lesson of the week: Shoulder radiograph

History:
77 year old male patient came to A & E with history of left shoulder pain and mild breathlessness. There was history of fall.

Image gallary:



Imaging findings:
The initial report by the registrar for the shoulder radiograph read 'no fracture or dislocation'. The chest radiograph read 'multiple well defined pleural based lesions, suspecious for pleural metastasis/ mesothelioma. Further clinical correlation required'.

The images were reviewed by the consultant with additional clinical information that the patient was treated for adenocarcinoma of the lung. The 'pleural lesions' lesions were actaully expansile lytic rib lesions, which are also seen on the shoulder AP view. In addition, the lytic lesion seen on both shoulder and chest radiograph was missed by the registrar.

CT was performed to confirm the findings:


Lesson:
It is common to miss many findings on a plain radiograph, especially by registrars.

1. One should not get carried away from the clincal information (hardly given in most of the cases and may even be misleading).
2. Always look for malignancies in elderly people