CASE REPORT

Shoulder Dislocation

1.
2.
3.
Orthopaedic and Traumatology Department
CASE REPORT| OCT 2017
Medical Faculty of Hasanuddin University

IDENTITY
Name : Mdm. N

Age : 70 y/o

Admission : 16 October 2017

Registration : 81531
 Orthopaedic and Traumatology Department
CASE REPORT| OCT 2017
Medical Faculty of Hasanuddin University

AUTOANAMNESIS
Chief Complaint : restricted movement of the right
arm
It happen 2 weeks before admitted.
Mechanism of trauma :
Patient is walking, and suddenly falls to the asphalt.
Landed with right arm
The patient having difficulty in moving the arm after the accident
She sometimes feel numbed at the upper lateral site of the right
arm, until the distal part of the fingers
There is a history massaging of the trauma area with the local
physician
There is a history of hypertension, asthma bronchial and smoking.
History of Diabetes Mellitus is denied.
Orthopaedic and Traumatology Department
CASE REPORT| OCT 2017
Medical Faculty of Hasanuddin University

GENERAL STATUS
Conscious / Well-nourished
Vital Signs:
Blood pressure : 130/80 mmHg
Pulse rate : 78x/min
Respiratory rate : 20 x/min
Temperature : 36.8 0C

NRS : 2
Orthopaedic and Traumatology Department
CASE REPORT| OCT 2017
Medical Faculty of Hasanuddin University

CLINICAL FINDING
Right Arm Region:
Look : Deformity (+), swelling (-), Wound (-),
hematoma (-)
Feel : Tenderness at proximal arm (-)
Move: Active and passive movement of humerus
joint are restricted (abduction, extention, ext.
rotation)
Active and passive movement of forearm
joint are normal
NVD : Good sensibility, pulsation of tibialis posterior
and dorsalis pedis arteries are palpable,
capillary refill time is less then 2 seconds
Orthopaedic and Traumatology Department
CASE REPORT| OCT 2017
Medical Faculty of Hasanuddin University

CLINICAL FINDING

Right (cm) Left (cm)

AL 74 70
Shoulder AP
 Orthopaedic and Traumatology Department
CASE REPORT| OCT 2017
Medical Faculty of Hasanuddin University

DIAGNOSIS
Dislocation of Shoulder

MANAGEMENT
IVFD
Analgesic ( ketolorac 30 mg /8 hour / i.v)
Anti-Ulcer (omeprazole 40 mg / 24 hour / i.v)
Open Reduction Internal Fixation (18/10/2017)
 CASE REPORT
OCT 2017

Orthopaedic and Traumatology Department

Medical Faculty of Hasanuddin University

DISCUSSION

Shoulder Dislocation


 Intra-articular
Lidocaine
Injection is preferred
over
IV Sedation


 CASE REPORT
OCT 2017

Orthopaedic and Traumatology Department

Medical Faculty of Hasanuddin University

THANK YOU
Shoulder Dislocation