Non-traumatic fractures mostly present a diagnostic dilemma. Fracture risk is less reported in non-epileptic seizures. Various metabolic conditions leading to a decrease in bone mineral density may also cause fractures. The authors report the case of non-traumatic fracture of an old woman who presented with fever, shortness of breath and right shoulder pain without any history of epilepsy. Episode of seizures was noted prior to admission. The patient had poorly controlled diabetes mellitus and severe hypoglycaemia was noted at the time of admission. She was admitted to a medical ward for a severe chest infection. Non-traumatic fracture dislocation of the right shoulder was also noted upon admission and treated conservatively. Bilateral hip fractures were not diagnosed till the fourth day. Patient had multiple comorbidities making the management very difficult. Here the authors will discuss the possible aetiology of this pattern of pathologies and the multidisciplinary management of such a rare case in detail.

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Background Atraumatic sternoclavicular joint (SCJ) instability is rare. Long-term outcomes are presented for patients managed with physiotherapy. A standardised method of assessment and treatment with a structured physiotherapy programme is also presented. Methods Long-term outcome was analysed in this prospectively collected series (2011-2019) of patients who were assigned to a structured physiotherapy programme for atraumatic SCJ instability. Outcome-measures (subjective SCJ grading of joint stability (SSGS score), Oxford shoulder instability score (OSIS adapted for SCJ) and visual analogue scale (VAS) for pain) were collected at discharge and long-term follow up. Results 26 patients (29 SCJ's) responded (return rate 81%). Mean follow-up was 5.1 years (range 0.9-8.3 years). 17/26 patients were hyperlax. 93% (27/29) of SCJs achieved a stable joint on SSGS score. Mean OSIS score at long-term follow up was 33.4 (range 3-48) and VAS 2.7 (range 0-9). 95% who were compliant with physiotherapy had a stable SCJ (mean OSIS 37.8 (SD 7.3) and VAS 1.6 (SD 2.1)). Those non-compliant, 90% were stable but had lower function (mean OSIS 25 (SD 14, p = 0.02) and more pain, VAS 4.9 (SD 2.9, p = 0.006). Conclusion The structured physiotherapy programme is highly effective in treating patients with atraumatic SCJ instability. Compliance was essential in ensuring better outcomes.

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