Incidental pathological humeral fracture on CXR

Case contributed by Dr Balint Botz

Presentation

Intellectual disability due to perinatal cerebral hypoxia. Known soft tissue sarcoma with abdominal metastases. Presented with dyspnea, absent respiratory sound upon auscultation on the left. Pneumonia, pleural effusion?

Patient Data

Age: 35 years
Gender: Female

A complete hemithorax white-out is apparent on the left with significant mediastinal shift to the right. Findings are in line with a very large unilateral hydrothorax (considering the pattern most likely due to the known metastatic primary malignancy) with resultant complete atelectasis on the left. 

These findings are in good agreement with the clinical picture, symptoms, and fit the results of the physical exam as well. The gross abnormality is therefore prone to satisfy the reader (satisfaction of search error), which unfortunately reduces the chance of detecting another significant "edge-of-image" pathology, a hitherto unknown, partially displayed irregular fracture of the right proximal humerus with adjacent hazy callus formation (see key image).

The reader therefore requested additional radiographs of the right shoulder. 

Minimally displaced, angulated proximal humeral fracture centered around a lytic metastatic lesion, showing extensive secondary callus formation. 

Case Discussion

Upon presented with an exam like this experienced readers tend to formulate a near-instantaneous "gestalt" diagnosis based on prior knowledge, quickly arriving at the diagnosis. Unfortunately these mental shortcuts leave one vulnerable to miss unexpected, subtle additional abnormalities insidiously lurking nearby. Rigid adherence to a systematic search pattern even after a seemingly complete diagnosis has been made can save the day and prevent us from falling into the trap of the satisfaction of search error.

Another key take home message of the case is the mental status of the patient. It is reasonable to state that such a proximal humeral fracture would have been very unlikely to go undetected in a patient with normal cognitive functioning. In patients with altered mental status or severe cognitive impairment expecting the unexpected is of particular importance during the assessment of any imaging study, as self-reported complaints are at best unreliable, and the physical exam is often of limited value too. 

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Case information

rID: 73660
Published: 17th Jan 2020
Last edited: 18th Jan 2020
System: Oncology, Chest
Inclusion in quiz mode: Included
Institution: University of Pécs

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