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SHORT CASE

JANUARY 2019

MAXILLOFACIAL TRAUMA
SEGMENTAL FRACTURE MANDIBULLA
+
INTRAORAL MUCOSAL LASERATION

NOVIARSIH MUSLIMAH
K1A1 13 117

Supervisor :
dr. Saktrio D. Subarno, Sp. BP-RE
IDENTITY

 Name : Mr. A
 Age : 16 years old
 Sex : Male
 Address : Konawe
 Admission : November 5 th 2018
 Doctor in charge : dr. Saktrio D. Subarno, Sp.BP-
RE
HISTORY TAKING
(Alloanamnesis and Heteroanamnesis)

 Chief complain :
Right facial pain
 Anamnesis :
Since 5 hours before admitted to the hospital due to traffic accident
 Mecanism of trauma :
The patient was riding a motorcycle with high speed, did not using
helmet. The patient tried to avoid a car and motorcycle and then his face hit
a tree at the right side. Another mechanism was unknown.
History of unconsciousness (+), nausea (+) vomiting (+)
History of alcohol consumtion and drugs
History of nosebleed (+), mouth bleeds (+) ear bleeds (-)
History of previous medication (+) at Konawe Hospital (IVFD Ketorolac,
Ranitidine, ceftriaxone, piracetam, mefenamic acid
PRIMARY SURVEY

A : Clear
B : RR : 20 x/m, symetrical, thoracoabdominal
C : BP: 110/70, HR: 86
D : E4 V5 M6
E : T: 36.6
SECONDARY SURVEY

General state :
Moderate illness, composmentis, normal
weight,
Vital sign :
BP = 120/80 mmHg
HR = 78x/m, regular, strong
RR = 20x/m, regular
Temperature = 36.5oC
STATUS PRESENT

Head : Within Normal Limit


Face : Localized state
Eye : Within Normal Limit
Nose : Within Normal Limit
Ear : Within Normal Limit
Neck : Within Normal Limit
Chest : Within Normal Limit
Abdomen : Within Normal Limit
Extremity
Superior : Within Normal Limit
Inferior : Within Normal Limit
LOCALIZED STATE

Facial Region
I : Deformity (+), Hematoma (-), swelling (+) right buccal region
wound (+) Vulnus excoriatum right sub mandible region,
active bleeding (-), visus (normal), diplopia (-)

P : Tenderness (+) at right zygomaticum region


Step off at rima orbitalis superior (-)
Step off at rima orbitalis inferior (-)
Step off at frontonasalis (+)
Step off at frontozygomaticum (-)
Maxilla (-), Mandible (-)
Unstable os maxilla (-)
Unstable os mandibula (+)
Intra oral : Malocclusion (+), right buccal mucosal avulsion(+)
CLINICAL FINDING
PLAN OF DIAGNOSTIC

BLOOD ROUTINE

X RAY SKULL AP/LAT


ROUTINE BLOOD

 WBC : 20.09 x 10^3/UL


 RBC : 14.73 x 10^3/UL
 HGB : 13.5g/dl
 PLT : 217 x 10^3/UL
DIAGNOSE

MAXILLOFACIAL TRAUMA
SEGMENTAL MANDIBLE FRACTURE
+
INTRAORAL MUCOSAL LACERATION
MANAGEMENT

Non Farmacology Farmacology

•IVFD
• Wound care •Analgetic Injection
•H2RA Injection
• Education •Antibiotic Injection

Consult To Plastic Reconstructive and Aesthetic Surgery


TINJAUAN PUSTAKA
Rusaknya kontinuitas os
mandibulla yang dapat FRAKTUR
disebabkan oleh trauma MANDIBUL
LA
langsung maupun tidak
langsung.
Etiologi
Perkelahian

Kecelakaan Kecelakaan
Kerja Kendaraan

Trauma
penetrasi (luka
Olahraga
pisau atau luka
tembak)
GEJALA
 Nyeri daerah mandibula
 Perdarahan
 Bengkak
 Gangguan fungsi
 Rasa kram/kebas di daerah mandibula
Pemeriksaan Fisik
 Hematom
 Maloklusi
 Spasme otot
 Krepitasi
 Step of
 Unstable mandibulla
PEMERIKSAAN PENUNJANG

Foto
Skull Panora
Skull CT-Scan
Water’s mic
AP/Lat Kepala
View View
obliq
Penatalaksanaan
 IVFD
 Antibiotik
 Pengobatan
simptomatis
Pembedahan

Reposisi
Close Reduction
Ligatur dental Imobilisasi
Arch bar
Splint protesa
Fiksasi
Mobilis
Open Reduction asi
Kawat, pelat dan
sekrup, miniplat,
mikroplat.