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