Case Presentation

MALE 59 YEARS OLD WITH CLOSED FRACTURE

1/3 DISTAL OF LEFT FEMUR

Arranged by:

Esti Rahmawati S G0007064

Tutor:

dr. Tangkas Sibarani, SpOT, FICS

Clinical Department of Orthopaedic & Traumatology Sebelas Maret University

Hospital of Dr. Moewardi/ Orthopaedic Hospital of Prof. Dr. Soeharso

Surakarta

2012

LEGALY SHEET

Case presentation entitled “Male 59 Years Old with Closed Fracture 1/3

Distal of Left Femur” is arranged to fulfill the requirement of clinical department of

Orthopaedic & Traumatology Sebelas Maret University Hospital of Dr.

Moewardi/Orthopaedic Hospital of Prof. Dr. Soeharso, by:

Esti Rahmawati S G0007064

Has been approved by the case presentation tutor of the Orthopaedic

Hospital of Prof. Dr. Soeharso on May, 2012.

Tutor

dr. Tangkas Sibarani, SpOT, FICS

CASE PRESENTATION

I. ANAMNESIS

1. IDENTITY

Name : Mr. S

Age : 59 years old

Sex : Male

Address : Bungur V RT ¾ Punggawan Banjarsari

Medical record : 00219868

2. CHIEF COMPLAIN

Pain in his left upper leg when used for walking

3. PRESENT ILLNESS

Less than 2 days before hospital admission, patient got a traffic accident.

Suddenly a motorcycle crushed him. He fell to the left side with his feet hit the

asphalt. He couldn’t move his left leg and felt pain for walking. Then he taken

to Sangkal Putung but did not improved. Than he was taken to the Orthopaedic

Hospital of Prof. Dr. Soeharso, in order to get more treatment.

4. PAST HISTORY

History of previous trauma : denied

History of heart disease : denied

History of drug allergy : denied

Asthma history : denied

II. PHYSICAL EXAMINATION

1. PRIMARY SURVEY

Airway : Free

Breathing : Spontan, Thoracoabdominal, RR : 18 x/mnt

Circulation and control haemoragik : T : 110/70 mmHg, HR : 88 x/mnt

Disability : GCS E4 V5 M6, Light refleks (+/+)

Exposure : look local status

2. SECONDARY SURVEY

General condition : concious

Head : mesocephal

Eyes : pupil isokor (3mm/3mm), light refleks (+/+), redness

conjungtiva (-/-), jaundice sklera (-/-)

Nose : saddle nose (-/-), rhinorhea (-/-), deformity (-/-)

Mouth : malocclusion (-), maxillary shake (-), tooth loss (-)

Ears : bloody otorhea (-/-)

Neck : JVP was not increased, thyroid enlargement (-), an

enlarged lmpyh node (-)

Thorax : normochest, symetris, retraction (-), lession (-)

Cor

Inspection : ictus cordis invisible

Palpation : ictus cordis not strong enaugh to lift

Percussion: no abnormality

Auscultation: normal intensity of heart sound, reguler, murmur (-)

Pulmo

Inspection : retraction (-/-), chest development right = left

Palpation : fremitus right = left

Percussion : sonor/sonor

Auscultation : vesikular (+/+), addition sound (-/-)

Abdomen

Inspection : abdominal wall // chest wall

Auscultation : intestinal sound (+) normal

Percussion : thympani

Palpation : supel, pain (-)

Extremity

Motoric: upper extremity (5/5), lower extremity (5/x)

Sensoric: upper extremity (+/+), lower extremity (+/+)

III. LOCAL STATUS

Left femur region :

Look : swelling (+), shortening (+), skin intact, hematom (-).

Feel : NVD (-), the temperature of the skin in left upper leg is warmer than

around and right upper leg, pain (+),

Motion : ROM of coxae articulation and genu articulation are limited because

of pain. ROM ankle (+) full

LLD : 2 cm

IV. ASSESSMENT I

Suspect closed fracture of left femur

V. PLANNING I

Family motivation

X-ray of left upper leg in AP and lateral position

X-ray of pelvis in AP position

VI. ADDITIONAL EXAMINATION

X-ray of left upper leg in AP and Lateral position:

The x-ray of male 59 years old, was taken in Orthopaedic Hospital of Prof. Dr.

Soeharso.

The x-ray worth to read. Can be differentiated between soft tissue and bone.

Normal contrast and sentration. Swelling (+).

There is fracture line in 1/3 distal left femur with transversal configuration.

X-ray of pelvis in AP position :

The x-ray of male 59 years old, was taken in Orthopaedic Hospital of Prof. Dr.

Soeharso.

The x-ray worth to read. Can be differentiated between soft tissue and bone.

Normal contrast and sentration. No edema. Within normal limit.

VII. ASSESSMENT II

Closed fracture 1/3 distal of left femur

VIII. PLANNING II

Analgetic injection

complete blood check

immobilitation (Skin traction)

hospitalized and pro ORIF

IX. ADDITIONAL EXAMINATION

Complete blood check

Hb : 13,8 g/dl

AE : 3,73 x 106/μl

Hct : 41 %

AL : 10,4 x 103/µl

AT : 169 x 103 /µl

Blood type: B

PT : 13,4 detik

APTT : 27,7 detik

HBsAg : (-)

GDS : 84 mg/ dL

INR : 1,09

SGOT : 14 U/L

SGPT : 16 U/L

Ureum : 33 mg/dl

Creatinin : 0,71 mg/dl

X. PROGNOSIS

Ad vitam : good

Ad sanam : good

Ad fungsionam: good