Supervisor : dr. James Pelealu, Sp.OT
Victor Kurniawan 2009 – 061 - 181
Monica Mangkuwerdojo 2009 – 061 – 183
Gwenda Dellagusta 2009 – 061 – 184
CASE PRESENTATION
IDENTITYName : Ms. IAge : 22 years oldTime of the event : Thursday, July 14th
2011, 18.00Time of admission : Thursday, July 14th
2011, 21.10Sent by : bajajPrehospital treatment : -Chief complaint :
Pain on left shoulderAdditional complaint : -
PRIMARY SURVEY
Universal PrecautionHand gloves
Airway with cervical controlCervical immobilization
Collar neck : -Airway assess
Obstruction : -Suction : -Oropharngeal airway : -Endotracheal : -
Patient can talk clear and spontaneously
Airway clear 21.11
Breathing and VentilationLook
Spontaneous breathing, deformity - , retraction –, symmetrical hemithorax movement, cyanosis -, difficulty in breathing -
ListenAir blown from nose. RR= 18 breaths/min
Feelbreath sound heard normally
Breathing clear 21.13
Circulation Blood pressure : 110/70 mmHgPulse : 92 times / minSigns of shock –CRT < 2 secs, hands and feet warm and
moist
Circulation clear 21.15
DisabilityGCS :E4M6V5 = 15 since arrivalPupil :symmetric, round, Ø 3mm/3mm,
light reflexes +/+Motoric : 5555 can’t be assessed
5555 5555
Exposure Axillary temperature : 36.8 oC
SECONDARY SURVEY
History of Present IllnessAbout three hours before admission,
patient was hit by a motorcycle while she was crossing the road. She fell on her left side. After the accident, she felt pain if she move her left arm. Before she came to the hospital, she went to a traditional therapist to get massage. She experienced no lost of consciousness. She didn’t complained any headache, nor experience any vomiting.
History TakingAlergic : deniedMedication : deniedPast illness : deniedLast meal : 9 hours before admission
(12.00)Event : accident
Physical Examination
Physical ExaminationGeneral condition : CalmConsciousness : compos mentisHEAD
Eyes : conjunctiva not anemic, isocor , round, Ø 3 /3 mm , light reflex + /+Nose, mouth, ears within normal limit
Physical ExaminationPulmo◦ Inspection : symmetric in static and dynamic,
swelling(-), hematome(-), open wound(-)◦ Palpation : left and right stem fremitus equal◦ Percusion :sonor on the both side◦ Auscultation : vesicular breath sounds, ronchi
-/-,wheezing -/-
Cor Heart sound I and II normal, no murmur, no
gallop
Physical ExaminationAbdomen:
Inspection : convex, no lesion
Auscultation : bowel sound +; 6 times/min
Percussion : tympanic in all quadrant
Palpation : tender, pain (-) , liver and spleen aren’t palpable
Back : local status
Physical ExaminationExtremities
Upper right : capillary refill time < 2 sec, warm, range of motion within normal limit
Upper left : local statusLower : capillary refill time < 2 sec, warm,
range of motion within normal limit
Local StatusOn the left cheek, excoriation wound, size 3
cm x 2 cm, active bleeding -
Local StatusLook : deformity +, swelling -, hematome -Feel : pain +, crepitation –, pulsation of left
brachialis and radialis artery were reguler, strong, and full
Move : pain on movement +, range of movement was limited
On the left back, excoriation wound, size 4 cm x 3 cm, tenderness, active bleeding -
Local StatusOn the left upper leg, excoriation wound,
size 3 cm x 2 cm, bleeding -, tenderness -, pain on movement -, deformity -
On the left knee, excoriation wound, size 2 cm x 1 cm, bleeding -, tenderness -, pain on movement -, deformity -
Local StatusOn the left lower leg, excoriation wound,
size 4 cm x 3 cm, bleeding -, tenderness -, pain on movement -, deformity -
Working Diagnosis Closed fracture 1/3 middle of left clavicle
boneMultiple excoriation wounds
Diagnosis Closed fracture 1/3 middle of left clavicle
bone complete oblique displacedMultiple excoriation wounds
Treatment Wound toiletteClavicle bandageKetorolac tromethamine,10 mg,
intravenous injectionAnti Tetanus Serum, 1500 U, intramuscular
injectionTetanus Toxoid, 0.5 mg, intramuscular
injectionAmoxicillin clavulanat 3 x 500 mg oralMefenamic acid 3 x 500 mg oral
Flow Chart21.10 21.15 23.00
Airway ---------------------Clear-------------------
Breathing ----------------Adequate------------------
GCS 15
BP (mmHg) 110/70
P (beats/min) 92
RR (t/m) 18
T (oC) 36.8
ArrivalArrival X-RayX-RaySplintingSplinting
Going Going HomeHome
REFERENCE
CLAVICLE FRACTURE
Mechanism of Injury Moderate or high-energy direct
traumatic impacts to the shoulder (87%).
