A 29-year-old woman presents to an urgent care clinic 6 hours after being involved in a motor vehicle collision. She was the restrained driver in a car that was struck on the driver’s side at approximately 30 mph. Airbags did not deploy. She was able to exit the vehicle and declined EMS transport at the scene. She now reports increasing pain over the top of her left shoulder and difficulty lifting her arm. She denies neck pain, headache, chest pain, or shortness of breath. On examination, her vital signs are normal. There is localized tenderness and mild swelling over the distal clavicle and acromioclavicular (AC) joint with a visible step-off compared with the contralateral side. Passive range of motion is painful above 90 degrees of abduction, but distal neurovascular status is intact.
Which of the following is the most appropriate initial management in the urgent care setting?
- Discharge with NSAIDs only and advise return if pain worsens
- Urgently transfer to the emergency department for suspected open fracture
- Immobilize in a brace without imaging and schedule routine follow-up in 2–3 weeks
- Apply a sling, obtain shoulder radiographs, and arrange outpatient orthopedic follow-up
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Correct Answer: d. Apply a sling, obtain shoulder radiographs, and arrange outpatient orthopedic follow-up.
Shoulder-girdle trauma is a common post-MVC injury and sometimes missed. This presentation is most consistent with an acromioclavicular joint separation or distal clavicle injury after blunt shoulder trauma in an MVC, suggested by focal tenderness, swelling, and a step-off at the AC region. The patient was fitted with a sling to immobilize her shoulder, appropriate radiographs were taken, and she was prescribed acetaminophen, 650 to 1000 mg orally, every 6 hours as needed. She was discharged with instructions for return should her pain worsen and provided an orthopedic referral for follow-up in 2-4 days. Other adjuncts to her injury were also discussed, such as the use of diclofenac gel, ice, and elevation.
Standard initial management in urgent care includes immobilization (eg, sling for comfort), appropriate imaging (AP and specialized shoulder/clavicle views) to classify the injury, pain control, and referral for orthopedic follow-up. Many low- to moderate-grade injuries can be managed nonoperatively and in the urgent care setting.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
