MORNING REPORT

Friday, July 13th 2018

dr. K. G. Mulyadi Ridia, Sp.OT (K)

TUS/PWP-APJ/STN/MLS/SNR/NCL
 Resume
• TOTAL PATIENT : 5 Patients
• ADMITTED : 4 Patients
• OPERATION : 3 Patient
• RSPTN : - Patient
 Ward
• TOTAL PATIENT : 29 Patients
• LOWER : 15 Patients
• SPINE : 4 Patients
• HAND : 5 Patients
• TUMOR : 3 Patients
• PEDIATRIC : 2 Patients
 I Ketut Darna / M / 42 y.o
T.arr 08.00 T.acc 17.00 (12/7/18) CM 18028719

• Conscious patient complain pain on his lower back since 15 hours prior to
admission
• Patient was climbing a clover tree 6 meters high then he slipped and fell
down in sitting position.
• History of unconciousness (-), nausea (-), vomitting (-)
• Patient was referred from Negara Hospital by Orthopedic Surgeon with
diagnosis Burst fracture CV L1

• Primary Survey
A : Clear
B : Spontaneous, RR 20x/min
C : BP: 130/85 mmHg PR: 98x/min
D : Alert
Secondary Survey
GCS : E4V5M6
Head : cephalhematome (-)
Neck : Tenderness (-), bruise (-), step off (-)
Eye : RP +/+ isocor, conjunctiva pale -/-
ENT : Otorrhea -/-, rhinorrhea -/-
Maxillofacial : Bruise (-), swelling (-), malocclusion (-)
Thorax :
Insp : Symmetric , bruise (-)
Palp : Tenderness (-), crepitation (-)
Perc : Sonor/sonor
Aus : S1S2 single reguler murmur (-)
Po: Ves +/+, rh -/-, wh -/-
Abdomen:
Insp : Bruise (-), distension (-)
Aus : BS (+)
Palp : defans (-)
Per : tymphani
Pelvis : Bruise (-), Tenderness (-), Stable Pelvis
Extremities : Warm
~ Local status
 L1

Lumbosacral Region
L : Swelling (+), bruise (-), deformity (-)
F : Midline tenderness (+) at L1-L2, step off (-)
Hipoaesthesia at Level L1

Motoric Evaluation Motoric Evaluation

Right Muscles Lef Right Muscles Lef
5 Shoulder Abd (C5) 5 4 Hip flexor (L2) 4
5 Elbow Flexor (C6) 5 4 Knee extensor (L3) 4
5 Elbow extensor (C7) 5 4 Ankle dorsoflexor (L4) 4
5 Finger flexor (C8) 5 4 Toe extensor (L5) 4
5 Finger abductor (T1) 5 4 Ankle Plantarflexor (S1) 4
Assessment
Susp Fracture Thoracolumbal

Imaging
Thoracolumbal X-Ray AP/Lateral View (Negara Hospital)
Lumbosacral X Ray AP/Lateral View
Negara Hospital (22/6/18)

LOH KA
L1 70% 22°
 Thoracolumbal CT-Scan
Sanglah Hospital (13/7/18)

L1

L2
Canal Encroachment 41%
 Thoracolumbal CT-Scan
Sanglah Hospital (13/7/18)
TLISS Score

• Total Score 6
Diagnosis:
Burst Fracture CV L1 Frankel D (S32.031)
Compresive Fracture CV L2 Frankle D (S32.032)

Treatment:
Pain Management
Gastroprotector
Neuroprotector
Log roll @2 hours
P/ Decompression - Stabilization - Fusion
 I Dewa Gede Kompiang/ M / 48 y.o
T.arr 13.00 T.acc 08.00 CM 15022678

• Conscious patient complained of pain on His Face, Lef knee and Lef leg afer got traffic
accident 5 hours prior to admission
• He was riding a motorcycle with high speed then sudden a minivan crossing on a crossroad,
he was too late to press a break then he crashed to the minivan with his lef knee and leg
bumped to the minivan
• Patient had a history of fracture Tibia Plateu in 2016 and undergo ORIF PS + Bone Graf
Procedure in Sanglah Hospital
• History of unconciousness (-), nausea (-), vomitting (-).
• Patient was referred from Bangli Hospital with OF Lef Distal Femur and CF Lef Tibia Middle
Third

