TUTORIAL REPORT

SCENARIO CASE B
BLOK 9

Supervisor : dr. R.A. Tanzila, M.Kes

Tutorial Group 7 :
1. M. Valeri Rivaldo 702017080
2. Barratush Febby Wulan 702017085
3. Iffat Nabila Ikbar 702017041
4. Neva Fiyolla Palupi 702017087
5. Aufa Rifqi Rizqullah 702017054
6. Muhammad Akip Aprianto 702017011
7. Retno Aqilah Fatma Pertiwi 702017072
8. Savira Chairunnisa 702017081
9. Romzi Khairrullah 702014091
10. Wishandra Inestasia Susilo 702017051

FACULTY MEDICAL
UNIVERSITY MUHAMMADIYAH PALEMBANG
2018

2
 FOREWORD

Praise our thanks to Allah SWT for all his grace and grace so that we can
finish the tutorial B Blok 9. Sholawat as greetings always pour out to our lord, the
great prophet Muhammad and his family, friends and followers until the end of the
age.
We recognize that this tutorial report is far from perfect therefore we expect
constructive criticism and suggestions, in order to refine the next tasks.
In completing this tutorial task, we have much help, guidance and advice. On this
occasion express the respect and gratitude to:
1. R.A. Tanzila, M.Kes as our supervisor.
2. All Members and related parties in the production of this report.
May Allah SWT give a reward for all the charity given to all those who have
supported us and hopefully this tutorial report useful for us and the development of
science. Hopefully we are always in the protection of Allah SWT. Amin.

Palembang, October 2018

Author

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 TABLE OF CONTENTS

TITLE PAGE
FOREWORD ............................................................................................................i
TABLE OF CONTENTS ..........................................................................................ii
CHAPTER I PRELIMINARY
1.1 Background ...................................................................................................1
1.2 Purpose and Objectives ................................................................................1
CHAPTER II DISSCUTION
2.1 Date of Tutorials ..........................................................................................2
2.2 Scenario of Case ..........................................................................................2
2.3 Clarification of Tems ...................................................................................4
2.4 Problem Identification ..................................................................................4
2.5 Problem Analysis ..........................................................................................6
2.6 Conculusion ..................................................................................................30
2.7 Conceptual Framework .................................................................................31
Bibliography .......................................................................................................32

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 CHAPTER I
PRELIMINARY

1.1 Background
The Neuro-Muskulo-Skeletal System Block is the ninth block in the second
semester of the Medical Education Competency Based Curriculum Faculty of
Medicine, Muhammadiyah University, Palembang
The case study scenario tutorial B in blok 9 presents the case Jojo a 20 years
old Karateka, came to emergency department with a chief complain of pain and
inability to move his right shoulder since 2 hours ago. The symptom occurs
during his full body contact full karate match, when his opponent kick Jojo's
shoulder from the side. After the incident, Jojo's right shoulder began to ache and
immoveable. The symptoms followed by some swelling and the pain is getting
more intense if he tries to move it. Jojo complains that he can't move his right
shoulder and sustains his ached arm with his left hand. Jojo was rushed to
emergency department immediately.

1.2 Purpose and Objectives

The purpose and objectives of this case study tutorial, namely:
• As a report to the tutor who is part of the KBK learning system at the Faculty of
Medicine, Muhammadiyah University of Palembang.
• Can solve the case described in the scenario with the method of analysis and
learning of group discussion.
• Achieving the objectives of the tutorial learning metho

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 CHAPTER II
DISCUSSION

2.1 Tutorial Date

Supervisor : R.A. Tanzila, M.Kes
Moderator : Savira Chairunnisa
Desk Secretary : Iffat Nabila Ikbar
Secretary Board : Aufa Rifqi Rizqullah

Tutorial Time : 1.Senin, October 29, 2018

2.Rabu, October 31, 2018
Tutorial rules :
1. Switch the phone off or in silence.
2. Raise your hand when going to argument
3. Permission when going out of the room
4. Relax and watch as the tutor gives directions
5. During the tutorial takes care of attitude and speech

2.2 Scenario Case

“Pinched shoulder”
Jojo a 20 years old Karateka, came to emergency department with a chief
complain of pain and inability to move his right shoulder since 2 hours ago. The
symptom occurs during his full body contact full karate match, when his
opponent kick Jojo's shoulder from the side. After the incident, Jojo's right
shoulder began to ache and immoveable. The symptoms followed by some
swelling and the pain is getting more intense if he tries to move it. Jojo
complains that he can't move his right shoulder and sustains his ached arm with
his left hand. Jojo was rushed to emergency department immediately.
Physical Examination :

