(BMJ)—A previously healthy, 74-yo woman was brought to the ski clinic w/ severe pain and inability to move her L arm after a fall on her shoulder while skiing. She felt a popping sensation w/ the fall. Exam: dimpled L shoulder; neurovascular exam intact. What is the dx?
Distal clavicle fracture
Posterior glenohumeral dislocation
Acromioclavicular joint separation
Luxatio erecta
Proximal humerus fracture
You are correct. Dimple or flattening of the anterior shoulder, posterior prominence of the shoulder, limited external rotation, and holding the arm in a “sling” position are common physical findings in posterior glenohumeral (GH) dislocations. In contrast, anterior GH dislocations fill the anterior shoulder and leave a hollowness below the posterior aspect of the acromion process, and the arm is held in slight abduction and external rotation. Pts w/ acromioclavicular separation, distal clavicle fx, and proximal humerus fx often present w/ deformity in the related anatomic locations, w/ significant local tenderness. In these cases, shoulder ROM is usually limited secondary to pain, w/ no mechanical limitation. This pt’s dislocation was reduced using gentle traction and arm forward flexion w/ posterior humeral head push in the ski clinic. She did very well w/ conservative management and returned to skiing the next ski season.

Emerg Med J 2017;34:740
(BMJ)—A 77-yo man w/ hx of HTN, COPD, and prostate hyperplasia presented w/ a 6-mo hx of oozing, foul-smelling skin lesions in the groin and around the umbilicus, as well as lip erosions. The lip erosions made it difficult to eat, which resulted in a 7-kg loss of weight. Exam: thick, oozing inguinal and periumbilical papillomatous plaques; swollen, erosive lips. Labs: erythrocyte sedimentation rate elevated at 47 mm/h, mild eosinophilia but otherwise normal WBC count. Bx confirmed the dx. What is it?
Tinea cruris
Hailey-Hailey disease
Pemphigus vegetans
Dermatitis herpetiformis
Bullous impetigo
You are correct. Pemphigus vegetans was confirmed by direct immunofluorescence on perilesional skin, which showed intercellular depositions of IgG, IgA, and C3 complement. Enzyme-linked immunosorbent assay confirmed circulating antibodies against desmogleins. Pemphigus vegetans is a rare form of pemphigus in which blisters are often not visible at time of presentation. In this pt, initial tx w/ prednisolone and mycophenolate mofetil failed, and azathioprine was discontinued due to elevated liver enzymes. He improved w/ repeated rituximab infusions and oral prednisone.

BMJ 2018;360:j5364