Hrev_master Emergency Care Journal 2022; volume 18:10691 [Emergency Care Journal 2022; 18:10691] [page 3] Question Given the patient’s history and the X-Ray imaging, what is the most likely diagnosis? 1. Septic arthritis 2. Hill-Sachs fracture 3. Hydroxyapatite deposition disease (calcific tendinitis) 4. Subcortical cyst of the humeral head Correspondence: Erika Poggiali, Emergency Department, “Guglielmo da Saliceto” Hospital, Via Giuseppe Taverna 49, Piacenza, Italy. Tel.: +39 0523 303044 E-mail: poggiali.erika@gmail.com Key words: Hill-Sachs fracture; bone loss; humeral lesion; anterior shoulder instability. Contributions: EP collected details of the case, cared for the patient, and drafted the manuscript. EB cared for the patient and critically revised the manuscript. Conflicts of interest: EP is member of the editorial board of Emergency Care Journal. The authors declare no conflict of interest. Availability of data and materials: All data underlying the findings are fully available upon reasonable request to Erika Poggiali, E.Poggiali@ausl.pc.it. Ethics approval and consent to participate: As this was a descriptive case report and data was collected without patient identifiers, ethics approval was not required under our hospital’s Institutional Review Board guidelines. Informed consent: The patient provided consent for the access to med- ical records at the time of admission. Received for publication: 21 June 2022. Revision received: 12 July 2022. Accepted for publication: 12 July 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Emergency Care Journal 2022; 18:10691 doi:10.4081/ecj.2022.10691 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. What lies behind the pain after shoulder dislocation? Erika Poggiali, Elisa Biancalana Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy A 38-year-old man presented to our emergency room with severe pain and inability to mobilize his right shoulder joint after a vio- lent blunt trauma during his work. The humeral head was palpa- ble anteriorly, with the loss of normal contour of the deltoid and acromion prominent posteriorly and laterally, as it occurs in the anterior shoulder dislocation. The shoulder was easily reduced on 1st attempt using 1.5 mg/kg intravenous fentanyl and 0.5 mg/Kg intravenous midazolam sedation in the emergency room. After the procedure, he complained of pain at the right humeral head, so we performed an X-Ray. Non commercial use only Answer The X-Ray demonstrated a successful reduction of the anterior shoulder dislocation but revealed a Hill-Sachs lesion. Hill-Sachs lesions are traumatic impaction fractures of the humeral head, often observed in patients with anterior shoulder dislocation1 or after seizures,2 firstly described in 1940 by two radiologists, Harold Arthur Hill and Maurice David Sachs. The mechanism for Hill-Sachs lesions is blunt trauma: the dislocated humeral head is displaced in an anterior-inferior-medial direction relative to the scapular glenoid fossa; subsequent strong muscular contractions lead to a violent bony collision between the anteroinferior region of the scapular glenoid rim and the posterosuperior-lateral aspect of the humeral head.3,4 Hill-Sachs lesions vary in length, width, depth, and orientation, and they can occur anywhere along the superior aspect of the humeral head, bare area, and greater tuberos- ity. Clinical presentation includes shoulder pain, weakness, and limited range of motion; a potential long-term complication is shoulder instability.5 Hill-Sachs fractures are common in the clini- cal practise, but often not recognized on post-reduction radio- graphs. Diagnosis can be significantly increased if radiologists are aware that the internal rotation view may fail to show the injury, and if all 4 views of a shoulder series are scrutinized.6 Ultrasonography is a valuable imaging technique in the diagnosis of Hill-Sachs lesion and a useful method to quantify small or medi- um size (up to 6 mm deep) lesions.7 Non-surgical management, including focused rehabilitation, is indicated in patients with small bony defects and non-engaging lesions in which the glenohumeral joint remains stable during desired activities. Surgical options include arthroscopic and open techniques.1 References 1. Provencher MT, Frank RM, Leclere LE, et al. The Hill-Sachs lesion: diagnosis, classification, and management. J Am Acad Orthop Surg 2012;20:242-52. 2. Goudie EB, Murray IR, Robinson CM. Instability of the shoul- der following seizures. J Bone Joint Surg [Br] 2012;94:721-8. 3. Herring A, Davis DL. Mimickers of Hill-Sachs Lesions [Formula: see text]. Can Assoc Radiol J 2021;72:258-70. 4. Kawakami J, Yamamoto N, Hatta T, et al. In which arm posi- tion is a Hill-Sachs lesion created? Am J Sports Med 2019;47:2464-8. 5. Fox JA, Sanchez A, Zajac TJ, Provencher MT. Understanding the Hill-Sachs lesion in its role in patients with recurrent ante- rior shoulder instability. Curr Rev Musculoskelet Med 2017;10:469-79. 6. Riebe B, Micheas L, Crim J. Improving detection of Hill- Sachs fractures on radiographs. Skeletal Radiol 2021;50:1889- 97. 7. Cicak N, Bilić R, Delimar D. Hill-Sachs lesion in recurrent shoulder dislocation: Sonographic detection. J Ultrasound Med 1998;17:557-60. Images in Emergency [page 4] [Emergency Care Journal 2022; 18:10691] Non commercial use only