CASE PRESENTATION

Supervisor : dr. James Pelealu, Sp.OT

Victor Kurniawan Monica Mangkuwerdojo Gwenda Dellagusta 2009 061 - 181 2009 061 183 2009 061 184

IDENTITY
Name

: Ms. I Age : 22 years old Time of the event : Thursday, July 14th 2011, 18.00 Time of admission : Thursday, July 14th 2011, 21.10 Sent by : bajaj Prehospital treatment : Chief complaint :
Pain on left shoulder

Additional complaint : -

PRIMARY SURVEY

Universal Precaution
Hand gloves

Airway with cervical control

Cervical immobilization
Collar neck : -

Airway assess
Obstruction : Suction : Oropharngeal airway : Endotracheal : -

Patient can talk clear and spontaneously Airway clear 21.11

Breathing and Ventilation

Look
Spontaneous breathing, deformity - , retraction ,

symmetrical hemithorax movement, cyanosis -, difficulty in breathing Listen

Air blown from nose. RR= 18 breaths/min

Feel
breath sound heard normally

Breathing clear 21.13

Circulation
Blood pressure : 110/70 mmHg

Pulse : 92 times / min

Signs of shock CRT < 2 secs, hands and feet warm and moist Circulation clear 21.15

Disability
GCS :E4M6V5 = 15 since arrival

Pupil :symmetric, round, 3mm/3mm, light

reflexes +/+ Motoric : 5555 cant be assessed 5555 5555

Exposure
Axillary temperature : 36.8 oC

SECONDARY SURVEY

History of Present Illness

About 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 didnt complained any headache, nor experience any vomiting.

History Taking
Alergic

: denied Medication : denied Past illness : denied Last meal : 9 hours before admission (12.00) Event : accident

Physical Examination

Physical Examination
General condition

: Calm Consciousness : compos mentis HEAD

Eyes : conjunctiva not anemic, isocor , round, 3 /3 mm , light reflex + /+ Nose, mouth, ears within normal limit

Physical Examination
Pulmo
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 Examination
Abdomen:
Inspection

: convex, no lesion

Auscultation : bowel sound +; 6 times/min Percussion

: tympanic in all quadrant

Palpation : tender, pain (-) , liver and spleen arent

palpable

Back : local status

Physical Examination
Extremities Upper right : capillary refill time < 2 sec, warm, range of motion within normal limit Upper left : local status Lower : capillary refill time < 2 sec, warm, range of motion within normal limit

Local Status
On the left cheek, excoriation wound, size 3 cm x

2 cm, active bleeding -

Local Status
Look

: 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 Status
On 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 Status
On 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 bone

Multiple excoriation wounds

Diagnosis
Closed fracture 1/3 middle of left clavicle bone

complete oblique displaced Multiple excoriation wounds

Treatment
Wound toilette

Clavicle bandage
Ketorolac tromethamine,10 mg, intravenous

injection Anti Tetanus Serum, 1500 U, intramuscular injection Tetanus Toxoid, 0.5 mg, intramuscular injection Amoxicillin clavulanat 3 x 500 mg oral Mefenamic acid 3 x 500 mg oral

Flow Chart
Airway 21.10 21.15 23.00 ---------------------Clear-------------------

Breathing GCS BP (mmHg) P (beats/min) RR (t/m) T (oC)

----------------Adequate-----------------15 110/70 92 18 36.8

Arrival X-Ray Splinting Going Home

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 Evaluation
Anteroposterior view

30-degree cephalic tilt view. No thoracic

overlap. Chest X-ray for comparison CT scan usually indicated to best assess degree and direction of displacement. And to differentiate sternoclavicular joint dislocation from epiphysis injury in children

Fractures Classification
Group I : middle third (80% )

Group II: lateral third (10-15%)

Group III: medial third (5%)

Treatment Options Group 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 Options Group I (middle third)

Indications for surgical treatment Open fracture Neurovascular injury Shortening of >2cm Soft tissue interpositioning Seizures disorders Floating shoulder Multiple trauma Cosmetic, quick recovery

Group II: Lateral Third

Type I: Minimal displacement Interligamentous fracture Ligaments 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 Options Group 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 fixation

Tension band wiring (Most prefered) / PDS

sutures. Plate and screw fixation Single transacromial knowel pin Coracoclavicular 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 displacement

TypeII - Displaced
TypeIII - Intraarticular Type IV -Epiphyseal separation

Type V - Comminuted

Complications
Non-union (0.1% 7%)

Risk factors Location of fracture(distal third) Degree of displacement (marked) Primary ORIF (Periosteal stripping) Open fracture
Principles of treatment Restore length of the clavicle Rigid fixation with plate Bone graft

Complications
Malunion Initially treat with strengthening, especially of scapulothoracic stabilizers Consider osteotomy, internal fixation, if nonoperative treatment fails

Complications
Neurological 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