Case Report

CLOSED FRACTURE 1/3 MIDDLE LEFT CLAVICLE
TRAUMATIC BRAIN INJURY GCS 13 DUE TO
EPIDURAL HEMATOM
Siti Fatimah binti Othman
C111 11 881
ADVISOR:
dr. Yohannes Toban
dr. Michael Benjamin

SUPERVISOR:
dr. M. Ruksal Saleh, Ph.D, Sp.OT (K)
Orthopaedic and Traumatology Department
Medical Faculty of Hasanuddin University

PATIENT’S IDENTITY





Name
: RA
Register no.
: 771569
Sex
: Boy
Age
: 14 years old
Date of admission : September 13th
2016

MECHANIS M OF TRAUMA • Patient was riding a motorcycle when he loss control and fell with the left shoulder and head touch the ground first. .HISTORY TAKING CHIEF COMPLAIN T • Decrease of consciousness ANAMNESI S • Suffered since 9 hours before admitted to Wahidin Sudirohusodo Hospital due to motorcycle accident. Patient was then consulted by the neurosurgery department to the orthopaedic department. History of projectile vomiting (-). History of prior treatment (-).

spontaneous. strong on palpation • GCS 13 (E4M5V4). thoracoabdominal. Ø 3 mm/3 mm. pupil isokor.7°C (axilla) .PRIMARY SURVEY Airway Breathing Circulation Disabilty Exposure • Patent. light reflex +/+ • Temp 36.clear • 20x/min. HR 88x/min. regular. symmetric • BP 110/70mmHg.

NVD Sensibility cannot be evaluated due to decrease of consciousness.SECONDARY SURVEY LEFT SHOULDER REGION Look Deformity(+). Feel Tenderness cannot be evaluated due to decrease of consciousness. edema (+). Move Active and passive movement of shoulder joint cannot be evaluated due to decrease of consciousness. Pulsation of the radial artery and ulnar artery are palpable. CRT <2 second . hematom(+) of size 4 x 5 cm at superior aspect.

CLINICAL FINDINGS Anterior view .

Lateral view .

Superior view .

RADIOLOGY FINDINGS Cervical Lateral .

Thorax AP .

MSCT Scan Skull Axial .

0 RBC 4.0 4.00-6.00 HGB 15.4 12.0-48.0 PLT 160 150-400 CT 8’00” 4-10 BT 3’00” 1-7 HBsAg Non Reactive Non Reactive Unit 10^3 /uL 10^6 /uL gr/dL % 10^3 /uL minute minute .0-16.94 4.0 HCT 47 37.00-10.LABORATORY FINDINGS Result Normal Values WBC 17.

Mechanism of trauma patient was riding a motorcycle when he loss control and fell with the left shoulder and head touch the ground first. • From laboratory finding there is leukocytosis. edema(+) and hematom(+) size 4 x 5 cm at superior aspect. .RESUME • A boy 14 years old admitted to Wahidin Sudirohusodo Hospital with chief complaint of decrease of consciousness. • From radiologic finding there is epidural hematom at left parietal region and fracture at 1/3 middle left clavicle. suffered since 9 hours before admitted to hospital due to motorcycle accident. • From physical examination on the left shoulder region there are deformity(+).

DIAGNOSIS  Traumatic Brain Injury GCS 13 due to Epidural Hematom at Left Parietal Region  Closed Fracture 1/3 Middle Left Clavicle .

MANAGEMENT • Apply neck collar • O2 10-12 lpm via NRM • IVFD crystalloid • Analgesic From Neurosurgery Department : • CITO Craniotomy From Orthopaedic Department : • Apply arm sling at left upper limb .

DISSCUSSI ON FRACTURE OF CLAVICLE .

DIAGNOSIS History and Mechanism of Trauma Physical Examination Radiological Examination .

2010 . The Shoulder 4th edition. In: Solomon L. Apley’s System of Orthopaedics and Fractures Ninth edition. 2008 Nalyagam S. Matsen. Principles of Fractures.HISTORY TAKING LITERATURE • History of some form : direct or indirect injury to the Traumatic shoulder • The details of the mechanism of injury Repetitive Fractures Stress CASE  Patient was riding a motorcycle when he loss control and fell with the left shoulder and head touch the ground first. TRAUMATI C Pathologic Fracture Rockwood.

Apley’s System of Orthopaedics and Fractures Ninth edition. 6th Edition. In: Solomon L. eds. Principles of Fractures. Direct impact to shoulder (7%). Nalyagam S. Vol 2. Green DP. Falls onto an outstretched hand (6%). 2006 . Rockwood CA. CASE  History taking: Patient fell with the left shoulder and head touching the ground first. 2010 Bucholz RW.  Physical exam: Hematoma at superior aspect on the left shoulder region.MECHANISM OF TRAUMA LITERATURE • • • Falls onto the affected shoulder leading to a bending force (87%). Rockwood & Green's Fractures in Adults. Heckman JD.

CASE  Deformity (+) edema (+). hematom (+) size 4 x 5 cm at the superior aspect on the left shoulder region  Tenderness cannot be evaluated  Contusion on shoulder .PHYSICAL EXAMINATION LITERATURE • Deformity with the proximal fracture end is usually prominent. • Tenderness directly over the fracture site. • Abrasion or contusion on the shoulder.

Apley’s System of Orthopaedics and Fractures Ninth edition. Principles of Fractures.LITERATURE Fracture  a break in the structural continuity of bone CASE  The overlying skin on the left shoulder remains intact  If overlying skin intact : Close fracture  If skin not intact : Open Fracture CLOSE FRACTURE Nalyagam S. 2010 . In: Solomon L.

6th Edition. eds. Rockwood & Green's Fractures in Adults. Green DP. 2006 . Rockwood CA. Heckman JD.RADIOLOGIC FINDINGS LITERATURE CASE Bucholz RW. Vol 2.

CLASSIFICATION LITERATURE • Allman Classification – Group I : Fracture of middle third (80%) – Group II : Fracture of distal third (15%) – Group III : Fracture of lateral third (5%) CASE .

hematom (+) at superior aspect on the left shoulder region • Fracture at 1/3 middle left clavicle RADIOLOGIC AL FINDINGS Closed Fracture 1/3 Middle Left Clavicle .EVIDENCES LEADING TO DIAGNOSIS • Fell with the left shoulder and head touch the ground first HISTORY TAKING PHYSICAL EXAMINATIO N • Deformity (+) edema (+).

.Handbook of Fractures.TREATMENT LITERATURE • Non-operative: – – Minimally displaced Immobilization : arm sling • Operative : – – – Open fracture Associated neurovascular compromise Skin tenting with potential to progress to open fracture Koval. Zuckerman. 2006 CASE . 4th Edition. Kenneth J. Joseph D.

L.COMPLICATIONS LATE COMPLICATIONS EARLY COMPLICATIONS Non Union Lung and pleura injury Malunion Neurovascular injury Stiffness of the shoulder Solomon. et al. Apley’s System of Orthopedics and Fractures 9th Edition. 2010 .

THANK YOU ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT MEDICAL FACULTY OF HASANUDDIN UNIVERSITY .