This 47-year-old recreational player and coach presents one week after a fall onto his dominant right arm. He reports “dislocating his shoulder” and having this reduced at a local emergency department. X-rays at the time of injury were deemed to be normal and he was given a sling and analgesia. On examination he had a global restriction in his ROM with abduction to only 60 degrees. He had pain and weakness with rotator cuff testing and had normal axillary nerve function. There was no evidence of generalised laxity.
X-ray images conducted at the time of injury were reviewed and were also felt to be normal. An USS image shows cortical irregularity of the greater tuberosity involving the supraspinatus footprint. There were hypoechoic changes involving the anterior third of the tendon (adjacent to the greater tuberosity) measuring 7 x 7 mm. These appearances were suggestive of a minimally displaced greater tuberosity fracture with a small partial-thickness interstitial tear. A follow-up x-ray series (shown here) confirmed an undisplaced fracture of the greater tuberosity.
This player was managed with a short period (approximately two weeks) of sling immobilisation. This was primarily to manage his pain. He was then treated with range of motion exercises, progressive strengthening and a graded re-introduction of normal activities. He was back coaching within a week post-injury and returned to recreational football approximately two months following his injury.
This case illustrates two important learning points. The first is a generic point related to the use of x-ray following injury. Fractures are not always evident on x-rays taken immediately following an injury. Follow-up images conducted 7-10 days after the injury can be useful and should be performed when there is persisting clinical suspicion of a fracture. Occult or undisplaced fractures can be more obvious when there has been time for periosteal reaction (healing bone) to form and for some resorption to occur. The second point is specific to shoulder instability. The main issue following shoulder instability in younger patients relates to recurrence. Young patients (especially those in their teens or early twenties) have a very high risk of recurrent instability and may require a surgical stabilisation procedure. In contrast, older patients are less likely to experience recurring instability (the risk is less than 10% in those over the age of 40 years) but are much more likely to sustain an associated fracture or rotator cuff tear. A high index of suspicion is needed in this group to avoid missing these injuries. An x-ray should always be performed, while imaging of the rotator cuff (USS or MRI) should be arranged when there is persisting pain or weakness.
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