David Hall is a 32-year-old patient who comes to the emergency department at 11 pm on a Tuesday complaining of pain and numbness of his left arm after falling while walking down steps.
He was leaving a bar with some friends when he tripped and fell down about 5 steps, landing on his left shoulder and back. He says he felt a “popping and tearing” with severe pain in the shoulder starting immediately. His friends picked him up off of the ground and brought him to the ER when he tried to move his arm and couldn’t.
He says he is otherwise healthy and takes no medicines. He had no problems with the arm before his fall. He denies hitting his head or pain anywhere else.
Family history: his father has had a heart attack bypass surgery and has some kind of liver disease, his mom has diabetes, and his brother has had blood clots and has to be on a blood thinner.
Social History: He drinks beers with his friends several nights a week, smokes a pack a day, and is separated from his wife of 5 years and lives in an apartment. He works as a foreman in a heavy equipment and tractor manufacturing plant and is very worried about being able to work if he is injured.
HEENT: pupils reactive and equal, EOMI, no neck pain with palpation of spinous processes, full neck range of motion without pain. No abrasions or contusions on scalp palpation or on face. No JVD.
Thorax: bruising, TTP over left posterior thorax. Lung sounds equal bilaterally.
CV: RRR, pulses 2+ in all extremities, good perfusion and cap refill
Abdomen: SNTND, no HSM
MSK: left shoulder held in abduction and external rotation and contour of shoulder is abnormal. Passive range of motion prevented by pain. Wrist drop noted as well as decreased fine touch, temperature, and pain sensation over left arm. Right arm, both legs with normal passive and active range of motion and no pain or sensory loss.
An x-ray of the left shoulder is shown in X-ray #1:
David is given IV pain and sedation medications and the ER physician and a nurse place his shoulder back into the proper alignment. A follow-up xray is taken. X-ray #2:
Repeat physical exam after sedation has worn off shows decreased strength of shoulder abduction, decreased strength of elbow extension and flexion, absence of wrist dorsiflexion, and decreased sensation over the anterior left chest and anterior of the left arm down to the wrist and for the left thumb. Ability to flex and move the fingers is normal, as is sensation on the posterior arm.
David is placed in a sling and swathe, instructed to follow up with an orthopedic doctor in the next couple of days, and discharged from the ER.
David makes an appointment at the orthopedist’s and is seen 2 days after his injury. His examination of his left arm is unchanged. He is very upset about his inability to use his left arm and brought the paperwork his workplace requires his doctor to fill out under the FMLA for him to have an alternative work assignment or be on medical leave related to this problem. (form is a PDF posted with this case.) He needs that paperwork filled out at the visit today so he does not get fired for being unable to work the last 2 days since being injured. He also wants to know how long he has to keep the sling and swathe on, and if the weakness and numbness is going to get better or he should apply for permanent disability.