A classic radiology board exam case with a single shoulder radiograph showing a pathological humerus fracture, rib metastases and a lung cancer. The candidate looking at this radiograph needs to recognize that the fracture site and orientation (transverse humeral shaft) is atypical for a standard fracture related to a fall in elderly patient, as most fractures occur at the surgical neck or are spiral in nature if within the shaft. The candidate then needs to appreciate the subtle underlying lytic lesion, the multiple rib lesions and the likely left upper lobe pulmonary mass, and then put this all together into the unifying diagnosis of lung cancer with metastatic disease.