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Close Fracture
middle right clavicula
Susnari Ahmad
111 2015 1149
SUPERVISOR:
dr. Ariyanto Arief, M.Kes, Sp.OT
ADVISOR :
dr. Stefan
Patient’s Identity
Name : Mr. A
Age : 19 years old
Sex : Male
Address : Jl. Latasakka No. 43 Kel.
Lumpue Pare-pare
Work : College student
Date of admission : December, 23 2017
Medical record : 141442
History Taking
• Chief Complain : Pain in the right shoulder.
• Anamnesis : Patients arrived with a right shoulder pain
suffered from less than 4 hours before admitted to Andi
Makkasau Hospital due to traffic accident. History loss level of
conciousness (-), headache (-), projectile vomitting (-)
• Mechanism of Trauma : Patient was riding his motorcycle and
hit by another motorcycle from opposite side.
•Patient right hand dominant.
Primary Survey
Airway and C-spine • Airway : Patent, clear
control • C-spine control : clear
CLINICAL FINDING
Radiologal Finding
Imuno-Serologi:
Negative
HBsAg (Kualitatif)
Negatif
Hemostasis:
CT
BT 9’00’’
< 15’00”
1’15’’
Minutes 1’00” – 3’00”
minutes
Resume
• 19-year-old man arived to Andi Makkasau Hospital with pain in
his right shoulder, Can't be moved since about 4 hours of SMRS.
The man was got the traffic accident when he was rode his
motorcycle
• Primary survey clear.
• Secondary survey: localis status: Regio sholder dekstra.
• Look: deformity (+), swelling (+), hematoma (-), wound (-).
• Feel: tenderness (+)
• Move: difficult to evaluate due to pain. NVD within normal limits.
• Investigations of Thorax AP photos:.
Diagnosis
Closed Fracture
1/3 middle right clavicula
Planning of Diagnosis
Non Operatif Non Education for the patient about his
Medikamentosa condition
Arm sling
Medikamentosa
• IVFD Ringer Lactate 20 tpm
• Analgetik: Ketorolac inj.
1amp/8j/i v
Physical Examination
• NVD evaluation
Treatment
NON OPERATIVE
Arm sling
OPERATIVE
open reduction with internal
fixation (ORIF).
Complication
EARLY COMPLICATION LATE COMPLICATION