Orthopaedic Case

Presentation:

AC JOINT DISLOCATION
Agustian Deny
I 11109090
Consulent :
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 backup.
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 mmHg
Heart rate
: 82 x/mnt
Respiratory rate : 20 x/mnt
Temperature
: 36 ,7C

GENERAL STATUS

Head: Normocephal, Head

circumstance, injury (-),
tenderness (-)

Heart : S1 and S2 heart sounds

are single, regular.

Abdomen

Eye: Conjungtiva anemis -, sklera

ikterik -, pupil isokor +/+

Ear
within normal limit

Nose
within normal limit

Palpation
: Liver is not
palpable, lien is not palpable.

Mouth and throat

within normal limit

Perkusio
: Timpani in all of
field of abdomen

Neck
within normal limit

Lungs : Vesikuler +/+, crackles

-/-, wheezing -/-

Inspection

: Flat

Auskultasion : Bowel (+) normal

Ekstremity
status

: look at local

Local status
Right shoulder
Look:
- 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

Movement

Shoulder joint

Explanation

Right

Left

Fleksi
(Aktive)

1700

1700

There are no limitation ROM

Fleksi
(Passive)

1700

1700

There are no limitation ROM

600

There are limitations extenxion ROM Active

extenxion of the right shoulder joint 450

Ekstensi
(Aktive)

Ekstensi
(Passsive)

450

450

600

There are limitations extenxion ROM Passive

extenxion of the right shoulder joint 450

Range Of Motion Test

Movement

Shoulder
joint
Right Left

Explanation

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

Special test

Adduction
test in
extension: (+)

Rontgent Shoulder Joint AP with Stress

View

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

Diagnosis
Acromioclavicular 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 Up
Friday, 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 Up
Saturday, 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

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 IVVI: 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