Upload
christophore-santoso
View
229
Download
0
Embed Size (px)
Citation preview
7/30/2019 Patta Indral Fraktur Femur
1/31
Name : P
Age : 20 years old/ male
Admission : April 20th, 2011
Registration : 46 45 45 (18: 28)
Status : UMUM
7/30/2019 Patta Indral Fraktur Femur
2/31
Chief complain : Decrease of consciousness
Anamnesis : Suffered since 4 hours before admittedto the hospital due to traffic accident
Trauma mechanism : The patient was riding a
motorcycle then got hit by another motorcycle fromthe left side.
History of nausea (+), vomited (+).
Prior Treatment at Takalar General Hospital
7/30/2019 Patta Indral Fraktur Femur
3/31
Primary survey (18: 35)
A : Patent, airway obstruction (-)B : RR = 20 x/min, equals, spontaneous,
thoracoabdominal type.
C : BP = 110/80 mmHg, PR = 78 x/minregular, strong.
D : GCS 14 (E3M6V5) pupil equal 2.5 mm,
light reflex +/+
E : T = 36.7o C (axillar)
7/30/2019 Patta Indral Fraktur Femur
4/31
Secondary Survey(18:43)
Frontalis Region
I : multiple stitched wound at the left side size 4cm and 2 cm. excoriated wound at the right sidesize 1 cm x 1 cm. Active bleeding (-), hematoma
(-) P : tenderness (+)
7/30/2019 Patta Indral Fraktur Femur
5/31
7/30/2019 Patta Indral Fraktur Femur
6/31
Secondary Survey
Left thigh region I : Deformity (+), swelling (+), hematoma (+), wound (-)
P : Tenderness (+)
ROM : active and passive motion at hip and knee joints arelimited due to pain
NVD : sensibility is good, pulse of dorsalis pedis artery ispalpable, , capillary refill time < 2
R LALL 96 cm 94 cmTLL 86 cm 84 cmLLD 2 cm
7/30/2019 Patta Indral Fraktur Femur
7/31
7/30/2019 Patta Indral Fraktur Femur
8/31
Secondary Survey
Left Leg Region
I : Deformity (+), swelling (+), hematoma (+),wound (-)
P : Tenderness (+)
ROM : active and passive motion at knee and
ankle joints are limited due to pain. NVD : sensibility is good,, the pulse of dorsalis
pedis artery is palpable, capillary refill time < 2
7/30/2019 Patta Indral Fraktur Femur
9/31
7/30/2019 Patta Indral Fraktur Femur
10/31
Secondary Survey
Right Leg Region
I : Deformity (+), swelling (-), hematoma (-),wound (-)
P : Tenderness (-)
ROM : active and passive motion at knee and
ankle joint is normal NVD : sensibility is good,, the pulse of dorsalis
pedis artery is palpable, capillary refill time < 2
7/30/2019 Patta Indral Fraktur Femur
11/31
7/30/2019 Patta Indral Fraktur Femur
12/31
Secondary Survey
Left ankle Region
I : lacerated wound at medial aspect sized 2 cm x0,5 cm. Deformity (+), swelling (+), hematoma(+).
P : Tenderness (+)
ROM : active and passive motion at ankle jointsare limited due to pain
NVD : sensibility is good,, the pulse of dorsalispedis artery is palpable, capillary refill time < 2
7/30/2019 Patta Indral Fraktur Femur
13/31
7/30/2019 Patta Indral Fraktur Femur
14/31
LABORATORY FINDINGS
WBC 17,17 x 10
3
/uL RBC 5,35 x 106 /uL HGB 16,0 gm/dL HCT 44,9 % PLT 377 x 103 /uL Na 133 K 4,4 Cl 108 HBsAg (-)
BS 147 mg/dl Ureum 34 mg/dl Kreatinin 0,8 mg/dl SGOT 27 SGPT 22
7/30/2019 Patta Indral Fraktur Femur
15/31
Radiologic Findings
7/30/2019 Patta Indral Fraktur Femur
16/31
7/30/2019 Patta Indral Fraktur Femur
17/31
7/30/2019 Patta Indral Fraktur Femur
18/31
7/30/2019 Patta Indral Fraktur Femur
19/31
7/30/2019 Patta Indral Fraktur Femur
20/31
7/30/2019 Patta Indral Fraktur Femur
21/31
7/30/2019 Patta Indral Fraktur Femur
22/31
7/30/2019 Patta Indral Fraktur Femur
23/31
7/30/2019 Patta Indral Fraktur Femur
24/31
Diagnosis Pre Operation
Mild Head Injuries GCS14 (E3V5M6)
Open fracture deppressed of the left frontalis region
Union fracture of the left clavicle Closed communitive fracture of the left femur
Closed fracture 1/3 distal of the left fibula
Open fracture of the left medial malleolus grade IIIA
7/30/2019 Patta Indral Fraktur Femur
25/31
7/30/2019 Patta Indral Fraktur Femur
26/31
Operation report
1. Patient lied supine under GA
2. Disinfection and drapping procedure
3. Identification wound at medial aspect of the left foot , seen lacerated woundsize 2 cm x 0,5 cm
4. Rinse wound with normal saline and peroxide until clean5. Rinse wound again with normal saline
6. Sticth the wound with daclon 3.0
7. Closed the wound apply sterile gauge and daryatule
8.Apply back slab
9. Apply skin traction
10. Apply bohler brown
11.Operation finished
7/30/2019 Patta Indral Fraktur Femur
27/31
7/30/2019 Patta Indral Fraktur Femur
28/31
Post operation diagnosis
Mild Head Injuries GCS14 (E3V5M6) Open fracture deppressed of the left frontalis region
Union fracture of the left clavicle
Closed communitive fracture of the left femur
Closed fracture 1/3 distal of the left fibula
Open fracture of the left medial malleolus grade IIIA
7/30/2019 Patta Indral Fraktur Femur
29/31
7/30/2019 Patta Indral Fraktur Femur
30/31
7/30/2019 Patta Indral Fraktur Femur
31/31