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AC joint dislocation
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Orthopaedic Case Presentation:
AC JOINT DISLOCATION
Agustian DenyI 11109090Consulent : dr. Ganda Purba, Sp.OT, M.Kes
Identity of patient
• Name : Mr. P• Sex : Male• Age : 42 years old• Occupation : Laborer
Chief complaint
• There is swelling on the right shoulder
ANAMNESIS
• The chief complaint about ± 2 months ago• Complaints occur began after he got accident, slip in slippery floor,
which the right arm holding on the pole, its attracted toward the back-up.
• There are tenderness, expecially when the burden on the right shoulder. Pain radiating to the neck and right arm and it will weariness when carrying. There are no limitations to move the right arm.
• Patient has no complain of weakness and numbness on the right arm, fever (+) intermittent.
• History alternative treatment: (+)
CLINICAL EXAMINATION
GENERAL STATUS• Conciouss, good nourish• Vital sign :
Blood pressure : 120/70 mmHgHeart rate : 82 x/mntRespiratory rate : 20 x/mntTemperature : 36 ,7C
GENERAL STATUS Head: Normocephal, Head
circumstance, injury (-), tenderness (-)
Eye: Conjungtiva anemis -, sklera ikterik -, pupil isokor +/+
Ear : within normal limit
Nose : within normal limit
Mouth and throat : within normal limit
Neck : within normal limit
Lungs : Vesikuler +/+, crackles -/-, wheezing -/-
Heart : S1 and S2 heart sounds are single, regular.
Abdomen Inspection : Flat Auskultasion : Bowel (+) normalPalpation : Liver is not palpable, lien is not palpable.Perkusio : Timpani in all of field of abdomen
Ekstremity : look at local status
Local status
Right shoulderLook: - deformity (+)- discoloration (-)- atrophy (-)- shortening (-)- vulnus (-)Feel:- tenderness (+)- skin moist (-)- crepitation (-)- NVD : Sensory ( + )
same with healty (left shoulder)
Move :- ROM limited, pain motion
(+) minimal
Range of Motion Test
MovementShoulder joint
ExplanationRight Left
Fleksi (Aktive) 1700 1700 There are no limitation ROM
Fleksi (Passive) 1700 1700 There are no limitation ROM
Ekstensi (Aktive) 450 600
There are limitations extenxion ROM Active extenxion of the right shoulder joint 450
Ekstensi (Passsive) 450 600
There are limitations extenxion ROM Passive extenxion of the right shoulder joint 450
MovementShoulder
joint ExplanationRight Left
Abduksi (active) 1800 1800 There are no limitation ROM
Abduksi (pasive) 1800 1800 There are no limitation ROM
Endorotasi (aktive) - + There are limitations internal rotation ROM active
internal rotation of the right shoulder joint
Endorotasi (pasive) - + There are limitations internal rotation ROM passive
internal rotation of the right shoulder joint
Eksorotasi (aktive) 600 600 There are no limitation ROM
Eksorotasi (pasive) 600 600 There are no limitation ROM
Range Of Motion Test
Special test
Adduction test in extension: (+)
Rontgent Shoulder Joint AP with Stress View
R L
• Alignment : There is desrupsion on the right shoulder, deformity (+) on the right shoulder (os clavicula and os acromion separated)
• Bone Density : There is no abnormality• Cartilage : There is widening of the joint space (acromioclavicular joint/coracoclavicular joint)• Soft Tissue : There is no widening of the size of soft tissue • Impression : AC joint dislocation
DiagnosisAcromioclavicular joint dislocation
Treatment– Preparation Of Reconstruction AC joint• Informed Consent• Lab: DL, BT, CT, Ureum, Kreatinin, GDS, SGOT, SGPT• Fasting 6 hours before surgery• Profilaksis Antibiotic IV before surgery
Operation Procedure• The patient lies supine position under the influence of general
anesthesia • Perform disinfection procedures and drapping• Anterolateral incision is then deepened by blunt approach• Perform AC joint reconstruction procedures + fixation with
tension band wirring• Check the stability• Wash the wound with 0.9 % NaCl • Sewing wound layer by layer • Cover with sterile gauze • Install the Armsling• The operation completed
Post Surgery Instruction• Monitoring of bleeding, pain, and NVD• Free Diet• IVFD RL 20 drip per minute• Antibiotic 1 vial/12 hours IV• Analgetic 1 amp/8 hours IV• H2 blocker 1 amp/8 hours IV• Rontgen Dextra Shoulder Joint AP• Maintain armsling• Wound care and changing bandages/2 days
Prognosis– Ad vitam : bonam– Ad fungtionam : dubia ad bonam– Ad Sanactionam : dubia ad bonam
Follow UpFriday, November, 27 2015• S : Pain post surgery (+), nausea (-), vomitting (-), fever (-)• O : Consiousness CM, generalis status within normal limit
– Localized status : right shoulder joint – L : Armsling (+), Installed elastic verban (+), blood seep (-), pus
seep (-)– F : Edema (-), tenderness (+)– M : motion pain (+), Limited ROM (+)
• A : Post Ac joint Reconstruction Right shoulder Day 1• P : Antibiotic 1 vial/12 hours IV, Analgetic NSAID 1 amp/8 hours IV,
H2 Blocker 1 amp/8 hours IV, Wound care/ 2 hari
