Head of the Department : Prof. Dubrovin G.M.

Teacher in Charge: Dr. Doroshev M.E.

Clinic Task

Patient: Vakarev Aleksander Valelevich Clinical diagnosis: Closed dislocation of the acromian part of the right clavicle

Name: Parthevan Rajasingam Group: 2

Course: 5th year 2nd semester

KURSK 2014

Department of Traumatology Department of Traumatology & Extreme Medicine& Extreme Medicine

Case HistoryCase History

Patient details:

Name: Vakarev Aleksander Valelevich

Sex: MaleAge:35(D.O.B:13/08/1979)

Address: Dubrovinskovo street,

Apartment No 4, Kursk

ComplaintsComplaintsPatient complains of pain in his

right arm. It is a continuous pain which irradiates to his right forearm and back. His pain increases when he tries to move his hand upwards.

Medical historyMedical history

Patient fell from his bicycle on 09/03/14 landed on his right shoulder.

He felt a deep aching pain around the shoulder joint, which intensified upon movement. His movements and sensation of his right arm and forearm were normal.

His right shoulder joint became red and his clavicle can be seen close to his skin near the acromian process.

He admitted himself to the traumatological department.

Sol. Baralgin 2%-2.5ml intramuscularly given. He was given a shoulder slint and admitted to

the hospital for further investigation.

Life historyLife historyBorn in Kursk. Driver for over 20 years and now is

not working. He is single. No systemic diseases.He smokes a packet of cigarettes a

day. He drinks alcohol occasionally No previous operations done. No blood transfusion. No allergies.

General ExaminationGeneral ExaminationGeneral condition: Satisfactory. Show: Patient appears according to his

age.Consciousness: Alert. Patient remembers

well and answered to my questions clearly.Posture: active.Face: normal appearance, Normal

development of subcutaneous tissue. No edema of the face.

Patient weighs: according to his height and age (Height:180cm,Weight:71kg)

Body constitution: Normosthenic.

General ExaminationGeneral ExaminationSkin: pinkish red skin. Normal skin turgor

and moisture of skinNails: Absence of clubbing and brittleness.Hair: Normal hair growth. Subcutaneous fat: good development 1.5 cm

for the thickness of skin flap.Edema: absent.Musculature: good development,

symmetrical development, normal muscular tension, pain on the right arm, no convulsion or tremor.

General ExaminationGeneral Examination Lymphatic system: No enlarged lymph nodes, no

palpable lymph nodes. Bones: Present all bones, symmetrical

development, no deformities or fractures. Joints: Normal, no pain present. Thyroid gland: No swelling, nodes or nodules are

found. Body temperature: normal 36.7o C. Head: no scars, absence of deformity of the skull Nose: normal, no nasal bleeding Eyes: Clear sclera- absence of jaundice or

hemorrhage, no conjunctivitis, absence of edema in the lids

Neck: no thyroid enlargement, no enlarged lymph nodes, no pulsating vessels.

Local ExaminationLocal ExaminationPosture is active. Patient has

limited range of movement of shoulder joint.

Palpation revealed pain on the region of the right shoulder joint and the acromion end of the right clavicle. Any movement of the right shoulder joint causes pain. Superficial sensation and pulsation of the radial artery is present.

Measurement of upper Measurement of upper extremityextremityExtremity Length Axis

Right arm 43cm Normal axis (point passes through cubital fossa)

Left arm 43cm Normal axis (point passes through cubital fossa)

Plan of InvestigationPlan of InvestigationGeneral blood analysisBiochemical blood analysisBlood analysis for glucose

contentX-ray of right armECG

ResultsResults

Red blood cells 4.6 × 10¹²

Hemoglobin 150

Colour Index 0.89

Leucocytes 9.8 × 109

Basophils -

Eosinophils -

Band 6

Segmented 76

ESR 2 mm/h

General blood analysis

ResultsResults

Biochemical AnalysisBiochemical Analysis

Protein 71g/l

Urea 4.2mMol/l

Creatinine 66 Mkmol/l

Bilirubin 12.0 Mkmol/l

ResultsResultsBlood analysis for Blood group Rh- Blood group II (A)

Blood analysis for glucose content— 4.6 ммоль/л

X-ray of right shoulder X-ray of right shoulder jointjoint

Radiograph of patient's right shoulder joint before operation in AP view;

Clinical DiagnosisClinical Diagnosis

Dislocation of the acromian part of the right clavicle

Plan of treatmentPlan of treatmentSurgical treatment (Osteosynthesis

with plate and screws)Conservative treatment:

Sol. Analgini 50%-2.0(IM)Antibiotic therapy after operation:

Penicillin 250-500mg I.V twice a day as prophylaxis.

Exercises and massages on the right shoulder joint.

Operational treatmentOperational treatment

Open reduction & internal rotation with osteosynthesis using k-wires and screws.

Post-operative x-ray Post-operative x-ray picturepicture

TasksTasks

Things to be done on scene of accident: General condition can be assessed by realizing

the danger around checking patients response and start ABC ( Airway Breathing Circulation assessment) proceed with CPR if the patient is unconscious.

In our case, patient was conscious:1. Call for help, give analgesics (Narcotic or non

narcotic)2. Transport immobilized by Kramer splint or

hard objects fixating his arm to his body3. Transport to specialized hospital.

TasksTasks Main symptoms: 1. General symptoms: Pain of right shoulder radiating

down to his arm. 2. Authentic symptoms: Limitation of movement on

his shoulder joint.

Preliminary diagnosis: Closed dislocation of the acromion part of the right clavicle.

The first aid done was:1. Analgesics (Narcotic or non narcotic)2. Transport immobilized by Kramer splint or any hard

objects which fixate his hand to his body.3. Transport to specialized hospital.

TasksTasksOther symptoms for this patient are

absent.Full diagnosis: Closed dislocation of the

acromion part of the right clavicle.Additional survey may be a CT scan or

MRI. Ultrasound examination.Treatment: 1.Operation (Open reduction and internal

fixation with osteosynthesis using plate and screws)

2.Conservative with analgesics intramuscularly. Exercises of his arm and shoulder joint are also recommended.