patta indral fraktur femur

7/30/2019 Patta Indral Fraktur Femur

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Name : P

Age : 20 years old/ male

Admission : April 20th, 2011

Registration : 46 45 45 (18: 28)

Status : UMUM


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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


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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)


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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 (+)


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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


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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


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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


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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


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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


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Radiologic Findings


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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


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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


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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


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patta indral fraktur femur

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