Laporan Kasus

CLOSED FRACTURE OF THE RIGHT

COSTAE 4-7 POSTERIOR ASPECT SIMPLE
Julia Kasab

Pembimbing
dr. Zaka Susetyawan Dh, Sp.B

PROGRAM INTERNSIP DOKTER INDONESIA

RS BADARUDDIN KASIM
TABALONG, 2019
IDENTITAS PASIEN
• Nama : Tn. L

• Jenis Kelamin : Laki-laki

• Usia : 35 tahun

• Pekerjaan : Karyawan swasta

• Pendidikan terakhir : SMA

• Alamat : Kambitin RT 1

• MRS : 5 Agustus 2019

 30 menit
ANAMNESIS
SMRS

Pingsan (-)
muntah (-) setelah
perdaraha KLLD
n telinga, tunggal
hidung (-) Nyeri
kepala

Helm (-) Terjatuh ke

kanan
ANAMNESIS Nampak
bengkak

Riwayat Penyakit Dahulu: (-)

Riwayat Penyakit Keluarga:
(-)
Nyeri
dinding Sulit
dada tidak digerakkan
menggangu Nyeri
bahu
kanan

kesulitan Disertai
bernapas nyeri
dinding
(-) sesak dada kanan
napas (-) (+)
 PRIMARY SURVEY
A: Bebas
B:
• Inspeksi: pengembangan dada simetris, retraksi (-) jejas (+) pada 1/3 superior
hemithorax (D) dan shoulder (D), RR : 20x/menit
• Palpasi: krepitasi (-/-), nyeri tekan (+) pada 1/3 superior hemithoraks (D)
dan shoulder (D).
• Perkusi: sonor pada seluruh lapangan paru.
• Auskultasi: vesikular pada seluruh lapangan paru.
C: N: 88 x/menit, kuat angkat, regular, TD: 130/80 mmhg
D: GCS E4V5M6 reflek cahaya (+/+), pupil isokor (3 mm/3 mm)
E: suhu 36,8 ºC, jejas dan hematom dan jejas (+) lihat status lokalis
 Hematom et regio fronto-
temporal (D) 3x2x1 cm,
Kepala/ Leher t.a.k
krepitasi (-), nyeri tekan (+),
vulnus (-).

Inspeksi: t.a.k
Perkusi: t.a.k
Dada Jantung:
Palpasi : t.a.k
Auskultasi : t.a.k

Inspeksi : simetris
Palpasi : fremitus vokal simetris
Perkusi : sonor pada seluruh lapang paru
Paru: Auskultasi : vesikuler pada seluruh lapang paru
Rh - / - Wh - / -
-/ - -/-
-/ - -/-

Abdomen
t.a.k SECONDARY
Ekstremitas dan genital t.a.k
SURVEY
STATUS LOKALIS

Inspeksi: retraksi (-), bruise (+) 2x3 cm et regio

Regio thorax 1/3 superior hemithorax dextra, vulnus
dextra excoriatum (+) 6x2 cm et regio shoulder dextra,
pengembangan dinding dada kanan = kiri.

Palpasi: nyeri tekan

(+) et regio 1/3 Auskultasi:
superior hemithorax Perkusi: sonor vesikular pada
dextra dan shoulder pada seluruh seluruh lapang
dextra, krepitasi (-), lapang paru. paru.
fremitus raba
kanan = kiri.
 Hasil laboratorium darah tanggal 5 Agustus 2019.
Pemeriksaan Hasil Nilai Rujukan Satuan
HEMATOLOGI
Hemoglobin 12,4 12,0-18,0 g/dl
Leukosit 13,8 4,0-10,5 ribu/ul
Eritrosit 4,20 4,5-6,0 juta/ul
Hematokrit 34,8 35-52 vol%
Trombosit 134 150-450 ribu/ul
MCV,MCH,MCHC
MCV 82,9 80,0-97,0 Fl
MCH 26,9 27,0-32,0 Pg
MCHC 32,5 32,0-38,0 %
HITUNG JENIS
Gran% 81,8 50,0-70,0 %
Limfosit % 8,6 25,0-40,0 %
MID% 0,5 4,0-11,0 %
KIMIA
GULA DARAH
Gula Darah Sewaktu 144 <200 mg/dl
CT 3 2-6 menit
CXR pada tanggal 5 Agustus 19.
Fraktur costae dextra posterior 4-7
SKULL AP 5 Agustus 19
Kesimpulan
- Tidak didapatkan garis fraktur
 DIAGNOSIS

