A Fracture In A Young Healthy Man

HISTORY: 18 year-old male with prior RUE fractures presenting to the ED with left shoulder pain.His hand slipped while bench-pressing 145 pounds, and the bar fell onto his left shoulder.He is reporting 7-9/10 pain to his shoulder at rest, with 10/10 pain with movement. Denies any other injuries. PHYSICAL EXAM: Well-built young man, uncomfortableBlue sclera Tenderness to palpation of shoulder and proximal arm. No tenderness to palpation of the elbow, forearm, wrist, hand.Pain with passive and active abduction and elevation of the shoulder. No pain with ROM of elbow, wrist, handFires anterior/posterior interosseous, ulnar, and axillary nerves.Sensation intact to light touch to median, radial, ulnar, and axillary nerves. 2+ radial pulse, fingers warm and well-perfused No lacerations or abrasionsNo ecchymosis to the shoulder or arm DifferentialProximal humerus fracture in setting of Osteogenesis Imperfecta (OI)Proximal humerus fracture in setting of toxic-metabolic abnormalityProximal humerus fracture in setting of male Athlete TriadRotator cuff tear/sprainAcromioclavicular joint dislocation/tear ImagingX-ray demonstrated an acute traumatic transverse fracture of the left proximal humeral shaft with minimal displacement. Bones are osteopenic. DISCUSSION: This patient suffered a blunt traumatic injury resulting in a fracture to the proximal humeral diaphysis. In setting of low-impact mechanism, this fracture occurs most often in older patients with underlying bone disease. This patient had a known diagnosis of Type 1 OI, and the classic blue sclera on exam. However, in setting of fractures and osteopenia in young healthy men, the differential diagnosis should also include other etiologies such as osteopetrosis, rickets, osteosarcoma, male athlete triad, and usage of steroids or alcohol. OUTCOME: The patient placed in cuff and collar sling, made non-weight being, and discharged with a referral to orthopedic surgeryA radiograph 1 week later demonstrated periosteal reaction suggestive of partial interval healing. ORIF of the left humerus was offered, though the patient opted for non-operative management.He was encouraged to range his shoulder and elbow 6 weeks after the injury, and began weight-bearing at week 10.An x-ray obtained 3 years later demonstrated healed fracture with callus formation.