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Orthopedics & Traumatology

Humeral Shaft Fracture, Left, Closed, Initial Encounter

ICD-10 Code
S42.302A_1

Standardized diagnosis for Humeral Shaft Fracture, Left, Closed, Initial Encounter.

Clinical Presentation & Protocol

Patient Usually Complains Of

Patient presents with acute left arm pain following [mechanism of injury, e.g., mechanical fall]. Reports localized swelling, deformity, and inability to move the left upper extremity. Denies numbness, tingling, or distal weakness. No prior history of trauma to the left humerus.

Clinical Examination Findings

Left upper extremity: Obvious deformity and swelling noted at the mid-shaft humerus. Tenderness to palpation over the humeral shaft. Distal neurovascular status: Radial pulse 2+, capillary refill <2 seconds. Sensation intact to light touch in radial, ulnar, and median nerve distributions. Motor function: Unable to assess due to pain; no clinical signs of radial nerve palsy (wrist drop absent).

Treatment Protocol

Immobilization with coaptation splint/sling and swathe applied. Orthopedic consultation requested for definitive management. Pain managed with [medication]. Radiographs confirm closed humeral shaft fracture. Patient advised to maintain immobilization and avoid weight-bearing on the left arm.

Detailed clinical guide coming soon.