Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with right shoulder pain and instability following a traumatic anterior glenohumeral dislocation. Reports a sensation of "popping" or "catching" during overhead activities. Mechanism of injury involved [insert mechanism, e.g., fall onto outstretched hand]. Currently experiencing localized posterior-lateral humeral head tenderness and apprehension with abduction and external rotation.
Clinical Examination Findings
Right shoulder inspection reveals no gross deformity or ecchymosis. Palpation demonstrates tenderness over the posterior-lateral aspect of the humeral head. Range of motion is limited by pain, particularly in abduction and external rotation. Positive apprehension test noted. Neurovascular status is intact distally. Imaging (X-ray/MRI) confirms a cortical depression fracture of the posterolateral humeral head consistent with a Hill-Sachs lesion.
Treatment Protocol
Initial management includes immobilization in a shoulder sling for comfort, cryotherapy, and non-steroidal anti-inflammatory drugs (NSAIDs). Referral to physical therapy for rotator cuff strengthening and scapular stabilization. Follow-up imaging scheduled to monitor healing. Surgical consultation advised if recurrent instability or significant bony defect is noted.