A 38-Year-Old Woman with Shoulder Pain

Differential Diagnosis

• Shoulder dislocation
• Distal clavicle fracture
• Avulsion of the greater tuberosity
• Osteolytic lesion
• Scapular fracture

Diagnosis
This patient sustained an avulsion of the greater tuberosity. The x-ray shows oblique lucency undermining greater tuberosity of the humerus, with cortical irregularity.

Learnings

• An avulsion of the greater tuberosity is sometimes called a “hidden fracture” because it usually presents as an undisplaced fracture, which often does not show up on x-rays
• This injury is often associated with tear of the supraspinatus tendon
• When minimally displaced, treatment is often successful without surgery

Pearls for Initial Management and Considerations for Transfer

• Shoulder trauma should be imaged in the urgent care, looking for:
  • Dislocation
  • Fracture of the humerus, clavicle, and scapula
  • Acromioclavicular (AC) separation
  • Abnormalities of associated structures such as rib fractures or pneumothorax
• A dislocation can be reduced in the urgent care, per provider experience.
• Indications for transfer include:
  • Patients with severe pain
  • Diagnostic uncertainty
  • Dislocation unable to be reduced