Fraktur radius

Ulna
IDENTITAS

▹ Nama : Tn. AY
▹ Jenis Kelamin : Laki-laki
▹ Usia : 30 tahun
▹ No Rekam Medik : 81-40-86
▹ Tanggal Masuk RS : 31 Nov 2021
ANAMNESIS

Pasien laki-laki usia 30 tahun datang ke IGD RS X dengan keluhan

nyeri pada pergelangan tangan kanannya yang dirasakan sejak 2
jam SMRS. Sebelumnya pasien terjatuh setelah terpeleset di
kamar mandi karena lantai yang licin. Di katakan pasien terjatuh ke
sisi kanan dengan posisi tangan kanan yang menumpu sisi tubuh
sebelah kanan. Saat ini pergelangan tangan kanan dirasakan nyeri
dan disertai bengkak kemerahan. Tidak ada riwayat terbentur pada
bagian tubuh yang lain. Riwayat penurunan kesadaran, mual,
muntah, kejang disangkal. BAB dan BAK tidak ada keluhan.
PEMERIKSAAN
FISIK

▹ KU Sedang
▹ Kesadaran CM
▹ TD :130/80
mmHg
▹ HR : 78x/menit
▹ RR : 20x/menit
▹ T : 36.8C
 Status
Generalis
Kepala
• Normocephal, tidak ada jejas

Mata
• Conjungtiva tidak anemis, sclera anikterik
• Racoon eyes tidak ada

THT
• Battle sign (-), otorrhea (-), rhinorrhea (-)

Leher
• Tidak ada jejas
Thorax
• Ekspansi dada simetris, tidak tampak ada jejas

Cor
• BJ I dan II regular, tidak ada murmur dan gallop

Pulmo
• Vesikuler, tidak ada rhonki dan wheezing

Abdomen
• Supel, bising usus normal, tidak ada nyeri tekan, jejas (-)

Ekstremitas
• Akral hangat, CRT<2s

Status lokalis region antebrachii dextra

• Tampak edema pada regio antebrachii dextra, hiperemis (+) krepitasi (+), nyeri tekan (+) hangat pada perabaan. ROM
terbatas
X-RAY

Tampak diskontinuitas
komplit pada 1/3 distal os
radius dan os ulna dextra.
Fraktur komplit 1/3 distal os radius dan
os ulna dextra

DIAGNOSIS
ICD-10

▹ S52.10 : Fracture of upper end of

radius, closed
▹ S52.00 : Fracture of upper end of ulna,
closed
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