6
 General Appearance:
Consciousness: compos mentis; Respiratory rate 26 x/m; Pulse rate 102 x/m; the
fill and it tension is normal; Blood Pressure 130/80 mmHg, temperature 37,0 ° C.
VAS 7
Spesific Examination :
Height: 160 cm, Weight: 57 kg
Head: anemic conjungtive (-), Icteric Sclera (-)
Thoraks : heart and lung is normal
Abdomen: Flat, supple, hepar and lien are not palpable.
Upper Extremities: right shoulder regio
Look:
- Asymmetric, swollen, shoulder contour are diminishing
- Hematome (+)
- open wound (-), active bleeding (-)
Feel: Tenderness (+), Crepitation (-), Right shoulder skins was tense if palpated
Move: pain if the right shoulder was moved (+)
ROM: Shoulder joints range from motion was undetermined due to pain.
Radialis artery pulsation was palpable
Left shoulder regio: within normal limits
Lower extremities: within normal limits.
Additional examination:
Blood Chemistry: Hb: 14 gr%, Leukocytes 9,000 /mm3 ,platelets 150x109 /L
Radiological Examination

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2.3 Clarification of Terms
Emergency situation that puses immediate risk to health, life , property
onvironment
Pain feeling of discomfort suffering or pain cause by stimuly at
certain nerve endings
Swelling transient abnormal erlargement of body part area noted due
to cell proliferation

Vas measuring instrument for checking pain intensity and

specifically covering 10-15 cm lines, with
each end is marked by a level of pain intensity
Hematome a localize collection of ontra vosated blood usually clothed
in an organ
Ache discomfort that persists for some time and settles.
Tenderness feeling that very sensitives by pressure of by tow
Asymmetric less or asymatical inaquality of the corresponding part of
organ on the opposite side of the body which is normally
2.4 Problem Identification
1. Jojo a 20 years old Karateka, came to emergency department with a chief
complain of pain and inability to move his right shoulder since 2 hours ago. The
symptom occurs during his full body contact full karate match, when his
opponent kick Jojo's shoulder from the side.

8
2. After the incident, Jojo's right shoulder began to ache and immoveable. The
symptoms followed by some swelling and the pain is getting more intense if he
tries to move it. Jojo complains that he can't move his right shoulder and sustains
his ached arm with his left hand. Jojo was rushed to emergency department
immediately.
3. Physical Examination :
General Appearance:
Consciousness: compos mentis; Respiratory rate 26 x/m; Pulse rate 102 x/m; the
fill and it tension is normal; Blood Pressure 130/80 mmHg, temperature 37,0 ° C.
VAS 7
4. Spesific Examination :
Height: 160 cm, Weight: 57 kg
Head: anemic conjungtive (-), Icteric Sclera (-)
Thoraks : heart and lung is normal
Abdomen: Flat, supple, hepar and lien are not palpable.
Upper Extremities: right shoulder regio
Look:
- Asymmetric, swollen, shoulder contour are diminishing
- Hematome (+)
- Open wound (-), active bleeding (-)
Feel: Tenderness (+), Crepitation (-), Right shoulder skins was tense if
palpated
Move: pain if the right shoulder was moved (+)
ROM: Shoulder joints range from motion was undetermined due to pain.
Radialis artery pulsation was palpable
Left shoulder regio: within normal limits
Lower extremities: within normal limits.
Additional examination:

9
 Blood Chemistry: Hb: 14 gr%, Leukocytes 9,000 /mm3 . platelets 150x109 /L
5. Radiological Examination

10
2.5 Problem Analysis
1. Jojo a 20 years old Karateka, came to emergency department with a chief
complain of pain and inability to move his right shoulder since 2 hours ago.
The symptom occurs during his full body contact full karate match, when
his opponent kick Jojo's shoulder from the side.
a) What is the anatomy and fisiology of superior extremity?
Answer:
Anatomi ekstremitas superior

Bone: Os scapula, os humerus, os radius, os ulna , ossa carpalia, os metacarpale,

os phalanges.
Joint : articulatio humeri, articulatio cubiti ( articulatio humeroradialis, articulatio
humeroulnaris, articulatio radioulnaris proximalis ), articulatio radioulnaris
distalis, articulatio radiocarpalis, articulatio mediocarpalis, articulationes
carpometacarpales, articulationes metacarpophalangeae, articulationes
interphalangeae manus proximales, articulationes interphlangeae manus distales.

