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CASE REPORT

Case II
Man, 48 years old man, came to hospital with chief
complain: Wound at the left hand
 History: It had been suffered since 2 hours before
admission to ER.
 Mechanism of injury: He was in a car and his hand at
window of the car, suddenly there is another car
came from another direction and hit his hand.
History of prior took medicine at the Camba Hospital
then referred to RSWS
 Defecation : not yet since accident
 Micturation : not yet since accident
Primary Survey:
A : Patent, no air way obstruction.
B : RR= 20 x/min, spontaneous, equal,

thoracoabdominal type.
C: BP=120/70 mmHg, PR=82x/mnt,
adequate,regular,strong.
D: GCS 15 (E4V5M6), pupil equal, Ø 2mm/2mm,
light reflex +/+.
E: T = 36,70 C (axillar)
Secondary survey
Local status (left humerus region)
I : Seen lacerated wound 10 x 10 cm, there were
active bleeding, tendon expose, bone expose,
and deformity
P: There was tenderness
ROM: Limited active and passive movement of the
shoulder and elbow joint caused of the pain
NVD : There were sensibility, capillary refill time
> 2 second
Radial and ulnar artery difficult to evaluated
LABORATORY FINDINGS
WBC : 21,5 x 103 /uL
RBC : 4,96x 106 /uL
HGB : 14,9 g/dL
HCT : 42,5 %
PLT : 265 x 103 /uL
CT : 8’00’’
BT : 3’00’’
Blood glucose : 201
Ur : 30
Cr : 0,6
SGOT : 29
SGPT : 34
Humeral X-Ray
Preoperation Diagnosis

Open fracture of left distal humerus and
Suspicious left brachialis artery rupture
Management

 O2
 IV-line
 Antibiotic
 Analgesic
 H2RA
 Exploration wound, debridement and
tromboembolectomy
OPERATION PROCEDURE

 Patient lied in supine position in GA
 Sterilization procedure and draping
 Identification brachialis artery, seen trombus 2 cm at
the 10 cm from elbow .
 Do the trombectomy
 Apply patency test with catheter and heparin was
good result
 Stitch brachialis artery
 The operation continue with external fixation
Postoperation Diagnosis

Open fracture of left distal humerus
Trombosis at left brachialis artery