Backpainslashshoulderinjury – what?

An interesting thing happened today while on shift. I saw a patient, who’s card told me this was a 60-something year old female, who had recently been seen around 2 weeks back in ED following a fall, resulting in a fractured humerus (upper end, basically a fracture of the shoulder) and had presented today with a few days history of lower back pain which was very severe. As I walked to the waiting area to call her in for my assessment, I began making a plan in my head of what I needed to rule out: was this new back pain unrelated to her prior fall, or was this a consequence of some missed injury from that fall? I called out her name and this lady wrapped in a huge jacket (loosely draped over her shoulders because of – presumably – the shoulder fracture) got up from one of the waiting area chairs and walked in behind me, slightly tilted towards the right, and walking at an angle, as if holding herself to avoid pain. We walked into a nearby cubicle to be examined; I introduced myself and asked her what had brought her to ED.

I noticed as she walked in and sat herself on the trolley, she required help with the jacket; she allowed me to help her out of it, which made her predicament apparent: She was not wearing a sling on her arm; it was dangling by her side (this was the arm that had the fracture in the upper part of the humerus, or upper arm bone forming the shoulder joint) – the hand appeared slightly swollen, as it would be from a long period of dangling, gravity would do the rest. I asked her where her sling was, and she mentioned that it had gotten dirty a few days back, and had been meaning to wash it but hadn’t gotten round to it. She told me the arm or shoulder wasn’t the problem, she was here today because her back hurt. I started asking her about the back pain (when did it begin – 5 days back; did you injure yourself during the prior fall – No; did you have another fall? No. The pain just began a few days ago and has just gradually worsened).

At this point she tried to shuffle backward in the trolley to get to a more comfortable position, and was unable to use her dangling arm. I couldn’t stand it any longer, so after I helped her get comfortable, I excused myself to go get her a new sling. I put her arm in the sling, and as she let the arm relax in the sling, her expression changed from one of long-standing pain and discomfort, to one of relief and comfort – ‘Doctor, you have somehow cured by back pain as well, I feel no pain in my back!’ I told her that very likely what had happened was that due to the painful left shoulder (which had been getting more painful because it was dangling beside her body as she walked around, rather than resting in a sling so her shoulder muscled could relax and allow the bones to heal) she was holding herself extremely taut in an uncomfortable abnormal posture, the only way to counteract or even avoid the pain of the shoulder – whether consciously or subconsciously – and that posture had caused her back to begin hurting as her back was being twisted into an abnormal position. The muscles of her back had been protesting, and now that she had put the shoulder to rest appropriately, it had caused her to relax in her posture – thereby causing her discomfort to disappear. She was raring to go home, but I still told her I had to examine her back, make sure we hadn’t missed anything else. There was no tenderness or bruising anywhere on her back, or any part of the bony prominences of her spine. I also assessed the neurovascular status of the limb that had been affected by the fracture – she was lucky there was still no distal neurovascular compromise.

Where she had required help to get comfortable into the trolley, she stood up on her own this time, without any support, bent over to pick up her bag from the floor with her good hand, thanked me for my time, and went home. I asked her if she required any pain relief, she waved the idea away as she walked off, saying ‘You’ve fixed me, Doc!’ She seemed like a completely changed woman; from the haggard, appears-to-be-in-pain-as-she-walked-into-the-exam-room old lady to the almost-bouncing-out-of-the-same-exam-room smiling chatting lady; the transformation was amazing to behold.

Just goes to show, always dot your ‘i’s and cross your ‘t’s, and never take anything for granted: you never know when the back pain that you think is something straightforward and expected turns out to be a not-so-straightforward posture issue resulting from an inadequately managed shoulder fracture.

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