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Musculus:
Regio deltoideus : m.deltoideus.
Regio brachii : m.biceps brachii caput longum et breve, m.brachialis,
m.coracobrachialis, m.triceps brachii caput longum laterale et mediale.
Regio antebrachii : m.pronator teres caput humerale et ulnare, m.flexor carpi
radialis, m.palmaris longus, m.flexor carpi ulnaris caput humerale et ulnare,
m.extensor carpi radialis brevis, m.extensor digitorum, m.extensor carpi ulnaris,
m.anconeus, m.supinator, m.flexor pollicis longus, m.flexor digitorum profundus,
m.extensor pollicis brevis, m.extensor pollicis longus, dan m.extensor indicis.
Regio manus : m.abductor pollicis brevis, m.flexor pollicis brevis, m.opponens
pollicis, m.adductor pollicis, m.abductor digiti minimi, m.flexor digiti minimi,
m.opponens digiti minimi,

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Innervation of the upper limb originates from the brachial plexus. the brachial
plexus is formed by Rr. anteriores to the spinal nerves of the upper and lower
cervical spinal cord segments. Branches of the brachialis plexus are :
a. radix : n.dorsalis scapulae (C3-C5), dan n.thoracicus longus (C5-C7).
b. truncus : n.suprascapularis (C4-C6), dan n. Subclavius (C5-C6).
c. fasciculus lateralis : n.musculocutaneus (C5-C7), n.pectoralis lateralis (C5-C7),
dan n.medianus, radix lateralis (C6-C7).
d. fasciculus medialis : n.pectoralis medialis (C8-T1), n.cutaneus brachii medialis
(C8-T1), n.cutaneus antebrachii medialis (C8-T1), n.ulnaris (C8-T1), dan n.
medianus, radix medialis (C8-T1).
e. fasciculus posterior : n.thoracodorsalis (C6-C8), n. axillaris (C5-C6), n.radialis
(C5-T1), Nn.subscapulares (C5-C7).
(Paulsen F. & J. Waschke, 2013)
Fisiology
Appendicular Frame
Ossa Membri Superioris
The bones of the superior body consist of a shoulder bracelet, and the upper
arm, forearm, and hand.
Bones of Shoulder Bracelets
The shoulder bones of the wristband consist of the clavicula and scapula, the
posterior jointed with each other in acromioclavicularis articulatio.
Clavicula

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 Clavicula are long bones that are horizontal in the base of the neck. This bone
is jointed with the sternum and the costal I cartilage is medially, and with
acromion lateral. Clavicula works as a buffer when the upper arm moves away
from the body. Clavicula also plays a role in channeling the force from the
upper arm to the skeleton of the body, and is the attachment of the muscles.
Clavicula is subcutaneous according to its length direction; the two medial
thirds are convex forward and the lateral third are concave forward. The most
muscles and ligaments attached to the clavicula.
Scapula
Scapula is a triangular flat bone located on the posterior wall of the thorax
between costa II, to VII. On the posterior surface, the spina scapulae protrude
back. The lateral end of the spina is scapulae free and collides with acromion,
which is jointed with the clavicula. Superolateralis Angular Scapulae form
cavities or glenoidal fossa shaped like pears and jointed with humeri head on
humeri articulatio. The coracoideus process protrudes upward and front above
the glenoid cavity and is the site of the attachment of the muscle and ligament.
Medial to the base of coracoideus proceccus there are iincisura suprascapularis
The anterior surface of the scapula is concave and forms the subscapularis
fossa. The posterior surface of the scapula is halved by the spinal scapula to the
supraspinate fossa above and the fossa infraspinata below. Inferior angular
scapulae can be palpated easily in living people and are indicative of the
position of the costa VII and the spinous process of the thoracicae VII vertebra.
Humerus
The humerus is jointed with scapula on humeri articulatio and with a radius
and ulna in cubic articulatio. The upper end of the humerus has a head, which
forms a third of the head joint and is jointed with the glenoidal scapula cavity.
Just below the head of the humeri is the anatomicum collum. Below the
collum, the majus and minus tuberculum are separated from each other by
sulcus bicipitalis. At the meeting of the upper end of the humerus and corpus
humeri there is a narrowing called the collum chirurgicum. The lateral
surrounding of the corpus humeri has a rough elevation called the deltoidea

