MEL/WUL/ dr. IN, Sp.K.F.R., K.R.

(K)
I. IDENTITY
Name : Ch. E 17/04/2023
Gender : Female
Age : 16 yo
Religion : Moslem
Address : Mojokerto
Educational : 1st grade senior high school student
Referred from Orthopedic OPC with Post Below Elbow Amputation + Lesi nervus brachial. Mohon
evaluasi dan tatalaksana prosthesis pada pasien.

II. ALLOANAMNESIS
Chief Complaint: Tangan kanan tidak bisa digerakkan
History of Present Illness:
Patient felt that her right hand has been difficult to move since 7 weeks ago when the patient had an accident,
with MOI falling from the motorbike in detail the patient did not remember, there was a history of unconsciousness,
no history of vomiting, no open wounds. The patient was immediately taken to Citra Medika Mojokerto Hospital, did
Xray examination and diagnosed with closed fractures at 3 locations (2 right UE, 1 finger left), she performed ORIF
plate screw and pinning, the patient was hospitalized for 4 days. from the first day of surgery until day 4 the patient's
hand became swollen and the oximetry result was weak. The patient was referred to RSDS for furthere treatment.
On February 14, the patient was referred to RSDS, orthopedic did fasciotomy on the right arm, evaluated for 6
days, during these 6 days the oximetry was weak and undetected on day 6, then she had an amputation on 20 February.
while after post op the patient had a back slap and elastic bandage attached, had consulted psychiatry OPC for
psychological assistance, the patient had never been referred to PMR OPC before.
Currently, there is no phantom sensation, phantom pain, and telescoping. There is no feeling of thickness,
tingling, pain in the amputated hand.

History of past illness :

HT (-)
DM (-)
Trauma (-)

History of Functional Ability:

Had difficulty in using clothes, buttoned up and down shirt and grooming
She able to write with her left hand, typing a message and use her cellphone with left hand
Not perform sholat yet
Defecation and micturition continence

History of medication :
Orthopedic OPC: Asamefenamat only if pain, kalk, vit b complex
No history of rehabilitation program.

History of hobby and work:

She doesn’t have any specific hobby. She is 1st grade junio high school student, she has not had difficulty in studying.

History of Psycho-Social Economy:

She lives in Mojokerto in one storey house with her father (60 yo, had warung infront of their house, senior high
school graduate), mother (55 yo housewife), brother (23 yo, shop keeper) with sitting toilet and shower jet toilet. Had
BPJS for insurance

Patient’s expectation:
She wants her right arm can be moved

III. PHYSICAL EXAMINATION

A. General status
Consciousness: compos mentis
Vital sign: BP 110/70, HR: 76x/m, RR: 16x/m Tax 36.7, SpO2 98%
Weight 60 kg, Height 155 cm, BMI: 24.6 (overweight)
Posture : rounded shoulder, shoulder assymetrical s>d, protruded abdomen
Ambulation : independent walking without assisstive device, right-handed dominance.

Head and neck :

Conjunctiva anemia (-|-), icterus (-|-), cyanosis (-), enlargement lymph node (-), anhidrosis -, ptosis -, enophtalmus -,
miosis -
Cor : S1-S2 normal, regular, murmur (-), gallop (-)
 Pulmo : Vesicular (+|+), wheezing (-|-), ronchi (-|-)
Abdomen : supple, peristaltic (+), tenderness (-)
Extremities : Warm acral (NE|+), edema (+|-) on area elbow, CRT < 2 seconds.

