What is the best course of action for a patient with right arm pain and weakness, particularly above the antecubital area, and thumb pain and bruising, after a fall onto their arm and thumb, with worsening symptoms despite taking Advil (ibuprofen) and Tylenol (acetaminophen), and no significant swelling or functional limitation?

Right Arm Pain and Weakness After Fall: Immediate Imaging and Multimodal Analgesia Required

This patient requires urgent radiographic evaluation to rule out occult fracture, followed by structured pain management with topical NSAIDs as first-line therapy, given the mechanism of injury, localized pain above the antecubital area, worsening symptoms despite oral analgesics, and functional impairment.

Immediate Diagnostic Workup

Obtain plain radiographs of the right humerus (AP and lateral views) and right thumb immediately to exclude fracture, given the direct trauma mechanism, progressive worsening of symptoms, localized tenderness with palpation, pain with resisted extension, and functional weakness 1. The ACR Appropriateness Criteria rates radiography as "usually appropriate" (rating 7-9) for acute elbow and forearm pain following trauma 1.

Key Clinical Red Flags Present

• Progressive worsening of pain over days (initially improving, now deteriorating) suggests evolving pathology 1
• Functional impairment with specific movements (opening car door, pushing door, forward elevation) indicates structural injury 1
• Pain rated 6/10 with nocturnal worsening suggests significant tissue damage 1
• Weakness and "heavy" sensation may indicate muscle, tendon, or nerve involvement 1

Optimal Pain Management Strategy

First-Line: Topical NSAIDs

Switch immediately from oral ibuprofen to topical diclofenac gel 1% applied to the affected area four times daily 2. The American College of Physicians and American Academy of Family Physicians recommend topical NSAIDs as first-line pharmacological therapy for acute musculoskeletal injuries, providing superior pain relief with fewer systemic side effects than oral NSAIDs 1, 2.

• Topical diclofenac reduces pain by 1.08 cm on a 10-cm visual analog scale at 1-7 days compared to placebo (moderate-certainty evidence) 2
• Topical formulations achieve equivalent pain relief to oral NSAIDs but with markedly fewer gastrointestinal adverse events 2
• Local skin reactions are the most common side effects but occur at similar rates to placebo 2

Scheduled Acetaminophen Dosing

Continue acetaminophen but optimize to scheduled dosing: 1000 mg every 6 hours (maximum 4000 mg/24 hours) 1, 3. Scheduled dosing provides superior and consistent pain control compared to as-needed administration 3.

• Acetaminophen has demonstrated efficacy in musculoskeletal trauma and is not inferior to NSAIDs in minor injuries 1
• Acetaminophen plus NSAIDs show additive analgesic effects 1
• No renal contraindications, making it safer than NSAIDs in vulnerable patients 3

Evidence Against Current Combination

The combination of oral ibuprofen plus acetaminophen does not provide superior analgesia compared to either agent alone for acute musculoskeletal injuries 4, 5. One randomized controlled trial of 90 ED patients with musculoskeletal pain found no significant difference in pain reduction among ibuprofen 800 mg, acetaminophen 1 g, or their combination 4. However, the topical NSAID formulation offers distinct advantages over oral administration 2.

Thumb Management

Apply topical diclofenac gel to the thumb as well, four times daily 2. For suspected hyperextension injury:

• Consider thumb spica splint if instability or significant pain with movement persists after imaging 1
• Ice application for 20-30 minutes, 3-4 times daily for first 48-72 hours 2
• Activity modification avoiding gripping and pinching motions until adequate healing 2

Critical Next Steps Within 48-72 Hours

If Radiographs Are Negative

1. Reassess pain and function within 2-4 days after optimizing topical NSAID therapy 6
2. If no improvement after 1-2 weeks of optimized therapy, obtain MRI to evaluate for soft tissue injuries including rotator cuff pathology, biceps tendon injury, or occult fracture 1
3. Refer to physical therapy for structured rehabilitation if pain persists beyond acute phase 1, 6

If Radiographs Show Fracture

• Immediate orthopedic consultation for fracture management 1
• Consider intra-articular corticosteroid injection if significant joint effusion present (provides short-term benefit with effect size 1.27 at 7 days) 1

Medications to Avoid

Do not prescribe opioids - they provide similar pain relief to NSAIDs but cause significantly more side effects including nausea, vomiting, and respiratory depression risk 1, 2. Opioid use concomitantly with other CNS depressants must be avoided outside highly monitored settings 1.

Avoid muscle relaxants - there is no evidence supporting their use in upper extremity trauma, and they increase CNS adverse events 2-fold 6.

Warning Signs Requiring Urgent Re-evaluation

• Increasing numbness or paresthesias (suggests nerve compression) 1
• Inability to move fingers or thumb (suggests tendon rupture or severe nerve injury) 1
• Fever or erythema (suggests infection) 1
• Compartment syndrome signs: severe pain out of proportion, pain with passive stretch, tense swelling 1