Primary Survey
A: Clear
B: spontaneus, RR: 24x/min
C: stable, BP:130/80 mmHg, HR: 96 x/min
D: Alert
Secondary Survey
GCS : E4V5M6
Head : Cephalhematome (-)
Neck : Tenderness (-), bruise (-), step off (-)
Eye : RP +/+ isokor, conjunctiva pale -/-
ENT : Otorrhea -/-, rhinorrhea -/-
Maxillofacial : Bruise (-), swelling (+) around lef mandible, malocclusion (-)
Thorax :
Insp : Symmetric , bruise (-)
Palp : Tenderness (-), crepitation (-)
Perc : Sonor/sonor
Aus : S1S2 single reguler murmur (-)
Po: Ves +/+, rh -/-, wh -/-
Abdomen:
Insp : Bruise (-), distension (-)
Aus : BS (+)
Palp : defans (-)
Per : tymphani
Pelvis : Bruise (-), stable pelvis
Extremities : Warm
~ Local status
Left Thigh Region
L : Swelling (+) on the distal part, bruise (-), Open Wound size 4cm x 3cm, muscle exposed (+)
bone exposed (+)
F : Tenderness (+) over the distal part, a. dorsalis pedis (+), CRT < 2 “, sensation normal
M : Active ROM Genu limited due to pain
Active ROM Ankle 30/40
Active ROM MTP-IP 0/90
Left Knee Region
L : Open wound (+) size 4x3 cm, swelling (+), muscle exposed (+), bone exposed (+) at
anteromedial side , fat bubble (+)
F : Tenderness (+) over the knee, crepitation when splint applied , CRT < 2 “, a. dorsalis pedis (+)
palpable , Sat O2 98 %
M : Active ROM knee limited due to pain
Active ROM Ankle 30/40
Active ROM MTP-IP 0/90
Left Leg Region
L : Swelling (+) around middle third of leg, Scar (+) on the medial and lateral side of Proximal part,
deformity (-)
F : Tenderness (+) over middle third part of leg, tense (-), crepitation (+) when splint applied, false
movement (-), a.dorsalis pedis (+) palpable, CRT < 2”, SpO2 99%
M : Active ROM Knee (+) limited due to pain
Active ROM Ankle (+) 30/30
Active ROM MTP-IP (+) 0/90
• Assessment
OF Lef Distal Femur Grade II
dd/ OF Lef Supracondylar Femur
dd/ OF Lef Intercondylar Femur
CF Lef Tibia
Open Wound at Right Thigh Region

• Imaging
Head CT-Scan + 3D Reconstruction
Lef Thigh X-Ray AP/Lateral View
Lef Knee X-Ray AP/Lateral view
Lef Leg X-Ray AP/ Lateral View
3D Reconstruction
Lef Thigh X-Ray AP/Lateral View
Sanglah Hospital (13/7/18)
Lef Knee X-Ray AP/Lateral View
Sanglah Hospital (13/7/18)
Lef Leg X-Ray AP/ Lateral View
Sanglah Hospital (13/7/18)
Diagnosis:
Floating Knee Fraser IIB
OF Lef Intercondylar Femur Grade III A (AO 33.A1)
CF Lef Tibia Middle Third
Fr. Lef Mandible
Open Wound Medial Right Thigh

Treatment:
Ortho:
Analgetic, Antibiotic, Antitetanus
Debridement + Backslab
P/ ORIF PS ( Femur & Tibia)

Plastic:
P/ ORIF Miniplate (Elective)
Clinical Picture Post Debridement +
Immobilization Backslab
Condition This Morning
 Komang Suardana /M/ 42 yo
T.arr 15.00 T.acc 14.00 CM 18028832

• Conscious patient complain pain of his right index finger since 1 hour prior to
admission
• Patient was working with printing machine then his index finger pulled to the
machine.
• History of unconscious(-), vomiting(-), nausea(-)

• Primary survey
A: Clear
B: Spontaneous, RR 22x/minute
C: BP 120/80 mmHg, PR 92x/bpm
D: Alert
Secondary Survey
GCS : E4V5M6

Head : Cephalhematome (-)

