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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


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.


Classification:

Stewart, dkk. Campbells Operative Orthopaedics. Vol. 4. 11tth Ed. Mosby


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.


Clinical examination:


ROM


ROM



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