Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of a left radius fracture sustained [Date]. Despite [Duration] of immobilization/treatment, clinical and radiographic evidence indicates failure of bone healing. Patient reports persistent localized pain, mechanical instability, and inability to bear weight or perform rotational tasks with the left forearm. No constitutional symptoms, neurovascular deficits, or signs of infection noted.
Clinical Examination Findings
Left upper extremity examination reveals localized tenderness over the fracture site at the [proximal/mid/distal] shaft of the radius. Visible deformity or abnormal mobility at the fracture site is noted. Range of motion is restricted by pain, particularly in supination and pronation. Neurovascular status: radial pulse 2+, capillary refill <2 seconds, intact sensation in median, ulnar, and radial nerve distributions. No overlying skin breakdown or sinus tracts.
Treatment Protocol
Plan: 1. Obtain CT scan of the left forearm to assess nonunion morphology. 2. Discuss surgical intervention (ORIF with bone grafting) vs. conservative management (bone stimulator). 3. Pain management with NSAIDs/analgesics as indicated. 4. Referral to orthopedic surgery for definitive management. 5. Maintain protective bracing/splinting as tolerated.