Follow UpSaturday, November, 28 2015• S : Pain post surgery (+) ↓, fever (-)• O : consiousness CM, generalis status within normal limit
– Localized status : right shoulder joint – L : Armsling (+), Installed elastic verban (+), blood seep (-), pus seep (-)GV dry wound conditions (+), expenditure of blood and pus (-)– F : Tenderness (+)– M : motion pain (+), Limited ROM (+)
• A : Post AC joint Reconstruction Right Shoulder Day 2• P : Antibiotic 1 vial/12 hours IV, Analgetic NSAID 1 amp/8 hours IV, H2
Blocker 1 amp/8 hours IV, Wound care/ 2 hari
Education For Patient Before Leave The Hospital
• Imobility the right arm• Controls to hospital (Orthopedic Section)
every 3 days • Medikamentosa : Antibiotic 1 tab/12 hours,
Analgetic NSAID 1 tab/8 hours, H2 Blocker 1 tab/8 hours
Rontgent of right shoulder joint AP Post Surgery
Radiology of right shoulder joint AP Post surgery (Friday, November, 27 2015)Fixation of the acromioclavicular + using k - wire, augmentation with tension band wiring
Discussion
Anatomy
Gambar 1. Anatomi Tulang Bahu
Thompson, Jon C. 2010. Netter Concise Orthopaedic Anatomy. 2nd Ed. Philadelphia: Saunders
X-ray of Shoulder Anatomy
Hansen, John T. 2010. Netter Clinical Anatomy. 2nd Ed. Philadelphia: Saunders
Hansen, John T. 2010. Netter Clinical Anatomy. 2nd Ed. Philadelphia: Saunders
MUSCLES
MUSCLES: ORIGINS AND INSERTIONS
Thompson, Jon C. 2010. Netter Concise Orthopaedic Anatomy. 2nd Ed. Philadelphia: Saunders
Biomechanics
Biomechanics
Biomechanics
AC Joint Dislocation
Definition
• Displacement of bones that form a joint surface to other bones.
• Dislocations can be completely separated (divorce joints) or partial (incomplete dislocation), or subluksasio.
De Jong,. 2010. Buku Ajar Ilmu Bedah. Ed. 3. Jakarta: EGC
AC Joint Dislocation
• Acute injury of the acromioclavicular joint is common and usually follows direct trauma.
Solomo, dkk. 2010. Apleys System of Orthopaedics and Fracture. 9th Ed. London: Hodder Education
Mechanism of injury:
A fall on the shoulder with the arm adducted may strain or tear the acromioclavicular ligaments and upward subluxation of the clavicle may occur; if the force is severe enough, the coracoclavicular ligaments will also be torn, resulting in complete dislocation of the joint.
Solomo, dkk. 2010. Apleys System of Orthopaedics and Fracture. 9th Ed. London: Hodder Education
Classification:
Stewart, dkk. Campbells Operative Orthopaedics. Vol. 4. 11tth Ed. Mosby
Thompson, Jon C. 2010. Netter Concise Orthopaedic Anatomy. 2nd Ed. Philadelphia: Saunders
Clinical features:
• The patient can usually point to the site of injury and the area may be bruised.
• If there is tenderness but no deformity, the injury is probably a sprain or a subluxation.
• With dislocation the patient is in severe pain and a prominent ‘step’ can be seen and felt.
• Shoulder movements are limited.
Solomo, dkk. 2010. Apleys System of Orthopaedics and Fracture. 9th Ed. London: Hodder Education
Clinical examination:
Clinical examination:
ROM
Thompson, Jon C. 2010. Netter Concise Orthopaedic Anatomy. 2nd Ed. Philadelphia: Saunders
ROM
Thompson, Jon C. 2010. Netter Concise Orthopaedic Anatomy. 2nd Ed. Philadelphia: Saunders
Clinical examination:
Special Test
Special Test
X-ray: Shoulder with stress view
Stewart, dkk. Campbells Operative Orthopaedics. Vol. 4. 11tth Ed. Mosby
Treatment
• Conservative treatment, types I and II: during the initial 2 wk, provide pain control (sling, NSAIDs, ice) and start range of motion exercises
• Type III: treatment is controversial; in patients with high demand (ie, throwing athletes), surgical repair is warranted; in others, an attempt at conservative treatment is commonly employed
• Types IV—VI: surgical repair or reconstruction
Conclusion• Men aged 42 years came with a complaint There is swelling on the
right shoulder since + 2 months before admission because the patient slip in slippery floor, which the right arm holding on the pole, its attracted toward the back-up.
• There are tenderness, expecially when the burden on the right shoulder. Pain radiating to the neck and right arm and weariness when carrying. There are no limitations to move the right arm.
• From LOOK examination there are deformity (+) on the right shoulder. • From FEEL examination the patient feel tenderness (+)• From MOVE examination, there are of a limited ROM, Passive and
Active ROM, and pain motion (+) minimum.• X-ray of Shoulder shown the Shoulder Separation• From the results of the investigation it was shown the AC joint
Dislocation
Conclusion (2)• Treatment non medikamentosa for patient is AC joint
reconstruction: using k - wire, augmentation with tension band wiring
• After the operation there was not found postoperative complications . Surgical wound pain began to minimize on the second day of treatment.
• Imobility the right arm
THANK YOU