Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute right shoulder pain following a mechanical fall onto an outstretched hand. Reports localized tenderness, significant swelling, and inability to move the right upper extremity. No associated numbness or tingling in the distal extremity.
Clinical Examination Findings
Right shoulder inspection reveals significant ecchymosis and edema over the proximal humerus. Palpation demonstrates point tenderness at the surgical neck. Passive range of motion is severely limited due to pain. Neurovascular exam: radial pulse 2+, capillary refill <2s, 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 analgesics as prescribed. Orthopedic follow-up scheduled for repeat imaging and assessment for potential surgical intervention.