The patient is an 82-year-old man who presented after having fallen backwards and landing on his back. He did not lose consciousness; nor did he vomit. The patient entered the clinic using a walk- er, which he reported using on a regular basis. Examination revealed an abrasion over his forehead and over the anterior right tibia. The neurological exam showed no acute changes.

The patient was specifically tender over the shoulder, but there was no spiny tenderness.
View the x-ray taken (Figure 1) and consider what your diagnosis and next steps would be. Resolution of the case is described on the next page.

Clinical Challenge: April, 2008

Nahum Kovalski, BSc, MDCM

Clinical Researcher at TEREM Emergency Services
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