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CASE

PRESENTATION
May 2015

Closed Anterior Dislocation Of


Left Glenohumeral Joint
Presented By :
Fyco Christian K
Advisor :
dr. Felix S. Batuna
dr. Aries Hutabarat
Supervisor :
dr. M. Ruksal Saleh, Ph.D, Sp. OT
Orthopaedic and Traumatology Department
Medical Faculty of Hasanuddin University
Makassar
2015

Patient Identity
Name

: Mr. PA

Age

: 65 y.o.

Gender

: Male

Admission Date

: May 10th, 2015

Registration

: 711437

History Taking
Chief Complain
:
Pain on the left shoulder
Anamnesis
:
Suffered since 1 hour before admitted to the
hospital due to traffic accident, felt continuously
and worsening when moving the arm, right hand
dominant, he was retired from civil servant
Mechanism of Trauma :
Patient sit at 2nd row and a passenger. The car
hit a tree, then he hit the seat with his left
shoulder. After that, he felt pain and can not
move his left arm

History Taking
History of Past Disease
:
The patient had experienced a fall from a
motorcycle 10 years ago and continuously felt
pain in his left shoulder, but never went to the
hospital. 1 year ago, the pain felt worsen and he
went to the hospital. Patient underwent surgery
for open reduction on his left shoulder by dr.
Faisal, Sp. OT in Masamba Hospital.

Primary Survey
Airway
: Clear
Breathing : RR 24 x/min, spontaneous,
thoracoabdominal type
Circulation : HR 98 x/min, strong, regular,
BP 130/70
Disability
: GCS 15 (E4M6V5), pupil
isochoric
3mm/ 3mm, light reflex +/+
Exposure
: Temp. (axilla) 36.5 oC

Seconday Survey
Left Upper Extremity Region
Look
: Deformity (+), Flat Shoulder (+), Acromion
Prominent (+), Humeral Head Prominent (-), hematome (-),
Swelling (-), Scar (+) at the left lateral shoulder with size 4
cm, Arm in slight Abduction (20o)
Feel
: Tenderness (+), Humeral head palpable at the
left anterior shoulder
Move
:
- Active and passive motions of shoulder joint can not be
evaluated due to pain
- Active and passive motion of elbow joint is normal (Flexion
0o - 140o, Extention 0o, Pronation 0o - 90o, Supination 0o - 90o)
- Active and passive motion of wrist joint is normal (Flexion
0o - 70o, Extention 0o - 80o, Radial Deviation 0o - 20o, Ulnar
Deviation 0o - 30o)

Seconday Survey
NVD
:
Sensoric function of the axillary nerve:
numbness (+)
- Sensoric function of musculocutaneus nerve,
radial nerve, median nerve and ulnar nerve are
normal
- Radial artery and ulnar artery is palpable
- OK Sign Test (+), Extend Thumbs Test (+),
Abduction Adduction Test of Finger (+)
- CRT < 2 seconds

Physical Findings

Anterior View

Physical Findings

Posterior View

Lateral View

Laboratory Findings
WBC :
RBC :
HBG :
HCT :
PLT
CT
:
BT
:
HBsAg :

10.000/ ul
4.070.000/ ul
12,9 g/dl
36 %
: 275.000/ ul
300
600
non-reactive

Radiological Findings

Diagnosis
Closed Anterior Dislocation of The Left Glenohumeral
Joint

Treatment
IVFD RL
Analgetic
Immobilization with arm sling
Closed Reduction
Arm sling after post closed reduction

Discussion

Evidence Leading to Diagnosis


History Taking

Physical Examination

Radiological Examination

Diagnosis
Closed Anterior Dislocation of The Left Glenohumeral
Joint

Treatment
IVFD RL
Analgetic
Immobilization with arm sling
Closed Reduction
Arm sling after post closed reduction

Complication
Early
Ligament injury
Neurological injury
Vascular injury
Fracture
Late
Joint stiffness

Thank you for your


attention!

Post Closed Reduction