What is the appropriate management for a patient with a suspected musculoskeletal injury?

From the Guidelines

The patient with a suspected musculoskeletal injury from a dislocated shoulder should be treated with topical nonsteroidal anti-inflammatory drugs (NSAIDs) with or without menthol gel as first-line therapy to reduce or relieve symptoms, including pain, and improve physical function and treatment satisfaction. The patient's history of dislocating their shoulder and then attempting to put it back in place by "slamming" their shoulder into the golf cart door suggests a significant musculoskeletal injury. Given the patient's current pain level of 3/10 and intermittent tingling/numbness to the fingers, it is essential to prioritize non-pharmacologic and pharmacologic management strategies that address both pain and physical function.

According to the American College of Physicians and American Academy of Family Physicians guideline 1, topical NSAIDs with or without menthol gel are recommended as first-line therapy for acute pain from non-low back, musculoskeletal injuries in adults. This recommendation is based on moderate-certainty evidence that topical NSAIDs can reduce or relieve symptoms, including pain, and improve physical function and treatment satisfaction.

Some key points to consider in the management of this patient include:

• The use of oral NSAIDs or oral acetaminophen may be considered as alternative options for pain management, as suggested by the guideline 1, but topical NSAIDs should be the first-line approach.
• The patient's current use of Tylenol and CBD for pain relief should be reassessed, and the patient should be advised on the potential benefits and risks of continuing these medications.
• The patient should be educated on the importance of avoiding activities that exacerbate the injury and advised to follow a gradual return to activity plan after the acute phase.
• Medical evaluation is essential to assess the severity of the injury and to rule out any potential complications, such as nerve damage or ongoing instability of the shoulder joint.

Overall, the management of this patient should prioritize a multimodal approach that addresses both pain and physical function, with a focus on non-pharmacologic and pharmacologic strategies that are supported by the most recent and highest-quality evidence 1.

From the Research

Patient Presentation and History

• The patient presents with right shoulder pain after a sudden movement while driving a golf cart, resulting in a self-reported dislocation.
• The patient managed to put their shoulder back in place by "slamming" it into the golf cart door.
• The patient reports a pain level of 3/10, with intermittent tingling and numbness in the fingers.
• The patient has been using Tylenol and CBD for pain relief.

Appropriate Management

• The patient's presentation suggests a musculoskeletal injury, potentially a shoulder dislocation or strain.
• Given the patient's use of Tylenol (acetaminophen) for pain relief, it is worth noting that studies have shown that oral acetaminophen is equivalent to intravenous acetaminophen for pain control in elderly trauma patients with rib fractures 2.
• However, long-term use of acetaminophen has been associated with adverse effects, including an increased risk of gastrointestinal bleeding and a small increase in systolic blood pressure 3.
• In terms of imaging, a CT scan may be sufficient for initial evaluation, but an MRI may be necessary to identify additional injuries or noncontiguous fractures, particularly in patients with ankylosing spinal disorders or neurological deficits 4.

Considerations for Treatment

• The patient's use of acetaminophen for pain relief should be monitored, and alternative pain management options may be considered to minimize the risk of adverse effects.
• The patient's self-reported dislocation and subsequent manipulation of the shoulder joint should be evaluated further to determine the need for additional imaging or orthopedic consultation.
• The patient's symptoms of tingling and numbness in the fingers should be monitored, and further evaluation may be necessary to rule out any underlying neurological conditions.