B. Head /Neck :
Look : edema (-), redness (-), deformity (-)
Feel : warmth (-), wound (-), muscle spasm (-)
Move : pain when move (-)
ROM MMT
Region Joint Movement Muscles Strength
Movement Range of Motion Muscles MMT
(active and passive)
Neck Flexion (0-450) F Flexor 5
Extension (0-45 )0
F Extensor 5
Lateral flexion (0-450) F/F Lateral flexor 5/5
Rotation (0-600) F/F Rotator 5/5

Special test : not evaluated

Cranial Nerve : not evaluated
Sensory : wnl

C. Trunk
Look : edema (-), redness (-), deformity (-)
Feel : warmth (-), wound (-), muscle spasm (-)
Move : pain when move (-)
ROM MMT :
Trunk Flexion(0-850) F Flexor 5
Extension (0-300) F Extensor 5
Lateral flexion(0-350) F/F Lateral flexor 5/5
Rotation(0-450) F/F Rotator 5/5

Special test :-
Sensory : wnl

D. Upper Extremities Region

Look : shoulder asymmetrical s>d, surgery wound at anterior medial arm dextra +- 15 cm, dry, redness
-, pitting edema -/-, stump edema (-), dog ear (+), dehiscense (-), pus (-) scar wound (+) 9 cm,

Feel : warmth (-), stump pain (-), phantom sensation (-), phantom pain (-), telescoping sensation (-), elbow
circumference 24cm / 23cm, arm circumference (5 cm above epicondyle) 27 cm/ 27 cm, forearm
circumference (5 cm below epicondyle) 25 cm / 24 cm, stump length 13 cm from olecranon, stump
presentation 32%

Move : pain when move (-/-)

ROM MMT
Shoulder Flexion(0-1800) P : 0-90 (pain) /F Flexor 0/5
Extension (0-600) P: 0-10 (pain) F/F Extensor 0/5
Abduction(0-1800) P: 0-90 (pain)/F Abductor 0/5
Adduction(0-450) P: F/F Adductor 0/5
Internal Rotation (0-900) P: 0-10 (pain)/F Internal Rotator 0/5
External Rotation (0-700) P: 0-10 (pain)/F External Rotator 0/5
Elbow Flexion (0-135 )
0
P: 0-30/F Flexor 0/5
Extension (135º-0) P: 30-0 F/F Extensor 0/5
Pronation (0-900) -/F Pronator 0/5
Supination(0-900) -/F Supinator 0/5
Wrist Flexion (0-800) -/F Flexor -/5
Extension (0-70 )0
-/F Extensor -/5
Radial deviation (0-200) -/F Radial Deviator -/5
Ulnar deviation (0-350) -/F UlnarDeviator -/5
Fingers Flexion -/F Flexor -/5
Extension -/F Extensor -/5
Abduction -/F Abductor -/5
Adduction -/F Adductor -/5
Special test :-
Reflex : BPR 0/+2, TPR 0/+2, Hoffman NE/-, Tromner NE/-
 Spastisitas :-
Sensoric : Sensoric deficit 20% on wound scar area
Brachial/brachial index: NE (due to wet wound)

E. Lower Extremities region

Look : edema -/-, deformity -/-, atrophy -/-, dry skin -/-, wound post skin graft donor, wet, epithel +,
diameter around 5cm
Feel : warmth -/-, tenderness -/-
Move : move with pain (-)
ROM MMT
Hip Flexion (0-1250) F/F Flexor 5/5
Extension (0-300) F/F Extensor 5/5
Abduction (0-450) F/F Abductor 5/5
Adduction (0-200) F/F Adductor 5/5
Knee Flexion (0-135 )
0
F/F Flexor 5/5
Extension (135º-0) F/F Extensor 5/5
Ankle Dorsoflexion (0-200) F/F Dorsoflexor 5/5
Plantarflexion (0-500) F/F Plantarflexor 5/5
Eversion (0-150) F/F Evertor 5/5
Inversion (0-35 )
0
F/F Invertor 5/5
Big Toes Flexion F/F Flexor 5/5
Extension F/F Extensor 5/5
Toes Flexion F/F Flexor 5/5
Extension F/F Extensor 5/5

Special test :-
Reflex : KPR +2/+2, APR +2/+2, Babinsky -/-, Chaddock -/-
Sensoric : wnl
Spastisitas : (-)

Functional Status
Count Tes : 18 Chest Expansion: 3/3/3
Balance :
Sitting balance static : good
Sitting balance Dynamic : good
Standing balance static : good
Standing balance dynamic : good

Mobilization (Transfer, ambulation)

