Ms. E is a healthy, 19-year-old white woman who injured her right shoulder after falling while running. At the emergency department, she was told that she had a proximal humerus fracture.

Ms. E’s arm was placed in a standard sling, and she was instructed to make an appointment with an orthopedic surgeon in the next few weeks, but she deferred orthopedic evaluation for six weeks while she prepared to move to another state.

New x-rays taken by her primary-care clinician revealed a minimally displaced proximal humerus fracture with a large osteolytic lesion of the humeral head, neck and proximal shaft (Figures 1 and 2). The patient underwent a CT scan that day and was referred to the orthopedic department for further evaluation.

Continue Reading


Ms. E reported no major illnesses or medical problems prior to this injury. No family history of cancer was noted. She had multiple surgeries as a child for right-hand pre-axial polydactyly. Ms. E was recently married to an active-duty soldier and reported no illicit drug or alcohol use. Prescribed medications included acetaminophen and hydrocodone (Vicodin) 5/500 as needed for pain, zolpidem (Ambien) for sleep and oral contraceptives.


The patient reported no fever, chills, night sweats, unexplained weight loss, fatigue or malaise. She stated her overall health was “great until this.” She reported no headaches, visual disturbances, sore throat, or sinus problems. No recent history of any swollen glands or neck pain was noted.

Ms. E had no cardiac history, no swelling of the right upper extremity and no coldness or pallor of the right upper extremity. She had no cough and no dyspnea at rest or with exertion. No nausea, vomiting, diarrhea, rectal bleeding, or change in stool habits was reported.

Ms. E was in a monogamous relationship with no prior sexual encounters. There was no history of vaginal discharge, itching, or lesions. She reported no prior injuries to the affected shoulder.

Ms. E currently had shoulder pain with active range of motion, with no pain at rest or distal to the shoulder. She had no history of transient or migratory arthralgias. While no numbness, tingling, or weakness in the right upper extremity was reported, Ms. E did note atrophy of the right shoulder musculature.