Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute right elbow pain following a fall onto an outstretched hand (FOOSH). Reports immediate onset of pain, swelling, and inability to bear weight or move the right upper extremity. No history of prior trauma to the area. Denies numbness, tingling, or distal paresthesia.
Clinical Examination Findings
Right upper extremity: Significant swelling and ecchymosis noted at the distal humerus. Tenderness to palpation over the supracondylar region. Deformity present. Neurovascular status: Radial pulse 2+ and symmetric. Capillary refill < 2 seconds. Sensation intact to light touch in median, ulnar, and radial nerve distributions. Motor function limited by pain; no gross motor deficit noted.
Treatment Protocol
Diagnosis: Right supracondylar humerus fracture (ICD-10: S42.401A). Plan: Immobilization with a long arm posterior splint in neutral position. Strict neurovascular checks every 2 hours. Pain management with NSAIDs and analgesics. Orthopedic surgery consultation for definitive management (closed reduction vs. ORIF). NPO status initiated.