Closed Fracture 1/3 Middle Right Humerus

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CASE REPORT

APRIL 2016

CLOSED FRACTURE 1/3 MIDDLE


RIGHT HUMERUS
BY :

ERIK PURNOMO
C111 11 275
ADVISOR :
dr. Ery Wildan
dr. Michael Horeb
SUPERVISOR :
dr. Muhammad Sakti, Sp.OT(K)

PATIENTS IDENTITY
Name

: Mrs. R
Age
: 19 yo
Reg. Number
: 755854
Sex
: Female
Date of Admission
: 5th May 2016

HISTORY TAKING
Chief

complain : Pain at the right upper

limb
Suffered since 5 hours before
admitted to Wahidin General
Hospital
MECHANISM OF INJURY

Patient was riding motorcycle and


then her got hit another motorcyle
from opposite direction

PRIMARY SURVEY
AIRWAY
BREATHING
CIRCULATION
DISABILITY
EXPOSURE

Patent, clear
18x/min, thoracoabdominal,
spontaneous, symmetric
BP 110/70mmHg, HR 80x/min,
regular, strong on palpation
GCS 15(E4M6V5), light reflex
+/+ , pupil isochors, :
2,5mm/2,5mm,
Temp 36.8C (axilla)

SECONDARY SURVEY

LOOK
FEEL
MOVE
NVD

deformity (+), hematom (+), swelling (+), deep


laceration in distal medial size 1cm x 1cm

Tenderness (+)

Active and passive movement of glenohumeral


joint can not be evaluated due to pain
Active and passive movement of right elbow joint
can not be evaluated due to pain
Sensibility is good,
Pulsation of the radialis artery and ulnar artery are
palpable.
CRT <2 second
Extend thumb (+), ok sign (+) abduction/adduction
fingers (+)

CLINICAL FINDING

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