Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute left shoulder pain following a mechanical fall onto the outstretched hand. Reports localized swelling, ecchymosis, and significant limitation of active range of motion. Denies numbness, tingling, or distal neurovascular deficits.
Clinical Examination Findings
Left shoulder inspection reveals significant swelling and ecchymosis over the deltoid region. Palpation demonstrates point tenderness at the proximal humerus. Passive range of motion is severely restricted by pain. Neurovascular exam: radial pulse 2+, capillary refill <2 seconds, sensation intact to light touch in axillary, radial, and median nerve distributions.
Treatment Protocol
Immobilization in a shoulder immobilizer/sling. Strict activity modification: no lifting, pushing, or pulling with the left upper extremity. Analgesia as prescribed. Orthopedic follow-up scheduled for repeat radiographic evaluation and assessment for surgical vs. non-surgical management.