Humeral Fracture

Patient presents with complaints of right shoulder pain and limited range of motion following a fall onto an outstretched hand.  Onset of pain was acute and coincident with the fall.  Patient reports severe pain localized to the right upper arm with associated swelling and ecchymosis.  Mechanism of injury is consistent with a humeral fracture.  Physical examination reveals tenderness to palpation along the humeral shaft.  Crepitus is palpable.  Neurovascular examination of the right upper extremity demonstrates intact radial, ulnar, and median nerve function with palpable radial and ulnar pulses.  Deformity of the right humerus is clinically evident.  Radiographic imaging of the right humerus was ordered and confirms a closed, displaced midshaft humeral fracture.  Differential diagnosis includes shoulder dislocation, proximal humerus fracture, and rotator cuff tear.  Diagnosis of closed, displaced midshaft humeral fracture was made based on patient history, physical exam findings, and radiographic confirmation.  Treatment plan includes closed reduction and immobilization with a coaptation splint followed by referral to orthopedics for definitive management.  Patient education provided regarding pain management, activity modification, and follow-up care.  Patient understands the diagnosis and treatment plan.  ICD-10 code S42.201A assigned for displaced fracture of shaft of right humerus, initial encounter.  Return to clinic scheduled in one week for follow-up evaluation and reassessment.