Author: Jeremy Swisher, MD
Co Author #1: Zachary Sitton, MD
Co Author #2: Chris Miles, MD, FAMSSM
Senior Editor: Kevin Gray, MD
Editor: Andrew Li-Yung Hing, MD

Patient Presentation:
Chief Complaint: Shoulder pain

History:
An 8-year-old female soccer player with a past medical history of Holt-Oram Syndrome presented to clinic with left shoulder pain after a fall the previous day. She reported that she was about to go down a slide when she was pushed off the slide and landed directly on her left shoulder. Since this injury, she had complained of a constant, 7/10, non-radiating, sharp pain in her left shoulder as well as decreased range of motion. Of note, she had a similar mechanism of injury in which she had a fracture of her left medial epicondyle 3 years ago which fully healed. She denied hitting her head, headache, pain in her elbow, wrist, or hand as well as any changes in sensation.

Physical Exam:
Vitals: Blood Pressure 113/90 | Pulse 65 | Height 4 foot 3 inches| Weight 54 pounds | SpO2 98% Cardiac: Regular rate and rhythm, III/VI holosystolic murmur heard best at left lower sternal border. Inspection Case Photo #4 and Case Photo #5 : Left shoulder effusion and deformity present. Absent left thumb and shortened radius/ulna. Palpation: Tenderness to palpation of the left proximal humerus. No tenderness to palpation of radius, ulna, sternoclaviculoar joint, clavicle, acromioclavicular joint. ROM: Unable to significantly move left arm with flexion at 10 degrees, abduction to 10 degrees, IR 15 degrees and ER 5 degrees. Strength: exam limited due to pain. Shoulder abduction 1/5, elbow extension 1/5, elbow flexion 1/5, grip strength 5/5. Neurovascular: 2+ radial and ulnar pulses, capillary refill less than 3s, no deficits in sensation.

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