Maxilofacial : Bruise(-), Floating maxilla (-)
Neck : Bruise (-), step off (-), tenderness (-)
Eye : RP +/+ isochor, anemia -/-
ENT : Otorrhea -/-, rhinorrhea -/-
Thorax :
Insp : Symmetric , bruise (-)
Palp : Tenderness (-), crepitation (-)
Perc : Sonor/sonor
Aus : Cor : S1S2 single reguler murmur (-)
Po: Ves +/+, rh -/-, wh -/-
Abdomen :
Insp : Bruise (-), distension (-),
Aus : BS (+)
Palp : defans (-)
Per : tymphanic
Pelvis : Bruise (-), stable pelvis
Extremities : Warm
~ Local status
Right Hand Region
L: Swelling (-), Bruise (-), disarticulated Index Finger level DIP, Ruptur FDP level Origo, degloving
wound at level proximal Phalanx, tendon exposed, amputee distal phalang with phalang distal
bone expose, FDP Exposed
F: Tenderness (+) on index finger
M: Active ROM MCP and PIP Index Finger 0/90
Active ROM MCP-IP 1st,3rd,4th,5th Finger 0/90
Assessment
Ring Avulsion Right Index Finger
Right FDP Tendon Rupture Index Finger
Open Disarticulated DIP Joint Right Index Finger
Degloving Wound Right Index Finger

Imaging
Right Hand AP/Oblique view ( Sanglah Hospital)
Right Hand X-Ray AP/Oblique View
Sanglah Hospital (13/7/18)
• Diagnosis
Ring Avulsion Right Index Finger
Right FDP Tendon Rupture Index Finger
Open Disarticulated DIP Joint Right Index Finger
Degloving Wound Right Index Finger

• Therapy
Ortho:
Antibiotic
Antitetanus
Analgetic
P/ Debridement + ORIF Pinning

Plastic Surgeon:
P/ Groin Flap
Clinical Picture Post OP
Condition This Morning
 Ni Made Mesiani/ F/ 29 y.o.
T.arr : 01.00 T.acc : 21.00 CM : 18028874

• Conscious patient complaint pain on his head and lef shoulder afer had an accident 4
hours prior to admission.
• He was riding a motorcycle then hit by another motorcycle from the right side,
mechanism of injury is unclear
• History of Unconsciousness (-), nausea (-), vomiting (-).

• Primary Survey :
A: Clear
B : Spontaneous, RR 21 x/min
C : BP : 110/80 mmHg, PR 80x/min
D : Alert
Secondary Survey :
GCS : E4V5M6
Head : Cephalhematom (+) right temporo-parietal, lef occipital
Maxillofacial : Swelling (-), floating maxilla (-), malocclusion (-),
Neck : Tenderness (-), bruise (-), step off (-)
Eye : RP +/+ isochore, periorbital echymosis -/-
ENT : Otorrhea -/-, rhinorrhea -/-
Thorax :
Insp : Symetric , swelling (-)
Palp : Tenderness (-)
Perc : Sonor/sonor
Aus : Cor : S1S2 single reguler murmur (-)
Po: Ves +/+, rh -/-, wh -/-
Abdomen :
Insp : Bruise (-) , distension (-),
Aus : BS (+)
Palp : defans muscular (-)
Per : tymphanic
Pelvis : Bruise (-), stable pelvis
Extremities : Warm
~ Local status
Right Leg Region
L : Swelling (+) at distal part, bruise (+) at the distal part, deformity (+) external rotation
F : Tenderness (+) at leg distal third, dorsalis pedis artery palpable,
CRT < 2”, SaO2 99%, sensation (+) normal
M : Active ROM Ankle limited due pain
Active ROM MTP-IP (+) 0/90
Right Foot Region
L : Open wound 4x3cm at the level MTP joint 2nd toe plantar side, flexion deformity at 2 toe,
bone exposed (+) at PIP 2nd toe, tendon and muscle exposed (+) at proximal phalang 2 nd
toe
F : Tenderness (+), a.dorsalis pedis (+), CRT < 2”, SaO2 97-99%, sensory normal
M: Active ROM MTP, DIP, PIP joint 2-5th limited due to pain
Assessment
Mild Head Injury (GCS E3V5M6)
CF Right Tibia
OF 2nd Middle Phalanx Right Foot