Lying to sitting : independent
Sitting to standing : independent
Ambulasi : independent walking
Hand dominance : previously right
ADL (Bartel Index) : 80 moderate dependent
Feeding 5/10 Bladder 10/10
Grooming 0/5 Toilet use 10/10
Bathing 0/5 Mobility 15/15
Dressing 0/10 Transfer 15/15
Bowel 10/10 Stairs 10/10
HDRS : 3 (no depression)

IV. SUPPORTING EXAMINATION (X-ray, MRI, CT Scan, Lab):

No imaging review

V. FUNCTIONAL ASSESSMENT (include ICF)

Problem List (ICF):
Body Function:
b270 Sensory function (Sensory deficit on surgical scar 20%
b530 Weight maintenance function (overweight)
b730 Muscle power function (Weakness of right shoulder and elbow)
Body Structure
s730 structure of upper extremities (right below elbow amputation, CF humerus D Post ORIF platting, CF digiti I,II
manus S Post ORIF Pinning)
s810 structure of areas of skin (post surgical wound)
Activity Limitation
d170 Writing
d430 Lifting and carrying object
d440 Fine hand use
d445 Hand and arm use
d449 Carrying, moving and handling object
d530 Toileting
d540 dressing
d630 preparing meals
d640 doing household
d669 carrying household object
Participation restriction:
d835 School life and related activities
Environmental factors
e310 immediate family (supportive parents)
e580 health service (BPJS Kesehatan cannot provide the prosthesa)
Personal Factor
Child, 1st grade senior highschool with below elbow amputation and had good family support.
 
VI. ASSESSMENT
Righ Hand Function Disturbance ec Right Below Elbow Amputation + Post Skin Graft (7 Weeks) + Suspect Right
Brachial Plexus Injury C5-C7 Incomplete Suspect Post Ganglionic + Closed Fracture 1/3 Proximal of Right Humerus
Post ORIF Platting (9 Weeks) + Closed Fracture Metacarpal Digiti I et II of Left Manus Post ORIF Pinning (9 Weeks) +
Overweight
 
PROGNOSIS
Ad vitam : bonam
Ad sanactionam : dubia
Ad functionam
- Transfer : independent
- Ambulation : independent
- Other ADL and hand function: independent with BI >90 and substitution to the left hand
 
Goal:
Short Term :
1. establish the level and severity of the right BPI
2. Promote wound healing on the stump area and right thight
2. Reduce edema
3. Maintainning ROM of right Shoulder and elbow
4. Maintainning ROM of left UE sinistra
5. Improve sensory function
6. Subtitution hand function to left hand
7. Improve Cardiorespiration function
8. Prevent depression
 
Intermediate Term:
1. Back to school activity
2. Improve hand function of left hand
 
Long Term :
1. Achieve good stump shape
2. Wear the Phrosthetic
3. Improved quality of live

Plan
PDx : EMG-NCV of Right UE, consult to Psychiatry (to continue their pre-amputation program)
 
PTx :
Modality :
• ES Galvanic current at right shoulder flexion, abduction, and elbow flexion until visible muscle contraction
• Laser 1 J/cm2 100% continuous scanning method at around the stump and right thight.
 
OT:
• Posture correction
• PROM exercise of right upper extremity
• Subtitution exercise hand function from right hand to left hand (writing, typing with mobile phone and laptop, handling
cutlery and bathing equipment and use and take off the clothes)
• Sensory resensitisation of right upper extremity
• Stump shaping using figure of 8
 
OP : below elbow prosthesis and shoulder support
 
PMx: clinical signs and symptoms, vital sign, ROM, MMT, stump shape
 
PEx:
1. Explain the patient's condition, the purpose of EMG NCV examination, the goal and the rehab program prescribed.
2. Continue exercise at home (BEA with diaphragmatic breathing, chest mobilization exercise, AROM exc Left UE, Left
and right LE, PROM Right UE, hand function substitution for ADL and school activity to the left hand)
3. Edema control with bandaging and elevation of the right UE
4. Regularly stump shaping with figure of 8 bandaging