A 66-year-old woman is transferred to your facility for evaluation of a posterior fossa hemorrhage with decreased level of consciousness. Upon the patient’s arrival, the nurse informs you that the woman is lethargic but arousable. “She seems to be constantly moaning and groaning about her left shoulder,” the nurse tells you.
No family is present, so history is somewhat limited. Review of the CT of her head suggests the patient may require surgical intervention. Physical exam shows an overall frail, elderly woman, with stable vital signs. Examination of the left shoulder reveals no obvious deformity, although she does moan with passive range of motion. Radiograph of the shoulder is shown.
Answer
The radiograph demonstrates multiple findings. First, there is a comminuted fracture of the humeral neck, associated with an underlying destructive lytic lesion with cortical destruction and irregularity. Suture anchors from previous surgery are noted, as well as an abnormal lucency within the diaphysis, which extends almost one-third of the way distally. Also note the damaged appearance of the glenoid and the scapula.
All of these findings are strongly suggestive of metastatic disease. In addition, part of the distal clavicle has been resected, and there is evidence of a previously performed kyphoplasty.
It was later determined that the patient had end-stage multiple myeloma, which is consistent with these findings.
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