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 tuberosity. Below the tuberosity occurs sulcus spiralis which is occupied by
N.radialis. The lower end of the humerus has the medial epicondylus and
lateral epicondylus for attachment of the humeral opitulum muscles and
ligaments which are jointed with the radii head, and the trochlea humeri is a
pulley to jointed with the trochlearis ulnae incisura. Above the capitulum is the
radial fossa, which receives the radii head when the elbow is flexed.
Anteriorly, above the trochlea, there is a coronoid fossa, which during the same
movement receives the coronoid process. Posteriorly, above the trochlea, there
is the olecrani fossa, which encounters olecranon when the elbow joint is in an
extension state.
Lower arm bones
The forearm bones are radius and ulna.
Radius
The radius is the lateral bone of the forearm. The upper end is jointed with the
humerus in cubital articulation with the ulna on the proximal radioulnaris
articulation. The distal end is jointed with the scaphoideum and eyebrow and
entangled lunatum, in radiocarpea articulatio and with the ulna in the
articulatio and distal radioulnaris. At the top end of the radius there is a small
round head. The upper surface of the head is concave and jointed with a
convex humeri capitulum. Circumferentia articulare radii is jointed with the
radial incisura ulnae. Beneath the head, the bones narrowed to form collum.
Under the collum there is a bicipitalis tuberosity or radii tuberosity which is
where the biceps musculus is inserted. Corpus radi is different from the ulna,
which is wider below the upper part. The medial corpus radii has sharp
interossea margins to place the attachment of the interossea membrane
connecting the radius and ulna. Pronatorial tuberculosis, for the place of
insertion of the pronator teres musculus, located midway along the lateral edge.
At the lower end of the radius there is the styloide process, which protrudes
down from the lateral edge. On the medial surface there is an incisura ulnae,
which is jointed with a rounded ulnae head. The inferior articular facies are
jointed with the scaphoideum os and os lunatum. On the posterior surface of

15
 the distal end of the radius there is a small tuberculum, the tuberculum dorsale,
which is sulcus at the medial edge to tendo musculus extensor policis longus
Ulna
Ulna is the forearm medial bone, the upper end jointed with the humerus in
cubic articulatio and with radii head on radioulnaris proximalis articulatio. The
distal end is jointed with a radius of articulatio radioulnaris distalis, but is
separated from radiocarpea articulatio in the presence of articular facies. The
upper end of the large ulna, known as the olecranon process, this part shows a
bulge on the elbow. This process has an incisura on the anterior surface,
incisura trochlearis, which is jointed with trochlea humeri. Under the trochlea
humeri there is a coronoid process which forms a triangle and on the lateral
surface finds the radial incisura to jointed with the radii head. Corpus ulnae
shrinks from top to bottom. Laterally it has a sharp interosseous margin to
place the interossea membrane attached. The posterior edge is rounded,
subcutaneously located, and is easily touched throughout the length. Below the
radial incisura there is an indentation, supinator fossa, which facilitates the
tuberosity movement of bicipitalis radii. The posterior fossa edge is shaped and
is known as the crista supinatoria, which is the origin of the supinator
musculus. At the distal end of the ulna there is a round head, which becomes a
bulge on the medial surface, called the styloide process.
Hand Bones
There are eight ossa carpi which are arranged in two rows, each consisting of
four bones. The proximal line consists of (from lateral to medial).
Scaphoideum, lunatum, triquetrum, and pisiform. The distal line consists of
(lateral to medial) trapezium, trapezoideum, captitaum, and hamatum. Together
the carpi on the anterior surface forms a basin, the anterior surface forming a
basin, vano ossa carpi pad on capitatum and hamatum. Together ossa carpi at
the lateral and medial ends is a membranous band called the retinaculum
musculorum flexorum. The bones of the hand at birth are the first bones of life,
and other bones are advanced at various intervals until the age of 12 years, at
this time scessus is prone. Os capitatum olympic during the year has been

