story of patient: “A 12 year old girl presented to the A&E department at a weekend, with pain on movement of the left shoulder. Initially there was no history of

story of patient:  “A 12 year old girl presented to the A&E department at a weekend, with pain on movement of the left shoulder. Initially there was no history of trauma. Although when seen in clinic, she mentioned having played rugby a few days before the onset of pain.” Physical examination: “…revealed minimal tenderness above the clavicle and painful shoulder movement.” Imaging: Radiography was performed, see Figure 1. “The initial radiograph was reported as no bony injury, the ‘fracture’ diagnosed [by the radiologist] as an anomalous articulation.” Treatment: a collar and cuff (Figure 2) and analgesia. Follow up:  “Another radiograph [Fig 3] six weeks later showed callus around the ‘anomalous articulation’, which supported our earlier diagnosis of fracture [of the first rib].  She…has had an uneventful recovery.”  In other words, the radiologist got this wrong, when s/he diagnosed an “anomalous articulation” on the first x-ray. This patient did not break any bones in the pectoral girdle or arm, yet had pain with movement of the shoulder.  Why do you think this was painful?  It may to study the articulated skeleton.