Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute right shoulder pain following high-energy trauma. Reports significant tenderness over the scapular region, exacerbated by shoulder movement and deep inspiration. Denies numbness or paresthesia in the upper extremity.
Clinical Examination Findings
Inspection reveals ecchymosis and localized swelling over the right scapula. Palpation demonstrates bony crepitus and point tenderness along the scapular body/spine. Range of motion is severely limited due to pain. Neurovascular status of the right upper extremity is intact with palpable distal pulses and normal capillary refill.
Treatment Protocol
Management includes immobilization with a shoulder sling for comfort, ice application for 20 minutes every 4 hours, and non-steroidal anti-inflammatory drugs (NSAIDs) for pain control. Referral to orthopedic surgery for fracture stabilization and follow-up imaging.