November 2022: More than Broken

"I have this older patient who fell on his buttock at home," said my resident. “He has shoulder pain, but didn't come down on the shoulder and was here within the month with an adhesive capsulitis. He had x-rays and is to see the orthopedist this week. I was only going to x-ray the hips. What do you think?" "Let me take a look," I said while pulling up the old images.The glenohumeral joint space looked rough and narrow. Perhaps there was a calcific tendonitis seen between the acromion and the humeral head. Given the extent of degenerative joint disease, certainly this patient could have chronic shoulder pain.The skin looked normal—no signs of trauma or infection. There seemed to be diffuse tenderness. The patient was completely unwilling to range the shoulder. Any passive attempts resulted in pleas to stop. The family said this was his fourth fall in a month.Returning to the resident, I recommended an x-ray. "He has a lot of pain," I said. “There might be something going on there."And there was.​ The glenoid fossa was completely obliterated. The bony destruction seemed to have extended as far medially as the coracoid process. The joint space was also impressively widened.While waiting for the CT, I cautioned the resident to think wider when the pain on exam exceeds the history. This patient could have had a pathologic fracture, metastatic disease, an occult infection, or perhaps elder abuse. It is possible for disease ...
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