Direct impact to clavicle( 7%) Fall on outstretched hand (6%) Vigorous muscle contractions, seizures
(Rare) Atraumatic ,pathologic (Rare)
Radiographic EvaluationAnteroposterior view30-degree cephalic tilt view. No thoracic
overlap.Chest X-ray for comparisonCT scan usually indicated to best assess
degree and direction of displacement. And to differentiate sternoclavicular joint dislocation from epiphysis injury in children
Fractures ClassificationGroup I : middle third (80% )Group II: lateral third (10-15%)Group III: medial third (5%)
Treatment OptionsGroup I (Middle third)Non-operative
Sling / Brace (Immobilization till pt. becomes pain free)
Surgical (2 wks immobilization) Reconstruction plating External fixation can be used in rare
cases.(Remove after 8 wks )
Treatment OptionsGroup I (middle third)Indications for surgical treatment
Open fractureNeurovascular injuryShortening of >2cmSoft tissue interpositioningSeizures disordersFloating shoulderMultiple traumaCosmetic, quick recovery
Group II: Lateral Third Type I:
Minimal displacementInterligamentous fractureLigaments still intact
Group II: Lateral Third Type II (Unstable)
Typically displaced secondary to # medial to the coracoclavicula ligaments, keeping the distal fragment reduced while allowing the medial fragment to displace superiorly
Type II A : Both conoid and trepezoid remain intact and atteched to distal segment.# is medial to conoid tubercle on x-ray
Type II B : Conoid torn, trepezoid attached to distal fragment. # is in line with conoid tubercle on x-ray
Type III:(Stable) : Extension to Acromioclav joint (Articular surface), intact ligaments
Treatment OptionsGroup II (lateral third) Nonoperative treatment
Chances of non-union or delayed union are much more compared to ORIF. Opted in undisplaced fracture
Operative treatment Fractures healing occures within 6 to 10
weeks after surgery Opted in all displaced fracture
Techniques for Acute Operative Treatment Group II (lateral third)K-wires fixationTension band wiring (Most prefered) /
PDS sutures.Plate and screw fixationSingle transacromial knowel pinCoracoclavicular ligament
reconstruction
Techniques for Late Operative Treatment Group II (lateral third)Excision of distal clavicle
With or without reconstruction of coracoclavicular ligaments
Reduction and fixation of fracture
Group III : Medial third Type I - Minimal displacementTypeII - DisplacedTypeIII - IntraarticularType IV -Epiphyseal separationType V - Comminuted
ComplicationsNon-union (0.1% – 7%)Risk factors
Location of fracture(distal third)Degree of displacement (marked)Primary ORIF (Periosteal stripping)Open fracture
Principles of treatmentRestore length of the clavicleRigid fixation with plateBone graft
ComplicationsMalunion
Initially treat with strengthening, especially of scapulothoracic stabilizers
Consider osteotomy, internal fixation, if non-operative treatment fails
ComplicationsNeurological Sequele
Occasionally, fracture fragments or abundant callus can cause brachial plexus symptoms
Treatment is reduction and fixation of the fracture, or resection of callus with or without osteotomy and fixation for malunions
Post-traumatic arthritis
THANK YOU
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