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

PATIENTS IDENTITY

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

HISTORY TAKING
CHIEF
COMPLAIN
T

Decrease of consciousness

ANAMNESI
S

Suffered since 9 hours before admitted to

Wahidin Sudirohusodo Hospital due to
motorcycle accident. History of projectile
vomiting (-). History of prior treatment (-).
Patient was then consulted by the
neurosurgery department to the
orthopaedic department.

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.

PRIMARY SURVEY
Airway
Breathing
Circulation
Disabilty
Exposure

Patent,clear
20x/min, thoracoabdominal,
spontaneous, symmetric
BP 110/70mmHg, HR 88x/min,
regular, strong on palpation
GCS 13 (E4M5V4), pupil isokor,
3 mm/3 mm, light reflex +/+

Temp 36.7C (axilla)

SECONDARY SURVEY
LEFT SHOULDER REGION
Look

Deformity(+), edema (+),

hematom(+) of size 4 x 5 cm at
superior aspect.

Feel

Tenderness cannot be evaluated due

to decrease of consciousness.

Move

Active and passive movement of

shoulder joint cannot be evaluated
due to decrease of consciousness.

NVD

Sensibility cannot be evaluated due

to decrease of consciousness.
Pulsation of the radial artery and
ulnar artery are palpable.
CRT <2 second

CLINICAL FINDINGS

Anterior view

Lateral
view

Superior view

RADIOLOGY
FINDINGS

Cervical Lateral

Thorax AP

MSCT Scan Skull

Axial

LABORATORY FINDINGS
Result

Normal
Values

WBC

17,0

4,00-10,0

RBC

4,94

4,00-6,00

HGB

15,4

12,0-16,0

HCT

47

37,0-48,0

PLT

160

150-400

CT

800

4-10

BT

300

1-7

HBsAg

Non Reactive

Non
Reactive

Unit
10^3 /uL
10^6 /uL
gr/dL
%
10^3 /uL
minute
minute

RESUME
A boy 14 years old admitted to Wahidin Sudirohusodo
Hospital
with
chief
complaint
of
decrease
of
consciousness, suffered since 9 hours before admitted to
hospital due to motorcycle accident. 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 physical examination on the left shoulder region
there are deformity(+), edema(+) and hematom(+) size
4 x 5 cm at superior aspect.
From laboratory finding there is leukocytosis.
From radiologic finding there is epidural hematom at left
parietal region and fracture at 1/3 middle left clavicle.

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

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, Matsen. The Shoulder 4th edition. 2008
Nalyagam S. Principles of Fractures. In: Solomon L. Apleys System of Orthopaedics and Fractures Ninth edition. 2010

MECHANISM OF TRAUMA
LITERATURE

Falls onto the affected

shoulder leading to a
bending force (87%).
Direct impact to shoulder
(7%).
Falls onto an outstretched
hand (6%).

CASE
History taking: Patient fell
with the left shoulder and
head touching the ground first.
Physical exam: Hematoma at
superior aspect on the left
shoulder region.

Nalyagam S. Principles of Fractures. In: Solomon L. Apleys System of Orthopaedics and Fractures Ninth edition. 2010

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

PHYSICAL EXAMINATION
LITERATURE
Deformity with the proximal
fracture end is usually
prominent.
Tenderness directly over the
fracture site.
Abrasion or contusion on
the shoulder.

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

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. Principles of Fractures. In: Solomon L. Apleys System of Orthopaedics and Fractures Ninth edition. 2010

RADIOLOGIC FINDINGS
LITERATURE

CASE

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

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

EVIDENCES LEADING TO DIAGNOSIS

Fell with the left

shoulder and
head touch the
ground first

HISTORY
TAKING

PHYSICAL
EXAMINATIO
N

Deformity (+)
edema (+),
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

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, Kenneth J.; Zuckerman, Joseph D.Handbook of Fractures, 4th Edition. 2006

CASE

COMPLICATIONS
LATE
COMPLICATIONS

EARLY
COMPLICATIONS

Non Union

Lung and pleura injury

Malunion

Neurovascular injury

Stiffness of the shoulder

Solomon. L. et al. Apleys System of Orthopedics and Fractures 9th Edition. 2010

THANK
YOU
ORTHOPAEDIC AND TRAUMATOLOGY
DEPARTMENT MEDICAL FACULTY OF
HASANUDDIN UNIVERSITY