16
 carried out checks for tasks, but the position, shape, and two sizes of the
scaphoideum due to fracture. The teeth in the trapezium and hamulus ossis are
observed before they are studied
Ossa Metacarpi and Phalanges
There are five pieces of metacarpi ossa, each bone has a base, corpus and caput
Metacarpal 1 Os the thumb is the shortest and is very easy to move. The bone
is not located in the same plane as the other metacarpi bones, but is located
more anteriorly. This bone also rotates medially ninety degrees, so that the face
extensor surface faces laterally not to the dorsal. The base of metacarpi is
jointed with the distal sequence of the carp, the head which forms a hand book
jointed with the proximalis phalanx. Each corpus ossis metacarpi is slightly
sunken forward and has a triangular shape. Corpus has posterior, lateral and
medial surfaces. There are three phalanx for each finger, but only two phalanx
for the thumb.
(Snell,2011)
b) What is the meaning complain about pain in this since 2 hours ago?
Answer:
Feel pain from 2 hours ago means that there is acute pain on right shoulder. it is
a sudden injury that can caused by hypermobile of right shoulder, clash by
something hard, bad coordination of muscle and joint, or etc. the Acute pain is
felt from 1 second to less than 6 months. The pain shows that there is an
inflammatory process which are indicated by character likerubor, kalor, dolor,
and tumor.
(Nugroho. B, 2013)
c) What is the clasification of pain?
Answer:
Based on the duration of pain:
- Acute pain: pain that lasts less than 3 months
- Chronic pain: pain lasting more than 3 months
Based on pain intensity:
- Visual analog score scale: 1-10

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 - Wong Baker's face scale: painless, mild pain, moderate pain, pain weight.
Based on location:
- Superficial pain: pain in the skin, subcutaneous, sharp, located.
- Deep somatic pain: pain originating from the muscles, tendo, blunt, lacking
located.
- Visceral pain: pain originating from internal organs or organs packaging,
such as gastrointestinal colic pain and ureteric colic.
- Phantom pain: perception of pain is associated with body parts lost as in limb
amputation.
Cases, based on duration include acute pain, based on pain intensity include
visual analog scare scale, based on location include superficial pain.
(Setiyohadi. B. Alw dkk, 2009)
d) How the patofisiology of pain?
Answer:
Pain arises because of the ability of the nervous system to change various
mechanical, chemical, and thermal stimuli, electrically becoming action
potentials that are transmitted to the central nervous system. The mechanism of
pain starts from the transduction of stimuli due to tissue damage in the sensory
nerves to electrical activity and then transmitted through myelinated nerve fibers
A delta and the non-myelinated nerve C to the dorsal horn of the spinal cord,
thalamus, and cerebral cortex. These electrical impulses are perceived and
discriminated against as the quality and quantity of pain after modulation along
the peripheral nerves and arranged in the central nerve. Stimulation that can
cause pain can be mechanical stimulation, temperature (hot or cold) and
chemical agents released due to trauma / inflammation.
(Price. A. Sylvia. Lorraine Mc. Carty Wilson, 2006)
e) How to measure range of pain?
Answer:
 Numerical Rating Scale, where the patient is asked to give a number 1 - 10
of their pain condition.

18
  Visual Analogue Scale, there is a line that patien is asked to give a line of
their pain condition.
 Verbal Rating Scale, patient is asked to tell their pain condition without
instrument.
(Sudoyo, 2014).
f) What is the movement of superior extremity?
Answer:
 Fleksions
 Ekstensions
 Abduksi
 Adduksi
 Supination
 Pronation

(Snell, Richard S, 2006)

g) What is the relation his age and complain?
Answer:
Dislocation of joint frequently found in adults, rarely found in children where
71,8% of men who experienced dislocation, 46,8% of patients aged between 15-
29 years, 48,3% occur due to trauma as in sport activities.
(Legiran,2012).
h) What is the etiology of pain?
Answer:
Not only does one stimulus produce a specific type of pain, but pain has a
multimodal etiology. Pain is usually associated with several specific
pathological processes. Pain-causing disorders, including: infection, state of
inflammation, trauma, degeneration disorders, metabolic toxic conditions or
neoplasms. Pain can also arise due to mechanical distortion of nerve endings, for
example due to increased pressure on the viscus wall / organ. Many factors
influence pain (figure), including: environment, age, fatigue, previous history of

19
pain, mechanisms for solving personal problems, beliefs, culture and the
availability of people who provide support.
Most of the pain is severe due to: trauma, ischemia or inflammation with tissue
damage. This results in the release of certain chemicals that play a role in
stimulating peripheral nerve endings.
Pain can be aggravated by excessive stimulation of the environment, for
example: noise, very bright light and loneliness. Fatigue also increases pain so
many people feel more comfortable after sleeping. Previous pain history and
personal problem solving mechanisms also affect a person in dealing with pain,
for example: there are some circles who consider pain as a curse. The
availability of people who provide support is very useful for someone in the face
of pain, for example: children will feel more comfortable when close to parents.
Cognitive factors (such as: a person's beliefs) can increase or resist pain,
especially the understanding of pain that an individual has is a possible cause or
implication.
In a study conducted by Woodrow et al, it was found that tolerance to pain
increased in accordance with age, for example, as a person ages, the
understanding of pain and the effort to overcome it increases. According to
research conducted by Sternbach stated that anxiety adds pain sensitivity and
increases pain response

