Case

A 16 year old patient is brought into the emergency room after having fallen off of their skateboard. The patient is complaining of extreme left shoulder pain when moving their arm or taking a deep breath. There is a visible protuberance under the skin on the left upper anterior chest/shoulder, halfway between the neck and acromion. The protuberance is hard and highly painful to the touch.  

Question 2/3 - What is your differential diagnosis (aka, what do you think is going on)?

Click on your selected option(s) below  (correct = 1, over-thinking = 2+)

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Tumors can result in a mass visible under the skin, but they are rarely painful and develop slowly. Thus, they are not consistent with an acute occurrence after an accident.

The injury could have fractured a rib, this is the location of the first, possibly the second, rib. A fracture of the first rib is deep to the clavicle and will not be visible as a surface protrusion.  The second rib is deep to the pectoralis muscle and also will usually not be visible as a protrusion when it is fractured.

Good job!  The most likely reason for a distinct painful protrusion is a fractured clavicle, where the ends of the fracture are no longer aligned with one pushed up and one pushed down. This is extremely painful to touch and to any movement of the clavicle (thus, the patient pain on moving the arm).

The scapula is posterior on the thorax, so a fracture would be on the other side of the thorax and not visible on the anterior side.

Hematoma masses can form when a larger vessel is broken, typically via a penetrating injury, and have a softer feel to them compared to a hard protrusion. The patient history also does not have a penetrating injury and in this location there are no superficial vessels of a size sufficient to cause a hematoma (most large vessels are deep to the muscles in a more protected location).