Presentation
Fall. Left upper arm pain.
Patient Data
Mildly displaced and angulated transverse fracture of the left proximal humeral shaft. Site of fracture and the subtle impression of an underlying lucent lesion suggests pathological fracture. Additionally, there is lytic destruction and soft-tissue mass associated with the left 4th rib laterally, lysis of the upper aspect of the left 7th rib, and possible pulmonary mass superimposed over the left first costal cartilage. Overall appearance suggests left upper lobe lung cancer with osseous metastases and pathological humerus fracture.
Asymmetric density of the left first costal cartilage compared to the right suspicious for a superimposed left upper lobe pulmonary mass. Lytic destruction and soft-tissue mass associated with the left 4th rib laterally and lysis of the upper aspect of the left 7th rib. Overall appearance suggests left upper lobe lung cancer with osseous metastases.
CT confirms left upper lobe lung mass in keeping with primary cancer, and multiple osseous metastases including pathological fracture of the left proximal humeral shaft, rib metastases and vertebral metastases.
Case Discussion
A classic radiology board exam case with a single shoulder radiograph showing a pathological humerus fracture, rib metastases and a lung cancer. The candidate looking at this radiograph needs to recognize that the fracture site and orientation (transverse humeral shaft) is atypical for a standard fracture related to a fall in elderly patient, as most fractures occur at the surgical neck or are spiral in nature if within the shaft. The candidate then needs to appreciate the subtle underlying lytic lesion, the multiple rib lesions and the likely left upper lobe pulmonary mass, and then put this all together into the unifying diagnosis of lung cancer with metastatic disease.