20
 (Rinaningsih. Wahyu, 2008)
i) What is the clasification of trauma?
Answer:
 Mechanic trauma
- blunt trauma
- sharp trauma
 Chemical trauma
(Fadhila. K, 2009)
j) How the mechanisme trauma in this case?
Answer:
Pressure occurs on the humerus bone  bones fail to resist pressure  humerus
dislocation causes soft tissue damage  trauma
k) What is the clasification injury?
Answer :
According to Hardianto (2005), load classification is as follows:
A. Based on its light weight, trials can be grouped into:
1) Mild Injury
Injuries that are not followed by significant damage to our body tissues, for
example, muscle stiffness and disarray. In minor injuries, no treatment is
usually needed, and trauma will heal itself after some time.
2) Severe injury
Serious injuries, which cause damage to body tissues, such as muscle tears or
ligaments or fractures. Weight Tracking Criteria:
a) Loss of substance or continuity
b) Damage or tear of blood vessels
c) Local inflammation (characterized by heat / heat, rubor / redness, tumor /
swelling, color / pain, function-basting / cannot be used normally).
b. Based on the network affected, can be grouped into:
1) Soft Tissue Injury
Some soft tissue weaknesses
a) Injury to the skin

21
 The most frequent injuries are excoriations (blisters), lacerations (tears), or
punctum (puncture).
b) Injuries to muscles / tendons and ligaments
(1) Strains Are injuries that occur in muscles and tendons. Usually caused by
excessive strain. Symptoms: Localized pain, stiffness, swelling,
hematoma in the area of trauma.
(2) Sprain Is an abnormality that occurs with excessive stretching during
release of the ligament. Symptoms: pain, swelling, hematoma, unable to
move joints, difficulty in using injured limbs.
2) Hard Tissue Injuries
This injury occurs in bones or joints. Can be found together with soft tissue
removal. Which includes this injury:
a) Fractures (Broken Bones) That is the discontinuity of bone tissue structure.
The reason is that the spinal trauma (forced ruda) exceeds the ability limit
that is still accepted. The shape of the fracture can be just cracks to pieces.
Broken bones can be divided into 2 types, namely:
(1) Closed Bones
Where a fracture occurs is not followed by the tear of the surrounding
structure.
(2) Open Bone Broken
Where the broken end of the bone protrudes. This type of fracture is
more dangerous than a closed fracture, because with the opening of
the skin there is a danger of infection entering the germs.
b) Dislocation is a condition where the position of the bones in the joint is not
in the right place. Usually dislocations will be removed by ligament injury
(sprains).
(Hardianto.W, 2005)
2. After the incident, Jojo's right shoulder began to ache and immoveable. The
symptoms followed by some swelling and the pain is getting more intense if he
tries to move it. Jojo complains that he can't move his right shoulder and

22
 sustains his ached arm with his left hand. Jojo was rushed to emergency
department immediately.
a) What is the meaning after the incident jojo’s shoulder began the ache and
immoveable?
Answer:
The meaning possibility of joint dislocation in humeri Jojo’s right shoulder causing
pain and immoveable.
b) What is the etiology of sweling?
Answer:
Etiologi :
 increased hydrosatic pressure: hydrostatic pressure is the pressure of fluid
flowing in the blood vessels. Increased hydrostatic pressure as in heart
failure and liver disease will cause resistance to the fluid flowing in the
blood vessels, so that the fluid tends to move into the interstitial space.
 Lymphatic obstruction: resistance to lymph fluid flow as in advanced
malignant tumors, can also cause fluid to tend to move into the interstitial
space.
 inflammation: in both acute and chronic inflammation can cause dilation
in the inter-cell gap so that more fluid will accumulate in the interstitial
space.
 Infection
 Trauma (mechanical injury)
 Autoimmune
(Helmi, Zairin Noor. 2013)
c) What is the meaning the symptom followed by some sweeling and this pain is
getting more intense if try move?
Answer:
The meaning is because there is a scretch or tear in the ligament of his shoulder .
And the pain is more intense when move is because movement that will move the
ligament that already tear, will caused more tear.
d) What is the patofisiology of sweeling?

23
 Answer:
Opponent kick shoulder → torn of complex ligaments → inflamation process →
vasodilation blood vessel → permeability of vascular increased → many blood
fluid sent to the site of injury → seeps out from capillary to interstitial space →
swelling
(Wara, Kushartanti , 2015)
e) What is the clasification of sweeling?
Answer:

 Traumatic swellings develop immediately after trauma, like a hematoma or dislocation.

