What is the appropriate management for a patient with right elbow and anterior shoulder/bicep pain radiating down the arm, with sharp shooting pain and tingling, after a fall?

Management of Acute Elbow and Shoulder Trauma with Neurologic Symptoms

This patient requires immediate plain radiographs of both the right elbow (AP and lateral views) and right shoulder (AP in internal/external rotation PLUS axillary or scapular Y view) to rule out fracture and dislocation before initiating any other treatment. 1, 2

Immediate Diagnostic Workup

Initial Imaging - Critical First Step

• Obtain upright radiographs of the right elbow (anteroposterior and lateral views) as the initial imaging modality, since radiographs can identify occult fractures, intra-articular bodies, heterotopic ossification, or soft tissue calcification that may have resulted from the trauma 1
• Obtain upright shoulder radiographs with three mandatory views: AP in internal rotation, AP in external rotation, AND axillary or scapular Y view 2, 3
• The axillary or scapular Y view is absolutely critical because glenohumeral and acromioclavicular dislocations are frequently misclassified on AP views alone, with posterior dislocations missed in over 60% of cases initially 2, 3
• Never perform supine radiographs - upright positioning is essential to avoid underestimating malalignment 4, 3

Clinical Red Flags Requiring Immediate Assessment

• Perform thorough neurovascular examination documenting pulses, capillary refill, sensation, and motor function in the affected extremity 2, 3
• The mechanism (falling backward into door frame then forward catching themselves) represents high-energy trauma with potential for vascular injury, particularly with proximal humeral fractures 2
• Tingling in the bicep region suggests possible nerve involvement (musculocutaneous or lateral antebrachial cutaneous nerve) that requires documentation 5

Differential Diagnosis Based on Mechanism

Elbow Pathology

• Occult fracture (radial head, olecranon, or distal humerus) from direct impact against door frame 1
• Biceps tendon injury from eccentric loading while carrying the box 1
• Collateral ligament injury from valgus or varus stress during the fall 1

Shoulder Pathology

• Anterior shoulder dislocation from the forward fall with arm extended (most common traumatic shoulder injury) 2
• Proximal humerus fracture particularly given the age-related mechanism and anterior pain 2, 3
• Rotator cuff tear which is more common in older patients with shoulder trauma and frequently underreported 3
• Labral tear (Bankart or SLAP lesion) from the traumatic mechanism 3

Management Algorithm After Initial Radiographs

If Radiographs Show Dislocation

• Confirm successful reduction with post-reduction radiographs to evaluate for fractures that may have been obscured 2
• Obtain MRI without contrast to assess soft tissue injuries including rotator cuff tears, labral injuries, and capsular tears in the acute setting 2, 3
• Initiate acetaminophen or ibuprofen for pain management if no contraindications 4

If Radiographs Show Fracture

• CT without contrast is indicated for better characterizing complex fracture patterns when surgical planning is needed 2, 3
• Immediate surgical referral for open fractures or unstable/significantly displaced fractures 3

If Radiographs Are Normal or Nonspecific

• MRI of both elbow and shoulder without contrast is the next appropriate study to evaluate soft tissue pathology including tendon tears, ligament injuries, and occult bone injuries 1, 2, 3
• The combination of sharp shooting pain, radiation, and tingling suggests nerve involvement that MRI can help characterize 1
• Electromyography assists in workup of nerve symptoms if clinical suspicion remains high for peripheral nerve injury 1

If Vascular Compromise Is Suspected

• CT angiography is the preferred examination if there are diminished pulses, expanding hematoma, or signs of ischemia 2, 3
• This requires immediate surgical referral 3

Conservative Management Pending Imaging Results

Initial symptomatic treatment while awaiting imaging:

• Rest from aggravating activities and activity modification 1
• Analgesia with acetaminophen or NSAIDs if no contraindications 1, 4
• Avoid attempting any reduction maneuvers without radiographic confirmation, as this could worsen fracture-dislocations 2

Critical Pitfalls to Avoid

• Failing to obtain axillary or scapular Y views of the shoulder leads to missed dislocations in the majority of cases 2, 4, 3
• Attempting reduction without radiographic confirmation could worsen underlying fracture-dislocations 2
• Inadequate neurovascular examination documentation, particularly given the high-energy trauma mechanism 3
• Overlooking associated injuries such as rotator cuff tears, which are more common in patients with shoulder dislocation and can impact outcomes 2
• Delaying reduction (if dislocation is present) increases risk of neurovascular compromise 2

Follow-Up Considerations

• Most rotator cuff tears can initially be managed conservatively before considering surgery 3
• Labral tears without instability can be managed conservatively 3
• Physical therapy and gentle range of motion exercises should be initiated once fracture and dislocation are ruled out to prevent stiffness 4