left shoulder in particular. A shoulder x-ray is made (fig. 3).
Figure 3. AP image in exorotation (a) and a Y image (b) of the left shoulder.
- Comminuted scapular fracture. The fracture line continues up to the glenoid. The fracture lines are best identified on the AP image, however they remain subtle.
- Cortical interruption in left rib 4 with a dislocation of about a shaft's width. The imaged lung fields show no abnormalities, more specifically no pneumothorax is visible.
- Minor calcifications in the supraspinatus tendon (tendinitis calcarea).
- Intra-articular comminuted scapular fracture.
- Fracture of costa 4 left.
- Tendinitis calcarea of the supraspinatus tendon.
♦ Figure 3. Answer: intra-articular comminuted scapular fracture, fracture of costa 4 and tendinitis calcarea.
Case Study 4
A 13-year-old girl was romping about wildly with friends. She is experiencing severe pain after one of her friends accidentally stepped on her right shoulder.
A shoulder x-ray is made (fig. 4).
Figure 4. AP image in endorotation (a) and in exorotation (b) of the right shoulder.
No fracture or luxation. Both images show an epiphyseal plate of the humeral head and an as yet unfused ossification center of the acromion. Note that all cortical interruptions are nicely rounded.
No fracture. Patient was sent home with the diagnosis of contusion.
♦ Figure 4. Answer: no fracture.
Case Study 5
A 65-year-old woman lost her balance when cleaning the windows. She fell on her left shoulder.
A shoulder x-ray is made (fig. 5).
Figure 5. AP image in exorotation (a) and a Y image (b) of the left shoulder.
Proximal humeral fracture of the surgical neck and the greater tubercle. In view of dislocation < 1 cm and rotation < 45°, this is a Neer classification one-part fracture.
One-part proximal humeral fracture.
♦ Figure 5. Answer: one-part proximal humeral fracture.