Mr. D., 50 y.o.

Sp-01

CC : Instability at the right knee joint

Five years prior to hospital admission, he complained about instability at the right knee
joint when playing futsal. He fallen down with right leg sustain the body. He felt his leg twisting
and hear ‘pop’. He decided to come to Hasan sadikin hospital.

Physical examination
General condition :
Patient was fully alert
BP: 120/80 mmHg HR :88 x/minutes RR : 18 x/minutes Temperatur : 36,7 C

Local condition:
At the right knee joint:
Look : there was no swelling, there was no deformity, there was no scar, the skin colour and
texture was normal
Feel : There was no tenderness, distal sensibility was normal compare to the other side,
pulsation left dorsalis pedis, artery was normal, CRT < 2 seconds
Move : Range of motion of left knee joint
Active flexion : 0-1100

Active extension : 0-50

Passive flexion : 0-1100

Passive extension : 0-50

Anterior drawer sign :+

Posterior drawer sign :-
Posterior sag sign :-
Lachman test :+
Valgus test :-
Varus test :-
Patellar displacement test :-
Appley comprehension test :-
X-Ray examination
There was no bone discontinuity

MRI
Total rupture of ACL at right knee joint

Working diagnosis
Total rupture of ACL at right knee joint