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Case Presentation

A 33 Years Old Male with Closed Fracture of

Clavicula Sinistra 1/3 Medial Comminuted

Arranged by:

Antonius Bagus Budi Kurnia

G99131019

Tutor:

dr. Tangkas Sibarani, SpOT, FICS

Orthopaedic and Traumatology Department of Sebelas Maret University

Moewardi Hospital / Prof. Dr. R. Soeharso Orthopaedic Hospital

Surakarta

2013


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LEGALLY SHEET

Case presentation with title A 33 Years Old Male with Closed Fracture of

Clavicula Sinistra 1/3 Medial Community is arranged to fulfil the requirement in

Orthopaedic and Traumatology Department Sebelas Maret University, Moewardi

Hospital/Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta by:

Antonius Bagus Budi Kurnia. G99131019

Has been approved by Tutor of Orthopaedic and Traumatology Department in

Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta.

Surakarta, September 2013

Tutor

Dr. Tangkas Sibarani, SpOT, FICS


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CASE PRESENTATION

A. HISTORY1. Patient Identity

Name : Mr. H

Sex : Male

Age : 33 years old

Occupation : Construction labor

Address : Kawong 104 Manggosu 3/2 Ponorogo

Number of MR : 00242762

Date of Admission : 18th September 2013

Date of Examination : 18thSepember 2013

2. Chief ComplainPain in left shoulder

3. History of Present IllnessFive hours before admission, patient complained about pain in his

left shoulder after having a traffic accident. He rode a motorcycle and

suddenly hit by a motorcycle from left back side. The patient fell down to

the left and the left arm beard his body. Patient still conscious and didnt

vomit after that.

After the accident, patient was brought to Aisyah Hospital

Ponorogo. There, the doctor take an X-ray of his left hand. Because of

the patient wanted to use Jamkesmas card for the payment, then he

brought to the RSOP. Prof. Dr.Soeharso for further treatment.

4. History of Past IllnessHistory of trauma : was denied

History of hospitalized : was denied

History of allergy : was denied

History of asthma : was denied


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History of hypertension : was denied

History of diabetes mellitus : was denied

5. History of Family Illness

History of asthma : was denied

History of hypertension : was denied

History of diabetes mellitus : was denied

B. PHYSICAL EXAMINATION1. Primary Survey

Airway

Free, C-Spine Stable

Breathing

Spontaneous breathing, thoracoabdominal, 20 rpm

Circulation

BP: 138/77 mmHg, HR: 94 bpm

Disability

GCS E4V5M6, no lateralitation

Exposure

Axillary body temperature : 36,70C

2. Secondary Surveya. Head : mesocephal, black hair

b. Eye : periorbita hematoma (-/-), both pupils were isochor(3mm/3mm), light reflex (+/+), eye movement (N/N)

c. Ear : bloody otorrhea (-/-), tragus pain (-/-)d. Mouth : malocclusion (-), cross bite (-)e. Nose : bloody rinorrhea (-/-), discharge (-/-)f. Neck : normocolli, step off (-), pressure pain (-)g. Chest : normal


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h. CorInspection : ictus cordis was not seen

Palpation : ictus cordis was not palpable

Percussion : cardiac border was not widened

Auscultation : heart rate 94 bpm, the intensity of 1st and 2nd heart

sound was normal, there was no murmur

i. PulmoInspection : chest expansion was equal between left and right side

Palpation : tactile fremitus was equal between left and right side

Percussion : sonor in both of lung

Auscultation : vesicular sound (+/+), no additional sound of lung

j. AbdomenInspection : equal surface of abdomen and chest

Auscultation : normal bowel sounds

Percussion : tympani

Palpation : pressure pain (-), liver and spleen were not palpated

k. Extremity : (also see Local status)Oedema

- -

- -

Cold Acral

- -

- -

Motoric

+5 Couldnt be

evaluated+5 +5

Sensoric

+ +

+ +


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3. Local StatusShoulder Sinistra Region

a. LookSwelling (+), Vulnus (-). Skin Intact (-). Skins Color Changes (-),

Exorotaion (-). Angulation (-), Deformity (-)

b. Feel- There was touch pain at clavicula sinistra- Crepitation (+)- Wound side temperature more warm than other- Sensoric within normal limit- Vascular pulse of the radialis artery (+) normal, CRT < 2 secondsc. Motoric

Range of motion couldnt be evaluated because of the pain.

C. 1stASSESMENTInjury on shoulder sinistra region

D. 1st PLANNING1. X-Ray of thorax (AP)2. Laboratory Examination

E. ADDITIONAL EXAMINATION1. X-Ray of Thorax (AP) Finding

Picture can be seen on the last of this paper

Conclusion:

Close fracture of clavicula sinistra 1/3 medial comminuted

2. Laboratory FindingHb : 14,5 g/dl

Ht : 45 %

AL : 9300/ mm3

AE : 5.33 106

/mm3


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AT : 270000/ mm3

Blood type : O

PT : 13.3 seconds

INR : 1.07

APTT : 36.1 seconds

HbsAg : negatif

GDS : 115 mg/dl

Cr : 0.97 mg/dl

F. RESUMEA 33-years old male brought to the RSOP because his pain in his

left shoulder. Five hours before admission, patient complained about pain

in his left shoulder after having a traffic accident. He rode a motorcycle

and suddenly hit by a motorcycle from left back side. The patient fell

down to the left and the left arm beard his body. Patient still conscious

and didnt vomit after that.

After the accident, patient was brought to Aisyah Hospital

Ponorogo. There, the doctor take an X-ray of his left shoulder. Because

of the patient wanted to use Jamkesmas card for the payment, then he

brought to the RSOP. Prof. Dr.Soeharso for further treatment.

The result of the physical examination of left shoulder region :

sweling (+), deformity (-). There was touch pain at clavicula sinistra,

crepitation (+), wound side temperature more warm than other, sensoric

within normal limit, vascular pulse of the radialis artery (+) normal, CRT

< 2 seconds.

Range of motion couldnt be evaluated because of the pain. The

result of the additional examination: X-Ray of thorax sinistra (AP) found

fracture of clavicula sinistra 1/3 medial comminuted

While the laboratory found Hb: 14,7 g/dl, ht: 43 %, AL: 9300/

mm3

AT: 22000/uL, and blood type: O.


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G. 2ndASSESMENTClose fracture of clavicula sinistra 1/3 medial comminuted

H. 2nd PLANNING1. Education2. Arm sling3. Injection of ketorolax IV4. Pro ORIF

II. PROGNOSISAd vitam : bonam

Ad sanam : bonam

Ad fungsionam : bonam


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