Pediatric emergency medicine trisk 0865 0865
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A painful shoulder or humeral fracture that follows minimal trauma may be
caused by a benign or malignant tumor or by nonneoplastic bone lesions.
Osteochondromas (exostoses) are outgrowths of benign cartilage from the bone
adjacent to the epiphysis and present with a mass adjacent to a joint.
Nonossifying fibromas also known as fibrous cortical defects are common
asymptomatic lesions that may lead to pathologic fractures. Similarly, unicameral
or “simple bone” cysts are benign fluid-filled cavities most commonly localized
to the proximal humerus. They are usually asymptomatic until the bone fractures.
Aneurysmal bone cysts are more expansile, blood channel–filled lesions that may
cause pain and swelling. The malignant chondroblastoma is a rare tumor, but its
most common location is the proximal humerus. The patient often has joint pain
from an effusion associated with this tumor. Osteogenic sarcomas and Ewing
sarcoma are more common but involve the humerus in only 10% of cases.
Shoulder pain may also be referred from the neck (e.g., cervical disc
herniation), myocardium, or diaphragm (e.g., a splenic injury) after trauma to
those areas.
Thoracic outlet syndrome results from compression of the lower roots of the
brachial plexus (C8 to T1) or the axillary vein or artery, often in a pitcher,
swimmer, or weight lifter. The cause is generally thought to be related to
muscular hypertrophy or a cervical rib. Patients may present with shoulder pain
and associated numbness and paresthesias of the arm especially with repetitive
overhead use of the arm. If thrombosis of the vein occurs, arm swelling, venous
congestion, and distal cyanosis may occur, commonly referred to as Paget–
Schroetter syndrome. If the thrombus embolizes, the patient may have dyspnea
and chest pain. The neurologic symptoms may be induced (Roos test) by having
the patient rapidly open and close their hands for 3 minutes with the arm abducted
90 degrees and the shoulder externally rotated (ask the patient to “signal for a
touchdown”). The test is considered positive if it induces the patient’s pain and
paresthesias. A chest radiograph may identify a cervical rib. Ultrasonography is
the diagnostic test for venous thrombosis.
Acute brachial plexus injuries (“burners” or “stingers”) are common in highimpact sports. Most commonly, the shoulder is forcefully depressed and the head
and neck tilted to the opposite side, stretching the brachial plexus (see Fig. 43.5 ).
The patient has immediate arm weakness or paralysis, and paresthesias or
numbness along a cervical dermatome, most commonly C5 and C6. C5 and C6
can be tested by assessing shoulder abduction (deltoid muscle and axillary nerve),
external rotation (infraspinatus muscle and suprascapular nerve), and elbow
flexion (biceps muscle and musculocutaneous nerve). The symptoms may resolve
