A Fall Out of Bed

A 67-year-old woman presents to the Emergency Department with pain in her chest and right shoulder after falling out of bed while on vacation. She states that she has problems with "fragile bones" and has had several previous fractures caused by apparently minimal or incidental trauma. The patient’s medical history is significant for avascular necrosis of her right hip, for which years ago she underwent a total hip arthroplasty. The patient reports that she routinely takes pills to control inflammation and pain. She has no history of smoking or alcohol abuse.

On physical examination, the patient is awake and alert. Her heart rate is 100 bpm, her blood pressure is 174/82 mm Hg, her respiratory rate is 12 breaths per minute, and her oral temperature is 98.9°F (37.2°C). The patient’s heart rhythm is regular, no murmurs or gallops are heard, and the lungs are clear to auscultation. The abdomen is soft with normal bowel sounds. The skin examination reveals several hard nodules in the subcutaneous fat. One of the nodules appears to have resulted in a laceration associated with bleeding near the impact point of the fall.

Laboratory investigations reveal a normal complete blood count (CBC) and a normal basic chemistry panel. Twelve-lead ECG is ordered and shows a right bundle-branch block with no evidence of acute ischemia.

Plain radiographs of the chest, right shoulder, and right humerus are ordered. Images 1 and 2 show the lateral right humeral and anteroposterior (AP) shoulder radiographs, respectively. The lateral humerus radiograph (Image 1) demonstrates a minimally displaced fracture of the surgical neck of the humerus, with diffuse calcifications in the soft tissue. The patient also has severe osteopenia, which is most evident in the vertebral-body endplates and the humeral shaft. The AP radiograph of the shoulder (Image 2) demonstrates the acute fracture of the humerus superimposed on an old healed fracture with the same diffuse, soft-tissue calcifications.

What is the underlying medical condition?

What is the diagnosis?
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The extraosseous findings are typical, although not pathognomonic of this disorder.