 Congenital swellings are present since birth, such as a hemangioma or meningocele. Some
congenital swellings may not be discovered until later in life, such as a branchial
cyst, dermoid cyst or thyroglossal cyst.

 Inflammatory swelling may be either acute or chronic. The presentations of acute swellings
are redness, local fever, pain and impairment of function of the affected organ. The
related lymph nodes will be affected and will show signs of acute lymphadenitis. Chronic
inflammatory swellings will show the signs of acute inflammatory swellings, but in subdued
form. In this case, edema might not occur. Chronic swellings can be differentiated
from neoplastic swellings by the fact that neoplastic swellings never recede in size, but
inflammatory swellings may show occasional diminution.

(Kaspers,2015).

f) What is the meaning that jojo can’t move his right shoulder and sustains with his
left hand?
Answer:
The meaning possibility of joint dislocation in humeri Jojo’s right shoulder causing
pain and immoveable.
3. Physical Examination :
General Appearance:
Consciousness: compos mentis; Respiratory rate 26 x/m; Pulse rate 102 x/m;
the fill and it tension is normal; Blood Pressure 130/80 mmHg, temperature
37,0 ° C. VAS 7.
a) What is the interpretation of general appearence?

24
 Answer:
Respirasion Rate 26x/m : Takipnea
Pulse rate 102x/m : Takikardi
VAS 7 : severe pain
b) What is the patofisiology of abnormal general appearence?
Answer:
Pulse rate 102x/min:
Excercise (karate match) blunt of mechanical trauma torn ligament
anterior dislocation glenohumeral joint tissue damage ( inflamation )
release of infalammatory mediators increase of permeabilitas vascular
vasokontriksi blood vessel takikardi ( pulse rate 102x/mnt ).
VAS 7:
Pain arises because of the ability of the nervous system to change various
mechanical, chemical, and thermal stimuli, electrically becoming action potentials
that are transmitted to the central nervous system. The mechanism of pain starts
from the transduction of stimuli due to tissue damage in the sensory nerves to
electrical activity and then transmitted through myelinated nerve fibers A delta and
the non-myelinated nerve C to the dorsal horn of the spinal cord, thalamus, and
cerebral cortex. These electrical impulses are perceived and discriminated against
as the quality and quantity of pain after modulation along the peripheral nerves and
arranged in the central nerve. Stimulation that can cause pain can be mechanical
stimulation, temperature (hot or cold) and chemical agents released due to trauma /
inflammation.
(Price. A. Sylvia. Lorraine Mc. Carty Wilson, 2006)
4. Spesific Examination :
Height: 160 cm, Weight: 57 kg
Head: anemic conjungtive (-), Icteric Sclera (-)
Thoraks : heart and lung is normal
Abdomen: Flat, supple, hepar and lien are not palpable.
Upper Extremities: right shoulder regio
Look:

25
 - Asymmetric, swollen, shoulder contour are diminishing
- Hematome (+)
- open wound (-), active bleeding (-)
Feel: Tenderness (+), Crepitation (-), Right shoulder skins was tense if palpated
Move: pain if the right shoulder was moved (+)
ROM: Shoulder joints range from motion was undetermined due to pain.
Radialis artery pulsation was palpable
Left shoulder regio: within normal limits
Lower extremities: within normal limits.
Additional examination:
Blood Chemistry: Hb: 14 gr%, Leukocytes 9,000 /mm3 ,platelets 150x109 /L
a) What is the interpretaion of specific examination?
Answer:
No Spesific examination Interpretation
1 Hight 160 cm weight 57 kg Normal
2 Head : anemic conjungtive Normal
(-) icteric sclera (-)
3 Thoraks : heart and lung Normal
4 Abdomen : flat, supple, Normal
hepar and lien are not
palpable
5 Upper exremities : right
shoulder regio
Look :
- Asimetric, Abnormal
showllen, shoulder
conture are
dimminishing
- Hematome (+) Abnormal
- Open wound (-), Normal

26
 active bleeding (-) b)

Feel : tenderness (+) Abnormal

undetermined due to Abnormal

the pain.
6 Radialis artery pulsation Normal
was palpable
7 Left shoulder regio Normal
8 Lower extremites Normal
b. What is the patofisiology of abnormal spesific examination?
Answer:
 Hematoma