Closed Closed
CKR GCS 15 fracture of the fracture of the
+ hematoma r right clavicle right costae 4-
fronto- 2/3 medial 7 posterior
temporal D communitive aspect, simple.
displaced
 TATALAKSANA
• Pemberian O2 NK 1-2 lpm
• IVFD RL 2000 cc/24 jam
• Metamizole 1g/ 8 jam iv
• Ceftriaxone 1g/8 jam iv
• Piracetam 3g/ 8 jam iv
• Lansoprazole 30 mg/12 jam iv
• Observasi KU, tanda-tanda vital, dan pergerakan dinding dada.
• Arm sling kanan
• Rencana terapi fraktur klavikula: ORIF jika kondisi stabil
• Rencana terapi fraktur costae: konservatif.
PROGNOSIS
• Quo ad vitam : dubia
• Quo ad functionam : dubia
• Quo ad sanationam : dubia
 FOLLOW UP

Tgl Pemeriksaan 6/8/19 7/8/19 8/8/19 9/8/19 10/8/19

Subyektif
Nyeri kepala ++ + + - -
Nyeri bahu +++ ++ + + +
Sesak napas - - - - -
Muntah - - - - -
Obyektif
TD (mmhg) 130/80 130/70 120/80 120/80 120/80
Respiratory Rate 24 20 20 20 20
Pergerakan dinding dada Simetris Simetris Simetris Simetris Simetris
Terapi
IVFD RL 20 tpm + + + + +
Piracetam 3 g /8 jam iv + + + + +
Antrain 1g/8 jam iv + + + + +
Ceftriaxone 1 g/8 jam iv + + + + +
Lansoprazole30 mg/12 jam iv + + + + +
Imobilisasi shoulder D + + + + +
Observasi KU, tanda-tanda vital, dan
+ + + + +
pergerakan dinding dada.
PEMBAHASAN
Closed fracture of the right costae 4-7 posterior aspect simple
 Fraktur costae
“Diskontinuitas jaringan tulang/ tulang rawan Iga yang disebabkan oleh rudapaksa. ”

Trauma Non trauma

Akibat gerakan Contoh gerakan
yang menimbulkan olahraga lempar
Trauma tajam Trauma tumpul putaran rongga martil, soft ball,
dada secara tennis, golf.
berlebihan.

1. De Jong W, Sjamsuhidajat R 1997. Buku Ajar Ilmu Bedah Edisi Revisi. Penerbit buku Kedokteran EGC. Jakarta.
 EPIDEMIOLOGI

10% dari kasus

Prevalensi trauma, 30% dari
seluruh trauma
thorax.

tergantung usia dan >4 iga mortalitas 10%

jumlah iga yang Morbiditas >7 iga mortalitas 34%
patah mortalitas
Usia >60 th mortalitas 56%

1. De Jong MB, Kokke MC, Hietbrink F, Leenen LP. Surgical management of rib fractures: strategies and literature review. Scandinavian Journal of Surgery. 2014
Jun;103(2):120-5.
 KLASIFIKASI

Jumlah Jenis Letak Posisi

Single Simple Superior 1-3 Anterior

Multiple Communitive Median 4-9 Posterior
Segmental Inferior 10-12 Lateral

1. De Jong W, Sjamsuhidajat R 1997. Buku Ajar Ilmu Bedah Edisi Revisi. Penerbit buku Kedokteran EGC. Jakarta.
2. De Jong MB, Kokke MC, Hietbrink F, Leenen LP. Surgical management of rib fractures: strategies and literature review. Scandinavian Journal of Surgery. 2014 Jun;103(2):120-5.
 FRAKTUR IGA
BERDASARKAN LOKASI
1. KANI, Kimia Khalatbari, et al. Thoracic cage injuries. European journal of
radiology, 2018.
 MANIFESTASI KLINIS
• Nyeri tekan, Krepitus dan
deformitas dinding dada
• Gerakan napas
paradoksal
• Tanda insuffisiensi
pernafasan.
• Tampak ketakutan dan
cemas.
• Pasien bernafas dengan
cepat, dangkal dan
tersendat .
• Nyeri tajam di daerah
fraktur dan bertambah
ketika bernafas/ batuk
• Gejala perdarahan dalam
dan syok.