Imaging
Head CT-Scan ( Ganesha Hospital)
Right Leg X-Ray AP/ Lateral View ( Sanglah Hospital)
Right Foot X-Ray AP/ Oblique View ( Ganesha Hospital)
Head CT-Scan View
Ganesha (13/7/18)
Right Leg X-Ray AP/Lateral View
Sanglah Hospital (13/7/18)
Right Foot X-Ray AP/Lateral View
Sanglah Hospital (13/7/18)
Diagnosis
Mild Head Injury (GCS E3V5M6)(S06.0)
Brain Swelling
SDH Lef Temporoparietal
CF Right Tibia Fibula Middle Third
OF Right Head Middle Phalanx 2nd Toe

Treatment
Neurosurgeon :
Conservative
Observation

Orthopaedi :
P/ Debridement + ORIF Pinning (Foot) + ORIF PS (Tibia Fibula)  Not Approved
by Neurosurgeon
P/ Debridement + ORIF Pinning (Foot) + Closed Reduction under GA +
Immobilisation LLC (Tibia Fibula)  Not Approved by Neurosurgeon
WTHT + Closed Reduction + Buddy Tapping (Phalang) + Closed Reduction +
Immobilisation Long Leg Cast Immobilization (Tibia Fibula)
Right Leg X-Ray AP/ Lateral View Post
Immobilization Long Leg Cast

X Ray Preop

Angula AP Lateral
tion
Tibia 2.51° 6.83°
Fibula 1° 7.05°
Foot X Ray
Clinical Picture Post WTHT
Clinical Picture Post Immobilization LLC
Condition This Morniing
 I Komang Wirawan / M / 51 y.o
T.arr 05.00 T.acc 04.30 CM 18028878

• Conscious patient complained pain on his lef wrist afer involved in traffic accident
30 minutes prior to admission.
• He was riding a motorcycle then he hit a dog and lost his balance, patient fell to the
lef side and his hand bumped to the asphalt
• History of unconciousness (-), nausea (-), vomiting (-).

• Primary Survey
A: Clear
B: Spontaneus, RR: 20x/mnt
C: Stable Hemodynamic, BP: 110/70 mmHg, HR: 84x/mnt
D: Alert
Secondary Survey:
GCS E4V5M6
Head : Cephalhematome (-)
Eye : RP +/+ isochor, an -/-, periorbital echimosis (-),
ENT : Otore -/-, rhinore -/-
Thorax : Insp : Symmetric, bruise (-)
Palp : Tenderness can’t be evaluated
Perc : Sonor/sonor
Aus : Cor: S1S2 single reguler murmur (-)
Po: Ves +/+, rh -/-, whe -/-
Abdomen : Insp : Distension (-)
Aus : BS (+) N
Palp : Defans (-)
Per : Tympani
Pelvis : Bruise (-), Stable Pelvic
Extremities : Warm
~ Local status
Left Wrist Region
L : Swelling (+) over dorsal wrist joint, bruise (-), deformity (+) dorsal angulation
F : Tenderness (+) over the distal radius, crepitation (+) while splint applied, artery radialis (+)
palpable, CRT < 2”, normal sensation
M : Active ROM Wrist limited due to pain
Active ROM MCP-IP 0/90
Assessment:
CF Lef Distal Radius
dd/ CF Lef Radius Distal Third
CF Lef Distal Ulna

Radiology :
Lef Wrist X-Ray AP/Lateral View
Lef Wrist X-Ray AP/Lateral View

Radial Inclination : 0°
Radial Length : 1 mm
Volar Tilt : -16°
Diagnose
CF Lef Distal Radius Frykman VIII

Treatment :
Analgetic
Closed Reduction under GA + Immobilization with Long Arm Cast

Gambar Klasifikasi frykman

 Lef Wrist X-Ray AP/Lateral View
Post Closed Reduction Immobilization Short Arm Cast

Radial Inclination : 0°
Radial Length : 1 mm
Volar Tilt : -16°
Radial Inclination : 22°
Radial Length : 8 mm
Volar Tilt : 6°
 Clinical Picture
Post Closed Reduction Immobilization with LAC
THANK YOU