Clinical Assessment: Bony Pain in the Humeral Shaft Region (Between Elbow and Shoulder) in a 76-Year-Old Female

Anatomical Localization

Step 1: Differential Diagnosis - What Could This Be?

Internal rotation aggravating pain specifically raises concern for involvement of the lesser tuberosity region, subscapularis insertion, or periosteal/cortical pathology in the proximal-to-mid shaft where rotational forces are transmitted.

Step 2: Workup / Investigation

Mandatory First Steps:

1. Plain X-ray (AP + lateral of humerus, full length) - look for lytic/sclerotic lesions, cortical thinning, fracture lines, periosteal reaction
2. Complete blood count - anemia (myeloma), infection
3. ESR / CRP - inflammatory/infective/neoplastic
4. Serum calcium, phosphate, ALP - Paget's disease (elevated ALP), hypercalcemia of malignancy, metastases
5. Serum protein electrophoresis (SPEP) - multiple myeloma

If X-ray shows a lesion or is inconclusive:

• MRI humerus - gold standard for soft tissue and medullary involvement, marrow infiltration
• CT scan - better for cortical detail, fracture pattern
• Bone scan (technetium-99m) - identifies metastatic deposits elsewhere

If malignancy suspected:

• Tumor markers: CEA, PSA, CA-125, CA 15-3
• CT chest/abdomen/pelvis - search for primary tumor

Step 3: Management Approach

A. Immediate Symptom Relief (Pain Management)

• WHO analgesic ladder:
  • Step 1: Paracetamol 500-1000 mg TDS (safe in elderly)
  • Step 2: Add weak opioid (tramadol 50 mg BD with caution in elderly - risk of falls, confusion)
  • Step 3: Strong opioids (morphine) if severe pain - under specialist supervision
• NSAIDs (ibuprofen, naproxen) - use with caution in elderly: risk of GI bleeding, renal impairment, cardiovascular events. Use lowest effective dose + PPI cover (omeprazole 20 mg OD) if needed
• Sling immobilization if fracture is present or suspected - reduces pain from movement

B. If Osteoporosis / Fragility Fracture

• Calcium supplementation: 1000-1200 mg/day (diet + supplement)
• Vitamin D3: 800-1000 IU/day (most elderly are deficient)
• Bisphosphonates (first-line for osteoporosis):
  • Alendronate 70 mg once weekly PO
  • Risedronate 35 mg weekly PO
  • Zoledronic acid 5 mg IV once yearly (if unable to take oral)
• Falls prevention: physiotherapy, walking aids, home hazard assessment
• DEXA scan to confirm osteoporosis and baseline BMD

C. If Humeral Shaft Fracture (Non-Pathological)

"The majority of humeral shaft fractures can heal with nonsurgical management if they are within an acceptable degree of angulation."

• Acceptable alignment: <20° anterior angulation, <30° varus/valgus, <3 cm shortening
• Non-operative treatment (preferred in elderly):
  • Coaptation splint initially (U-slab), patient upright, with cuff and collar
  • Progress to functional brace (Sarmiento brace) at 1-2 weeks
  • Gravity aids alignment - avoid slings that abduct the arm
  • Gentle pendulum exercises from day 1
  • Active wrist/hand motion to prevent stiffness
• Radial nerve check: examine for wrist drop (Holstein-Lewis fracture pattern risks radial nerve injury)
• Surgical indications: bilateral humeral fractures, polytrauma, open fracture, unacceptable alignment, failed non-operative treatment

D. If Proximal Humerus Fracture

"The majority of proximal humerus fractures are minimally displaced and can be treated with sling immobilization, followed by early shoulder motion and pendulum exercises. Physiotherapy should be started within 2 weeks to prevent stiffness, especially in the elderly."

• 1-2 part fractures: Sling x 2-4 weeks, then physiotherapy
• 3-4 part fractures in elderly with osteoporosis: Reverse shoulder arthroplasty (RSA) is increasingly preferred - recent meta-analyses support this approach ([Lu et al., 2023, PMID 37024039])
• Hemiarthroplasty or ORIF if adequate bone stock

E. If Metastatic or Malignant Bone Disease

• Oncology referral - urgent
• Radiotherapy - for localized metastatic pain (highly effective for bone mets)
• Bisphosphonates/Denosumab - reduce skeletal-related events in bone metastases (zoledronic acid 4 mg IV 3-4 weekly for bone mets)
• Surgical stabilization (prophylactic intramedullary nail) if impending pathological fracture (Mirels' score >9)
• Systemic therapy per primary tumor type

F. Physiotherapy / Rehabilitation (For All Causes)

• Pendulum exercises (Codman exercises) early - maintain shoulder mobility
• Progressive active-assisted range of motion
• Strengthening (rotator cuff, deltoid, biceps) when pain allows
• Ergonomic advice - avoid internal rotation loading activities
• Occupational therapy assessment for ADL adaptations

Step 4: Special Considerations for a 76-Year-Old

• Polypharmacy risk - check drug interactions, avoid NSAIDs if on anticoagulants/ACE inhibitors
• Fall risk assessment - Timed Up and Go (TUG) test; balance training
• Nutritional status - protein malnutrition impairs bone healing
• Cognitive status - affects compliance with bracing/physiotherapy
• Comorbidities - renal function (affects bisphosphonate choice), cardiac status (affects surgical fitness)

Summary Algorithm

Bony pain between elbow and shoulder + pain on internal rotation (76F)
              ↓
   X-ray humerus (AP + Lateral)
              ↓
   ┌──────────────────────┬──────────────────────┐
   │                      │                      │
Fracture            Lytic/Sclerotic         Normal X-ray
   │                    lesion                   │
   │                      │                      │
Non-op (sling/          Blood tests           MRI / consider
functional brace)    Tumor markers           soft tissue cause
or surgery if          CT scan                (rotator cuff,
displaced           Bone biopsy if           biceps, PD)
(RSA if elderly)     needed → Oncology

Sources: Schwartz's Principles of Surgery, 11th Ed. (Proximal Humerus Fractures, Humeral Shaft Fractures); Lu V et al., J Shoulder Elbow Surg 2023 (PMID 37024039); PMC9604576 (Scoping Review, Proximal Humerus Fracture Management in Adults).