Case Report June 2013

CLOSE FRACTURE 1/3 MIDDLE LEFT HUMERUS

By Ahmad Ramdhani Amir (C 111 06 166) Advisor dr. Muh. Ihsan Kitta dr. Mervin O. O. Jakarimelena Supervisor dr. Wilhelmus Supriyadi, SpOT DEPARTMENT OF ORTHOPAEDIC AND TRAUMATOLOGY MEDICAL FACULTY OF HASANUDDIN UNIVERSITY MAKASSAR 2013

Identity
Name Age Gender Occupation Date of admittance Medical Record Number : : : : : : Mr. J 38 years old Male Clothing reseller June 15th, 2013 614196

History Taking
Chief complain Pain at left upper arm History of illness Suffered since 1 hours before hospital admittance due to workplace accident Mechanism of trauma Patient tried to refill water dispenser with a bottle (galon) of water. He held up the bottom of bottle by his right hand and the grasp the neck by right hand, suddenly his left arm twisted and provoked painful movement. History of previous illnesses (+) asthma bronchiale since childhood, routine medication taken till now.

History Taking
Chief complain Pain at left upper arm History of illness Suffered since 1 hours before hospital admittance due to workplace accident Mechanism of trauma To refill the dispenser, patient lifted and moved a bottle (galon) which full of water, suddenly he felt pain at the left upper arm. History of previous illnesses (+) asthma bronchiale since childhood, routine medication taken till now.

Primary Survey
A
Patent

B
RR 20x/i Spontaneous breath Symmetrical

C
BP 130/80 mmHg Pulse 80 bpm, regular

D GCS 15 Isochoric pupil, 2,5 mm, light refleks +/+

E Axillary temperature 36,7C

Secondary Survey
LOCALIZED STATUS Left Upper Arm Region Look: deformity (+), swelling (+), hematoma (-), open wound (-) Feel: tenderness (+) ROM: Active and passive motion of joint NVD: Sensibility is good, radialis artery palpable, capillary refill time <2 sec.

Clinical Pictures

Laboratory Findings
Leukocyte 15,0 103/L 4,0-10.0 4,0-6,0 12,0-16,0

Eritrocyte 4,57 103/L Hemoglobin 14,4 g/dL

Hematocrit
MCV MCH MCHC

43,9%
96,0 fl 31,4 pg 32,7g/dL

37,0-48,0
150-400 80-97 26,5-33,5 31,5-35,0

Trombocyte 411 103/L

Laboratory Findings
Na+ K+ Cl145 mmol/L 4,2 mmol/L 110 mmol/L 136-145 3,5-5,1 97-111

GDS
Ureum Kreatinin GOT GPT

103 mg/dL
25 mg/dL 0,9 mg/dL 15 u/L 40 u/L

<140
10-50 <1,3 <38 <41

Radiologic Findings

AP and lateral radiograph of upper arm

Resume
A man, 38 yo, came to the hospital due to wound at left upper arm after involved in a workplace accident since 1 hours before admision. Physical examination revealed deformity, swelling and tenderness of the left upper arm, ROM examination was not performed due to pain. No NVD impairment. Radiologic examination reveal discontinuity of 1/3
middle left humerus.

Diagnosis
Close fracture 1/3 middle left humerus

Management
Immobilization, apply U slab Analgetics Plan ORIF

DISCUSSION Fracture of Shaft Humerus