What are the next steps in managing a patient with a possible shoulder fracture and a small type one hiatal hernia?

Management of Possible Shoulder Fracture with Type 1 Hiatal Hernia

For a patient with a possible shoulder fracture (partially calcified left costal cartilage) and a small type 1 hiatal hernia, the next step should be CT shoulder without IV contrast to definitively evaluate the suspected fracture. 1

Evaluation of Suspected Shoulder Fracture

• CT shoulder without IV contrast is the preferred next imaging study when radiographs suggest a possible fracture, as it provides detailed evaluation of osseous anatomy with high spatial resolution to identify subtle nondisplaced fractures 1
• CT is superior to MRI in evaluating fracture planes in complex fracture patterns and characterizing proximal humerus fractures 1
• In cases where radiographs are positive for proximal humerus, scapular, or clavicle fracture, CT shoulder without IV contrast is usually appropriate as the next imaging study 1

Management Algorithm for Suspected Pathological Fracture

1. Initial Assessment:

   • Consider pathological fracture when a fracture occurs without sufficient traumatic force 2
   • Evaluate whether the patient had pain before the fracture occurred 2

2. Imaging Pathway:

   • Begin with radiographs (already completed in this case) 1
   • Proceed to CT without IV contrast for detailed fracture evaluation 1
   • If malignancy is suspected, consider MRI with contrast medium before fracture treatment 2

3. Treatment Decision:

   • If radiological diagnosis confirms benign cause, consider conservative treatment depending on location 2
   • For confirmed fracture requiring surgical intervention, plan appropriate fixation 2

Considerations for Hiatal Hernia

• The small type 1 hiatal hernia (sliding hiatal hernia) is a common condition affecting approximately 10-80% of the general population 3
• Type 1 hiatal hernias occur when the gastroesophageal junction herniates through the esophageal hiatus into the mediastinum 4
• Management of the hiatal hernia should be addressed separately from the fracture management, particularly if the patient develops reflux symptoms 5

Special Considerations and Pitfalls

• Avoid misinterpreting radiographic findings of diaphragmatic hernias, as initial findings can be misinterpreted in around 25% of cases 1
• Be aware that CT scan is the gold standard for diagnosing diaphragmatic hernia with a sensitivity and specificity of 14-82% and 87%, respectively 1
• Consider that patients with vertebral fractures may have a higher incidence of hiatal hernia - a study found that multiple vertebral fractures and hiatal hernia were significantly associated in postmenopausal women 6
• For the hiatal hernia, medical management with antacids, proton pump inhibitors, or histamine-2-receptor blockers may be appropriate if the patient develops reflux symptoms 5

Follow-up Plan

• After CT evaluation of the shoulder, determine appropriate orthopedic management based on fracture characteristics 1
• Monitor for symptoms related to the hiatal hernia, as these may require separate management 5
• If surgical intervention is required for the shoulder fracture, ensure proper pre-operative assessment that accounts for both conditions 2