SAEM Clinical Image Series: Left Shoulder Pain

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Chief complaint: Arm pain

History of Present Illness: A 30-year-old obese male presents to the ED after a ground level fall onto his left arm with immediate isolated left shoulder pain. He did not lose consciousness and denies dyspnea, numbness, weakness, vomiting, and chest pain.

Physical Exam

Musculoskeletal: Left shoulder is tender to palpation, with proximal deformity of the left shoulder and prominence of the left scapula posteriorly with rotation superiorly.

Neurologic: Intact sensation of all nerve distributions, but patient reports mild paresthesias to light touch of index, long, and ring fingers. Strength is intact at isolated joints.

Cardiovascular: No pallor or coolness to the arm, and radial pulse is 2+.

Laboratory Data

None acquired

Case Question: What injury has resulted and what additional imaging is necessary?

The chest X ray shows a scapulothoracic dissociation.

This rare and potentially limb threatening injury typically results from high energy trauma although it has been reported with trivial trauma. It is characterized by the lateral displacement of the scapula with resultant disruption of the scapulothoracic articulation making concomitant fractures and injury of the brachial plexus and subclavian artery very common.

A thorough physical exam and CT with angiogram of the extremity is required to rule out vascular and neurologic injuries. This patient had a normal CTA and his minor paresthesias were managed non-operatively with a sling and orthopedic follow up.

Case Discussion

Take Home Points

A scapulothoracic dissociation is typically a high-energy injury associated with neurovascular injury.
A CT angiogram of the extremity is required to rule out vascular injury.
A meticulous neurologic exam is needed to identify any nerve injury.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved. View other other cases from this series on ALiEM.