Case Of The Month

29 year old female with right shoulder pain following a fall. 

Investigations 

An ultrasound was initially requested (left image) which demonstrated a thickened subacromial bursa consistent with subacromial bursitis.  She was subsequently referred to an orthopaedic surgeon who organised an x-ray of her shoulder (centre image). This demonstrated  a focal lytic lesion in the proximal humeral metaphysis. The patient was then proceeded to CT (not shown) and MRI (right image) for further characterisation and local staging of the lesion. A surgical biopsy later demonstrated this to be an atypical chondroblastoma. 

Discussion 

This case highlights the importance of both ultrasound and plain radiographs in the initial assessment of most shoulder complaints. Both are deemed an essential component of initial management of shoulder pain by most specialists. Although ultrasound is able to evaluate the rotator cuff and subacromial bursa in the majority of cases, xrays are necessary to delineate anatomy that may be associated with impingement and to exclude bony pathology that may be a cause of pain.  These include:

Traumatic causes (fracture, dislocation)

Neoplasms

Osteomyelitis

Metabolic disease including Pagets disease

Arthropathies including osteoarthritis, inflammatory arthritides and osteochondromatosis