DOKTER MUDA STASE BEDAH

TRAUMA DISCUSSION
December 19th 2019

MARIA YOLANDA FELICITA

RAIS HAKIM
I GEDE RANDY W
ROSVINA DIAH NURULITA SUTRISNO
TRIAGUNG ARIF PRATAMA
HENRY TIMOTHY CHRISTIAN

SMF/DEPARTEMEN ORTHOPEDI DAN TRAUMATOLOGI-RSUD DR SOETOMO

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Patient Identity
• Name : Mrs. HF

• Age : 50 years old

• Sex : Female

• Address : Semampir, Surabaya

• Nationality : Javanese / Indonesian

• Reg number : 12796351

SMF/DEPARTEMEN ORTHOPEDI DAN TRAUMATOLOGI-RSUD DR SOETOMO

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Anamnesis
Chief complaint :
Pain in right upper arm

SMF/DEPARTEMEN ORTHOPEDI DAN TRAUMATOLOGI-RSUD DR SOETOMO

 DOKTER MUDA STASE BEDAH

History Taking :

• Patient came with pain in right upper arm after her car crash into the
sidewalk
• Patient sat on the right side of the car behind the driver when the car hit
the sidewalk on the right.
• Patient fell to the right side and hit the car door.
• After the accident, patient lost her consciousness and admitted to
Marsudi Waluyo hospital then reffered to Dr. Soetomo general hospital.

SMF/DEPARTEMEN ORTHOPEDI DAN TRAUMATOLOGI-RSUD DR SOETOMO

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Past Illness and medication

• No history of similar complaints

• Patient had hipertension since 10 years ago

Psychosocial history

• No drug allergy

SMF/DEPARTEMEN ORTHOPEDI DAN TRAUMATOLOGI-RSUD DR SOETOMO

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Primary Survey
A Clear airway. Stable cervical spine.
B Breathing spontaneously. Symmetric thorax movement. RR:
20x/m. SpO2: 98%

C Acral: red, warm, and dry. CRT < 2”.

BP: 140/80 mmHg. HR: 94 bpm. Stable pelvic.

D GCS 456. The pupil is round and isochoric 3mm/3mm. Light

reflex +/+. Lateralization (-)

E Deformity and swelling on the right upper arm

SMF/DEPARTEMEN ORTHOPEDI DAN TRAUMATOLOGI-RSUD DR SOETOMO

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General Condition
General condition : Good

GCS : 456

Body weight : 95 kg

Height : 159 cm

Pain Scale : 6/10

Vital sign

BP : 140/80mmHg RR : 20x/min

HR : 94x/min T : 36,6 C

SMF/DEPARTEMEN ORTHOPEDI DAN TRAUMATOLOGI-RSUD DR SOETOMO

 DOKTER MUDA STASE BEDAH

Head and Neck : Anemic-/icteric-/cyanosis-/dyspneu-

Thorax : Symmetric, retraction (-)

Cor : S1 S2 single, murmur (-), gallop (-)

Pulmonal : Vesicular/vesicular, rhonchi (-/-), wheezing (-/-)

Abdomen : Flat, peristaltic sound (+)

Extremities : Red, warm, dry acral, CRT <2”

SMF/DEPARTEMEN ORTHOPEDI DAN TRAUMATOLOGI-RSUD DR SOETOMO

 DOKTER MUDA STASE BEDAH

Local Condition of Right Upper Arm

• LOOK : Deformity (+) shortening, swelling (+), vulnus (-)

• FEEL : Warm perfusion (+), tenderness (+), normal distal

neurovascularization

• MOVE : Range of movement limited due to pain.

SMF/DEPARTEMEN ORTHOPEDI DAN TRAUMATOLOGI-RSUD DR SOETOMO

 Clinical photos

Medial

Lateral Anterior
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Working Diagnosis
• Closed fracture of right upper arm

SMF/DEPARTEMEN ORTHOPEDI DAN TRAUMATOLOGI-RSUD DR SOETOMO

 DOKTER MUDA STASE BEDAH

Final Diagnosis

Closed fracture of right humerus 1/3 middle

SMF/DEPARTEMEN ORTHOPEDI DAN TRAUMATOLOGI-RSUD DR SOETOMO

 DOKTER MUDA STASE BEDAH

Planning
Therapy
• Pracetamol tab. 3x500mg p.o.
• Close reduction
• Immobilization with U-slab

SMF/DEPARTEMEN ORTHOPEDI DAN TRAUMATOLOGI-RSUD DR SOETOMO

THANK YOU