Case Report

Closed Fracture Clavicula Sinistra

Mentor: Dr.dr. Adrian Khu, Sp. OT,FICS
ENRIKA SETIANI DAMANIK
Patient Status
Room No. : 515 B

Date of Entry: Desember 18, 2018

Doctor In Charge : Dr. dr. Adrian Khu, Sp.OT, FICS

Patient Identity
Name : Mr.SL

Date of Birth : Desember 7th, 1990

RM No. : 08.34.50

Age : 27 years old

Gender : Male
Anamnesis
Main complaint : pain in the shoulder the left
Study :
The 27-year-old male patient came to be taken by her family to the
Royal Prima Medan Hospital on Desember 18th ,2018 for treatment with
complaints of pain in the shoulder the left. On December 18, 2018, the
patient fall of the motorcycle when circumvent motorcycle that appears.

History of previous illness : Nothing

Histori of drug use : Nothing

VITAL SIGNS

General Condition : Good

Sensorium / GCS : Compos Mentis / 15 (E4V5M6)

Pressure : 140/90 mmHg

Pulse : 80 ×/i

Respiratory : 19 ×/i

Temperature : 37oC
Generalized Status
Head : Normocephali
Eyes : Pupil : Isokor (+/+)Sclera : Icteric (-/-)
Conjunctiva : Anemis (-/-) light reflex : (+/+)
Ears : Normal, secret (-)
Nose : Normal, konka hyperemic (-), septal deviation(-)
Mouth : Normal, cyanosis (-)
Neck : KGB dilatation (-)

Thorax (Lung)
Inspection : Chest is symmetric fusiform, retraction between ribs (-)
Palpation : Stem fremitus right = left
Percussion : Sonor
Auscultation : Breathing sound : vesikuler, additional sound : (-)
Orthopaedic Examination

Look
Swelling in the region clavicula (+)
Feel
Krepitasi (-)
Move
Feel pain when moved, movement stiffnes (+)
Temporary Diagnosis
 Closed Fracture Right Neck of Femoral

Advice

 Laboratory Examination
 Thorax PA, clavicular sinistra

 Hematology
 Blood Sugar Levels
 Liver Function
 Renal Function
 Coagulation

 X-Ray Photos : clavicula left

Complete blood count
No Pemeriksaan Hasil Satuan Normal
1. Hemoglobin 14.2 g/dL 13.5-15.5
2 Leukosit 13.92 103/uL 5-11
3 Laju Endap Darah 5 mm/1 hours <20
4. Trombosit 197 103/uL 150-450
5. Hematocrit 41.5 % 30.5-45.0
6. Eritrosit 4.48 10^6/mm3 4.50-6.50
7. MCV 92.5 um3 75.0-95.0
8. MCH 31.6 pg/cell 27.0-31.0
9. MCHC 34.1 g/dL 32.0-34.0
10. RDW 13.4 % 11.50-14.50

11. PDW 46.5 fL 12.0-55.0

12. MPV 8.9 fL 6.50-9.50
13. PCT 0.17 % 0.100-0.500
14. Hitung Jenis Leukosit      
  Eosinofil 1 % 1-3
  Basofil 0.0 % 0-1
  Monosit 2.7 % 2-8
  Neutrofil 87.2 % 50-70
  Limfosit 8.7 % 20-40
  LUC 0.4 % 0-4
coagulation

No Pemeriksaan Hasil Satuan Normal

1. Bledding time 4’ Menit 1-5

2. Cloathing time 9’30’’ Menit 5-15

 X-Ray Thorax PA

 The impression: cor and pulmo within normal limits radiology

 Fracture clavicular left
 X-ray Clavicula Sinistra

 The impression: fracture medial clavicular left with retraction and

avulsif
 Working Diagnosis: closed fracture clavicular sinistra

ACTION
 Position of lateral decubitus under spinal anesthesia
 Disinfectant dan drapping procedure
 Hemiarthroplasty is applied
 Wash wound, drainage is installed and then close the wound
Post-Operation X-ray Photo
 Conclusion :fracture os clavicular sinistra attached ORIF
Follow Up
 Injection cextriaxon 1 gr/12 hour IV
 Injection ketorolac 1 amp/ 12 hour IV
 Injection ranitidine 1 amp/12 hour IV
Post-Operation Assesment

 General condition : satisfying

 Awareness : awake
 Air way : free
 Respiratory : spontan
Education

 Do not doing maneuver that can inhibit healing,

such as lifting heavy loads
 Scheduling of re-consul for result monitoring
Thank you