PATIENT IDENTITY Name: MNA Age: 30 years old Sex: Male Date of admittance: 19th April 2015 MR Number: 708978

HISTORY Chief Complaint: Pain at the left knee. History of illness : Patient suffered from the knee pain since 2 day before admitted to the Wahidin Sudirohusodo Hospital due to accident. Mechanism of Trauma: The patient was riding a motorcycle and suddenly felt to the left side which his knee directly hitting the road and cannot stand up well after the accident. History of unconsciousness (-), nausea (-), vomit (-).

PHYSICAL EXAMINATIONPRIMARY SURVEY Airway: Patent Breathing: RR=20x/min, symmetrical, spontaneous, thoracoabdominal type Circulation: BP=130/80 mmHg, P=82x/minute regular and strong Disability: GCS 15 (E4M6V5), light reflex +/+, isochoric pupil 2.5/2.5 mm Environment: Axillary temperature of 36.5oC

SECONDARY SURVEY Left Knee Joint Inspection :Deformity (+), swelling (+), hematoma (+), excoriated wound (+) at anterior aspect of knee which same level as patella

Palpation :Tenderness (+), Patellar Tapping(+), Ballotement sign (+)

ROM :Active and passive motions of knee joints is limited due to pain.

NVD :Sensibility is good, pulsation of dorsalis pedis artery is palpable, Capillary refill time < 2.

Left Leg Region Inspection :Deformity (+), swelling (+), hematoma (+)

Palpation :Tenderness (+)

ROM :Active and passive motions of knee joints are limited due to pain.Active and passive motions of ankle joints is good.

NVD :Sensibility is good, pulsation of dorsalis pedis artery is palpable, Capillary refill time < 2.

LEG LENGTH DISCREPANCY (LLD)RightLeft

ALL93 cm80 cm

TLL93 cm80 cm

LLD0 cm

CLINICAL PICTURE

Figure 1: Anterior view of left knee

Figure 2: Lateral view of left knee

Figure 3: Lateral view of left knee

LABORATORY FINDINGSTESTRESULT

WBC11.6 x 103 /uL

RBC5.29 x 106 /uL

HGB16.0 g/dL

HCT47 %

PLT215 x 103 /uL

HbsAgNegative

CT800

BT300

RADIOLOGICAL FINDINGS

Figure 4: Knee X-ray at AP and lateral aspect shows fracture of tibial plateau

Figure 5: Tibia and fibula X-ray at AP and lateral view shows fracture of tibial plateau

DIAGNOSIS Closed fracture of left tibia plateau Hemarthrosis left knee joint

MANAGEMENT IVFD Ringer Lactat Analgetic Antibiotic Apply long leg back slab at left lower limb Elevation of left lower limb Plan for ORIF

RESUME A male, 30 years old suffered from the knee pain since 2 day before admitted to the Wahidin Sudirohusodo Hospital due to accident. From physical finding there are swelling, deformity, hematoma, excoriated wound at anterior aspect of knee which same level as patella, tenderness, positive patellar tapping and Ballotement sign at the left knee joint, active and passive motions of the knee joints are limited due to pain and distal neurovascular within normal range. From physical finding there are swelling, deformity, hematoma and tenderness at the left leg region, active and passive motions of the knee joints are limited due to pain and distal neurovascular within normal range. From radiological findings at both knee and tibia x-rays, there is fracture at tibial plateau.