Closed Fracture of Middle Clavicula

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Name : Child.

B
Age : 14 Years Old
Sex : Male
Address : Maleo Street
Occupation : Student
Admission : Jan, 19th 2019
Doctor in charge : dr. Benny Murtaza, Sp.OT
HISTORY TAKING

Chief Complain : Pain at the right shoulder


Anamnesis :Suffered since 1 hours ago after traffic accident
Mechanism of trauma :
The patient was ride a motorcycle with high speed and was not use a helmet. Other mechanism
unknown.
History of trauma
 There was no history of syncope, nausea and vomiting
 There were no history of bleeding from nose, ears, and mouth
 There were no history alcohol and drugs consumption
 There was no history treatment
A
12.06 WITA
Clear, Cervical Spine Control
Respiratory rate 20x/m,
B spontaneous, thoracoabdominal
type

C Blood Pressure 110/60 mmHg


Pulse 89x/m, reguler, strong

D Glasgow Coma Scale (E4M6V5),


isochoric pupil, Ø 2,5 mm/2,5mm,

E Temperature 36,7 C/Axillary


Secondary survey
12.10 WITA
GENERALIZED STATE
Head : Within normal limits
Face : Within normal limits
Mouth : Within normal limits
Neck : Within normal limits
Chest : Within normal limits
Abdomen : Within normal limits
Upper limb : Localized
Lower limb : Within normal limits
LOCALIZED STATE
Right Shoulder Region
I : Deformity (+), swelling (+), hematom (-), wound (-)
P : Tenderness (+), crepitation (dificult to access due to pain)
ROM : Active passive motions of shoulder joint, limited due to pain
NVD : Sensibility was normally, radialis and ulna artery pulse was palpable,
CRT<2 seconds
CLINICAL FINDINGS
PLAN OF DIAGNOSTIC

X-Ray of Thorac Ap/Lat Blood Routine


Routine Blood
Parameter Result Unit Reference value
WBC 12.50 10^3/uL 4.00-10.00
HGB 13.2 g/dL 12-16
PLT 262 10^3/uL 150-400
DIAGNOSIS

Closed fracture of the 1/3 medial right clavicula


THERAPY
FARMACOLOGY NON-FARMACOLOGY
 IVFD  Rest
 antibiotics  Immobilisation
 Analgetics injection  Apply mitela
 H2RA injection

Consult to Orthopedic Surgeon


Thank You

BAGIAN ILMU
BEDAH

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