Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute left shoulder pain following a mechanical fall onto an outstretched hand. Reports localized tenderness, significant swelling, and inability to actively abduct or rotate the left arm. No associated numbness, tingling, or distal neurovascular deficits noted.
Clinical Examination Findings
Inspection of the left shoulder reveals significant ecchymosis and edema over the proximal humerus. Palpation demonstrates point tenderness at the surgical neck. Passive range of motion is severely limited by pain. Distal neurovascular status is intact, with palpable radial pulse and normal capillary refill. Sensation to light touch is preserved in the axillary nerve distribution.
Treatment Protocol
Immobilization of the left upper extremity in a shoulder immobilizer/sling. Application of ice packs for 20 minutes every 2-3 hours. Analgesia initiated with NSAIDs/acetaminophen. Orthopedic follow-up scheduled for repeat radiographs and assessment for potential surgical intervention versus conservative management.