Shoulder → injury → dislocation → vasodilatation of blood vessel →

capillaries filled with blood rapidly → visible to surface skin → hematoma
 Pain when moved

Ligament damage → movement and instability decreased → accumulation of

collagen fibrous → arise fibrous tissue → elasticity of tissue decreased →
hypomobile right shoulder → pain when moved
 Ankle joint is limited

Ligament damage → stimulates nerves → proprioceptive decreased → ankle

reflex decreased → ankle joint is limited.
5. Radiological Examination
a) What is the interpretaion of radiology examination?
Answer:
Dislocation anterior glenohumerale joint dextra
7. How Diagnosis?
Answer:
 Anamnesis

27
 Jojo a 20 years old karateka,came to the emergency department with a chief
complain of pain and inability to move his right shoulder since 2 hours ago. The
symptom accurs during his full body contact karate match,when his opponent
kick Jojo’s shoulder from the side. After the incident, Jojo’s right shoulder
began to ache and immoveable.
 Phsysical examination
Conciousness : respiratory rate 26x/m (takipnea)
pulse rate 102x/m (takikardi)
VAS 7 = Severe Pain
Specific Examination
Look :
Asymmetric,swollen,shoulder contour are dimminishing
Hematome (+)
Feel : tenderness (+),crepitation (-) right shoulder skins was tense if
palpated
Move : pain if the right shoulder was moved
ROM : shoulder joints range of motion was undeterminded due to the
pain.
8. How DD?
Answer:
 Dislocation
 Sprain
 Strain

9. How additional examination?

Answer:
X Ray Photo

10. How WD?

Answer:
Dislocation anterior glenohumeral joint dextra

28
11. How treatment?
Answer:
Common causes of sports injury due to direct injury / impact or repetitive exercises
long time. injuries can be distinguished be: 1) External factors, namely: (a) Body
contact sports football, boxing, karate. (b) Tools Sports: trick, stick, racquet, ball.
(c) Conditions field: slippery, uneven, muddy. 2) Factors from in, namely: (a)
Anatomical factors. Long unequal limbs, flat feet, legs sneak, on the run will run
serve the movement. (b) Movement movements / wrong blow for example: a blow
backhand. (c) There is muscle weakness. d) Low fitness level 3) Usage excessive /
excessive. Movement or excessive and repetitive exercise in a relatively long time /
micro trauma
can cause injury.
Treatment.
With the RICE method (Rest / break: stop activity immediately) Excessive activity
will trigger further complications, Ice is the use of ice: giving cold compress / ice
will constrict the blood vessels thus reducing swelling, compression / emphasis: on
parts of injuries can be bandaged / bandaged, and elevation / elevation), cessation
of sport activity for 2 to 3 weeks. When experiencing pain is given anti-pain such
as ibuprofen and anti-inflammatory drugs. Prevention: by warming up before
exercising and cooling after exercising, practicing regularly, and not having
anatomical abnormalities
12. How complication?
Answer:
 Shock
 Rigid joints
 Impaired growth (deformed)
 Repeated dislocation
 Injury nervus axillaris
 Injury blood vessel

(Menkher Manjas,2013)

29
13. How prognosis?
Answer :
Dubia et bonam
14. How SKDU?
Answer:
Ability Level 3: diagnose, perform initial management, and refer to
3A. Not an emergency
Graduates of the doctor are able to make clinical diagnoses and provide
therapy introduction to non-emergency conditions. Doctor graduate able to
determine the most appropriate reference for handling patients next. Doctor
graduates are also able to follow up after returning from reference
15. NNI
Answer:

 “Whatever blessings you get are from Allah, and whatever disasters come
upon you, then from (mistakes) yourself.” (Q.S An-nisa : 79)

 “And truly we feel for them a small portion of the adhab in the world before
the greater adhab in the afterlife, hopefully they will return to the right path."
(Q.S As-Sajdah: 21)

30
  “Then we made the semen of blood, and then a lump of blood We made a
lump of meat, and a lump of meat We made the bones, then the bones We
wrap with flesh. Then We made him another (shaped) creature. So Glorious is
Allah, the Most Excellent Creator.”( Q.S Al-Mu’minun:14)

2.6 Conclusion
Jojo a 20 years old karateka, complain pain and inability to move shoulder because
dislocation anterior glenohumeral joint dextra.

2.7 Conceptual Framework

Exercise (Karate match)

)

Blunt of mechanical
trauma

Ligament over
streaching

Torn Ligament

Dislocation anterior
glenohumeral joint
dextra

31
Pain when moved Inability to move
Swelling hematome

32
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