Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute right shoulder pain following a fall onto the outstretched hand (FOOSH). Reports localized tenderness, significant swelling, and inability to abduct or rotate the right arm. No reported numbness or tingling in the distal extremity.
Clinical Examination Findings
Inspection reveals ecchymosis and swelling over the right deltoid region. Palpation demonstrates point tenderness at the proximal humerus. Range of motion is severely limited due to pain. Neurovascular status intact: radial pulse 2+, capillary refill <2 seconds, sensation intact to light touch in axillary, radial, and median nerve distributions.
Treatment Protocol
Immobilization with a shoulder immobilizer/sling. Strict non-weight bearing on the right upper extremity. Pain management with NSAIDs and acetaminophen. Referral to orthopedic surgery for fracture classification and management planning. Follow-up imaging as indicated.