CASE REPORT
CASE REPORT
Name : Sy. Rugaiyah AlkaffNIM : 09 777 037Supervisor : dr. Sri
Sikspriani, C.H, SpOTORTHOPEDIC & TRAUMATOLOGYMEDICAL
FACULTYALKHAIRAAT UNIVERSITYPALU2015
Malunion fracture humeri sinistra + Neglected fracture proximal
radius et ulna sinistra. Humeral fracture may be occur :Ephyfiseal
humeral fractureMetaphyseal humeral fractureDiaphyseal humeral
fractureHumeral FractureIt is usually found in childrenTrauma
mechanism : usually the patient fall to the hyperextension
position, such as fall when riding a bicycle1. Epiphyseal humeral
fracture Usually without displacementConservative therapy the first
option treatment2. Metaphyseal humeral fractureDiaphyseal humeral
fracture occured cause direct trauma of the humeralClinical
findings from the case is swelling and pain 3. Diaphyseal humeral
fractureClassification of ephyfiseal humeral fracture
(Neer-Horowitz)
Malunion healing time normal but the bone grafting a wrong
position.Malunion may be encountered after conservative treatment
or internal fixation of fractures, and also around a joint
prosthesis.Malunion can involve the greater and lesser
tuberosities, humeral head, bicipital groove, or the entire
epiphysis.Malunion Three situations may be at the origin of the
malunion :Problem with the initial reductionProblem with fixation
leading to secondary displacementProblem with the protection /
stability leading to secondary displacementMechanism of
malunionCASE REPORTI. Identity Name : Ms. Wiwin WastutiDate of
Examination : 26-01-2015Age : 25 years oldTime : 08.00 a.m Adress :
Desa Boya, BaliaseHospital : AnutapuraMild sicknessVital Sign : BP
: 110/70 mmHgHR : 82 x/secondRR : 20 x/secondT : 36oCII. General
condition Chief complaint : Left arm difficult to bent.Trauma
mechanism : This experienced has been 3 months. One years ago the
patients had a traffic accident and she was drived motorcycle by
herself with moderate speed. Suddenly, a motorcycle from her side
make she shocked and finally she was bumped terotoar untill she
fall down to the front and her left hand the first sustains, and as
a result her left arm broken. III. Anamnesis The patient was
unconscious for half an hour, but no nausea and vomit. After
incident she was taked to the hospital Wirabuana and received
treatment for 1 day. The patient forced go to the home for
alternative treatment because she afraid to surgery. But, the
patient was bored to alternative treatment, so this is makes her
come back to the hospital for treatment or surgery.Left below arm
region : Look : Swelling (-), scar (-), deformity (+), tendon
expose (-), muscle expose (-), active bleeding (-)Feel : Tenderness
(-)ROM : elbow joint flexi and extension limited of movement
IV. Physical Examination NVD : Pulse of radial and ulnar artery
adecuateCRT : 2 secondSensibility : normalAcral : warm, skin colour
same with arround itMotoric : Muscle strength 2N. Radialis : elbow
joint limited of movementN. Medianus : normalN. Ulnaris :
disturbed
Laboratory : whole bloodWBC = 7,6 RBC = 4,8 HB = 13,2 gr/dlHCT =
38,1 %PLT = 358HbsAg : non reactiveGDS = 80 mg/dl
V. Treatment Modalities X-Ray : elbow joint AP / Lateral before
ORIF
X-Ray control elbow joint AP post ORIF
VI. Diagnose Malunion fracture humeri sinistra + Neglected
fracture proximal radius et ulna sinistra. Medicamentous : -Non
MedicamentousBedrestMeasure ProcedureORIF K-Wire, reconstruction,
transolecranon-osteotomy.
VII. Therapy VIII. Prognose Dubia ad BonamNo.Date &
TimeVital SignFollow Up1.Post op. 27-01-2015 / 17.10 BP : 100/70
mmHgN : 80 x/secondP : 20 x/secondS : 36,5o CL : pain (+)F :
tenderness (+)ROM : difficult to be evaluated due to painP : - HB
test, if the value 8 gr % presently transfusion 1 bag PRC- IVFD RL
20 drops/second- Transamin 1 ampul, Vit.K 1 ampul, Vit.C 1 ampul
drips in 500 cc RL- Cefoperazone 1 gr/8 hours/IV- Santagesic 1
ampul/12 hours/IV- Ranitidin 1 ampul/8 hours/IV- Sohobion 1
ampul/12 hours/IV- Dialon 2 x 50 mg- Methylcobalt 3 x 500 mg- X-Ray
control elbow joint AP IX. Follow Up 2.28-01-2015 / 07.30 BP :
110/80 mmHgN : 82 x/secondP : 20 x/secondS : 36o CL : pain (+),
numbness (+), dizziness (-), febris (-)F : tenderness (+)ROM :
difficult to be evaluated due to painP : - IVFD RL 20 drops/second-
Cefoperazone 1 gr/8 hours/IV- Santagesic 1 ampul/12 hours/IV-
Ranitidin 1 ampul/8 hours/IV- Sohobion 1 ampul/12 hours/IV- Dialon
2 x 100 mg- Methylcobalt 3 x 500 mg3.29-01-2015 / 07.30 BP : 120/90
mmHgN : 78 x/secondP : 20 x/secondS : 36o CL : pain (+), numbness
(+), dizziness (-), febris (-)F : tenderness (+)ROM : difficult to
be evaluated due to painP : - IVFD RL 20 drops/second- Cefoperazone
1 gr/8 hours/IV- Santagesic 1 ampul/12 hours/IV- Ranitidin 1
ampul/8 hours/IV- Sohobion 1 ampul/12 hours/IV- Dialon 2 x 100 mg-
Methylcobalt 3 x 500 mg4.30-02-2015 / 07.30 BP : 120/80 mmHgN : 80
x/secondP : 20 x/secondS : 36,2o CL : pain (+), numbness (+)F :
tenderness (+)ROM : difficult to be evaluated due to painP : - Aff
drain- Aff infuse - Home care- Dialon 2 x 100 mg- Methylcobalt 3 x
500 mg- Cefixime 2 x 100 mg- Meloxicam 2 x 15 mg- OMZ 2 x 20
mgTERIMAKASIH
