Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of right radius fracture sustained [Date]. Despite [Duration] of immobilization/fixation, patient reports persistent localized pain, mechanical instability, and inability to bear weight or perform functional tasks with the right upper extremity. No interval improvement in symptoms noted.
Clinical Examination Findings
Right forearm inspection reveals localized swelling and tenderness over the fracture site. Palpation demonstrates abnormal motion at the fracture site (pseudoarthrosis). Neurovascular status is intact with distal capillary refill <2 seconds, radial pulse 2+, and intact sensation in median, ulnar, and radial nerve distributions. Range of motion of the wrist and elbow is limited by pain.
Treatment Protocol
Plan: 1. Obtain orthogonal radiographs of the right forearm to assess nonunion status. 2. Consider CT scan for detailed osseous assessment. 3. Discuss surgical intervention (ORIF with bone grafting) vs. non-surgical options (e.g., bone stimulator). 4. Continue activity modification and pain management as prescribed.