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CASE REPORT

Closed Fracture 1/3 Middle Left Femur


Closed Fracture 1/3 Middle Right Tibia

Muhammad Ichsan Prasetya


C 111 11 304
Advisor:
dr. Aries Freddy Hutabarat
dr. Yohannes Toban
Supervisor:
dr. Notinas Horas, M.Kes, Sp.OT
Orhtopedic and Traumatology
Faculty of Medicine ,Hasanuddin University
Makassar
2016

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

PATIENTS
IDENTITY

Name

: N

Age

: 11 years old / Girl

Date of

: Mei 3th, 2016

Admission
Registration

: 756258

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

HISTORY TAKING

Chief Complaint : Pain at the both


of leg
History taking:

Suffered since 7 hours before admitted to


Wahidin Sudirohusodo Hospital due to traffic
accident. History of treatment (-). History of
loss conciousness (-), nausea (-), vomitting (-)
Mechanism of trauma : Patient as a
passenger was riding a motorcycle with her
uncle, suddenly there was a car that turned
back, and her motorcycle hit the car, and
then she and her uncle fell down to the
ground.

CASE
REPORT
PATIENTS
IDENTITY

PRIMARY SURVEY

Airway

Patent, clear

HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

Breathing
Circulation
Disabilty
Exposure

20x/min, thoracoabdominal,
spontaneous, symetric.
BP 110/70mmHg, HR 100x/min,
regular, strong on palpation
GCS 15(E4M6V5), light reflex +/
+ , pupil isochors, :
2.5mm/2.5mm,
Temp 36.8C (axilla)

CASE
REPORT
PATIENTS
IDENTITY

Left Tight Region

HISTORY TAKING
PHYSICAL
EXAMINATION

CLINICAL
FINDING

INVESTIGATION
RESUME
ASSESMENT
THERAPY

SECONDARY
SURVEY

Look :
Deformity (+), Swelling (+), Hematoma
(-), Wound (-)
Feel :
Tenderness (+)
Movement :
Active and passive movement of hip
joint and knee joint cannot be evaluated
due to pain
NVD :
Sensibility is good, Pulsation of dorsal
pedis artery and tibialis posterior artery
are palpable, CRT < 2

CASE
REPORT
PATIENTS
IDENTITY

Right Leg Region

HISTORY TAKING
PHYSICAL
EXAMINATION

CLINICAL
FINDING

INVESTIGATION
RESUME
ASSESMENT
THERAPY

SECONDARY
SURVEY

Look :
Deformity (+), Swelling (+), Hematoma
(-), Wound (-)
Feel :
Tenderness (+)
Movement :
Active and passive movement of knee
joint and ankle joint cannot be evaluated
due to pain
NVD :
Sensibility is good, Pulsation of dorsal
pedis artery and tibialis posterior artery
are palpable, CRT < 2

CASE
REPORT

CLINICAL FINDING

PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

Anterior Aspect

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

CLINICAL FINDING

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

CLINICAL FINDING

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

X- Ray Left
Femur

RADIOLOGY
FINDING

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

X- Ray
Right
Cruris

RADIOLOGY
FINDING

CASE
REPORT

LABORATORY
FINDING
TEST

RESULT

REFERENCE

WBC

16,2

4,00-10,0

RBC

4,20

4,00-6,00

HGB

10,3

12,0-16,0

HCT

32

37,0-48,0

PLT

128

150-400

GOT

81

< 38

GPT

45

< 41

GDS

92

140

INVESTIGATION

CT

700

4-10

RESUME

BT

200

1-7

Ureum

16

10-50

Creatinin

0.37

<1.3

HBsAg

Non Reaktif

Non Reaktif

PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING

ASSESMENT
THERAPY

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

RESUME

Girl 11th Years old, admitted to the hospital


with chief complain pain at the both of leg,
suffered since 7 hours before admitted to
Wahidin Sudirohusodo Hospital due to traffic
accident. History of treatment (-). History of
loss conciousness (-), nausea (-), vomitting (-)
Mechanism of trauma : Patient as a passenger
was riding a motorcycle with her uncle,
suddenly there was a car that turned back,
and her motorcycle hit the car, and then she
and her uncle fell down to the ground.

CASE
REPORT
PATIENTS
IDENTITY

HISTORY TAKING
PHYSICAL
EXAMINATION

CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

RESUME

From physical examination, Deformity


(+), Swelling (+), Hematoma (-),
Wound (-). There is tenderness in
palpation.
Active and passive movement of left
hip joint and left knee joint cannot be
evaluated due to pain. Active and
passive movement of right knee joint
and right ankle joint cannot be
evaluated due to pain.
Neurovascular
distal
examination
within normal limits.

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

RESUME

From the radiology finding, there


are :
Fracture
Comminuted
1/3
Middle Left Femur
Fracture Oblique 1/3 Middle
Right Tibia

CASE
REPORT

DIAGNOSIS

PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

Closed

Fracture 1/3
Middle Left Femur
Closed
Fractur 1/3
Middle Right Tibia

CASE
REPORT
PATIENTS
IDENTITY
HISTORY TAKING
PHYSICAL
EXAMINATION
CLINICAL
FINDING
INVESTIGATION
RESUME
ASSESMENT
THERAPY

IVFD

THERAPY

Ringer Lactate
Analgetic
Antibiotic
Apply Long Leg Back Slab at right
lower limb
Apply Skin Traction at left lower
limb
Plan for Open Reduction Internal
Fixation

DISCUSSION

Orhtopedic and Traumatology


Faculty of Medicine ,Hasanuddin University
Makassar
2016

THANK YOU

MUHAMMAD ICHSAN PRASETYA