1. Mayasari D, Pratiwi AI. Penatalaksanaan Hematotoraks Sedang Et Causa Trauma Tumpul. Jurnal Agromedicine. 2017 Jun 1;4(1):37-42.
 PEMERIKSAAN DIAGNOSTIK

Angiography

MRI

CT SCAN

USG

CXR

1. Tai NRM, Boffard KD. Thoracic trauma: principles of early management. Trauma 2003;5: 123–36.
 TATALAKSANA
Primary Airway
survey Breathing
Circulation
Disability, exposure

Secondary AMPLE
survey Allergies, medications, past illness, last meal, environtment.

Head to toe

1. Subcommittee AT. American College of Surgeons’ Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg.
2013 May;74(5):1363-6.
 TATALAKSANA

Operative/ Konservatif
invasif • Managemen nyeri
• Damage control • Fisioterapi
• Rib Fixation pernapasan

1. HE, Zhe, et al. The ideal methods for the management of rib fractures. Journal of thoracic disease, 2019, 11.Suppl 8: S1078.
FIKSASI IGA
1. HE, Zhe, et al. The ideal
methods for the management of
rib fractures. Journal of
thoracic disease, 2019,
11.Suppl 8: S1078.
RIB FIXATION-
TRADITIONAL
INCISSION
Traditional incision is large and over-
emphasize on the exposure, resulting
in relatively large tissue damage
(two figures were from
two different cases).

HE, Zhe, et al. The ideal methods for the management of rib fractures. Journal of thoracic disease, 2019, 11.Suppl 8: S1078.
 Minimally invasive
plate osteosynthesis
(MIPO)
The application of MIPO helps to
operate with a small incision,
reducing the tissue damage. MIPO,
minimally invasive plate
osteosynthesis.

HE, Zhe, et al. The ideal methods for the management of rib fractures. Journal of thoracic disease, 2019, 11.Suppl 8: S1078.
 Minimally invasive
plate osteosynthesis
(MIPO)
MIPO technique was applied to fix
the 3–9 ribs fracture under the left
scapula with an 8 cm incision. MIPO,
minimally invasive
plate osteosynthesis.

HE, Zhe, et al. The ideal methods for the management of rib fractures. Journal of thoracic disease, 2019, 11.Suppl 8: S1078.
Foto thorax post
pemasangan fiksasi
Iga.
Nirula R, Diaz JJ, Trunkey DD, Mayberry JC. Rib fracture repair: indications, technical issues, and future directions. World journal of surgery. 2009 Jan 1;33(1):14-22.
 KRITERIA RAWAT JALAN

Tidak didapatkan komplikasi selama observasi

Kondisi umum dan tanda-tanda vital dalam kondisi

stabil
Nyeri minimal dan tidak mengganggu pola
pernapasan normal pasien.
 KOMPLIKASI
1. Tension pneumothorax.

1. Subcommittee AT. American College of Surgeons’ Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg.
2013 May;74(5):1363-6.
 KOMPLIKASI
2. Hemothorax.

1. Subcommittee AT. American College of Surgeons’ Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg.
2013 May;74(5):1363-6.
 KOMPLIKASI
flail chest

1. Subcommittee AT. American College of Surgeons’ Committee on Trauma; International ATLS

working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care
Surg. 2013 May;74(5):1363-6.
 KOMPLIKASI Lung contusion

Other visceral
injury

Pneumonia

1. Subcommittee AT. American College of Surgeons’ Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg.
2013 May;74(5):1363-6.
TERIMAKASIH
WHO STEP LADDER PAIN MANAGEMENT
OXFORD,
NHS, UK
Ben taub
hospital multi
modal pain
management
Clinical Practice
Guideline
Emergency department management of patients with
rib fracture based on a clinical practice guideline
Indication for internal fixation
REPORTING THE COMPLICATIONS