SHORT CASE

ORTHOPEDIC
TRAUMA

Rezky Syarifuddin
K1A1 14 106
 Name : Ms. WN
Age : 62 years old
Address : Tampo, Raha.
Occupation : Unemployment
Admission : January, 18th 2020
(10.20 pm)
Doctor in Charge : dr. Benny
Murtaza, M.Kes, Sp.OT

IDENTITY
 PRIMARY SURVEY
(at 09.00 pm)

A Clear, cervical spine control

B Respiratory rate 20x/m, spontaneous, symetris,

reguler, thoracoabdominal type

C Blood Pressure 170/100 mmHg

Pulse 84x/m, reguler, strong

D Glasgow Coma Scale (E4M6V5), pupil isochoric,

Light reflex +/+

E Temperature 36,6OC/axillary
 SECONDARY SURVEY
Chief complain: Pain in (at 09.10 pm)
the left Wrist
History taking:
Suffered since ± 24 hours before admitted
due to traffic accident.
Mechanism of trauma:
The patient wants to cross the road suddenly
hit by a motorcycle rider from behind and
then the patient falls.
History of Trauma:
 There was no history of unconsciousness.
 There was history of nausea and vomiting.
 There was no history of previous
medication.
 There was of previous treatment at the
Muna general hospital with a spalk for
immobilization, PPI, and antibiotic injection.

HISTORY TAKING
 SECONDARY SURVEY
(at 10.40 pm)
General
State
Moderate Illness, good nourish, composmentis.

Vital Sign
BP : 170/100 mmHg
HR : 84x/minutes, regular, strong
RR : 20x/minutes, spontaneous, symmetric, reguler
T : 36,6OC/axillar
VAS :5/10
 Head : Normally Neck : Norma
Face : Normally Chest :
Eyes : Normally Normally
Nose : Normally Abdomen :
Mouth : Normally
Normally Upper limb
Ears : Normally Localized state
Lower lim
Normally
Genitalia :
Normally

PRESENT
STATE
SECONDARY SURVEY
 Upper Limb
ight leg region
L
Inspection : Deformity (+), hematoma (-), OS
swelling (+), wound (-)
Palpation : Tenderness (+), crepitation CT
(+) AA
LT
• ROM : Active and passive movement ankle
joint limited due to pain
IE
• NVD : Sensibility was normally, ulnaris artery
Z
pulsation (+), Capillary refill time < 2 sec. E
 Clinical
Documentation
 PLAN OF DIAGNOSTIC

• Routine blood test (leukosit, HB, trombosit)

• Blood chemistry (GDS)
• X-ray Antebrachi sinistra AP/Lat
 LABORATORY FINDINGS

Parameter Result Normal Range

WBC 4.46 4.00-10.00 [10^3/uL]

HGB 12.7 12-16 g/dl

PLT 213 150-400 [10^3/uL]

Neut 35.2 32,0 – 75.0 %

Ct 2’30’’ ≤ 3 menit

Bt 7’30’’ 6-12 menit

LABORATORY FINDINGS

Parameter Result Normal Range

GDS 120 70-180 mg/dl

SGOT 18 L=< 45 U/L

P =<31
SGPT 20 L=< 41 U/L
P =<31
Ureum 31 19-44 mg/dl

Creatinin 0.4 0.7-1.2 mg/dl

RADIOLOGY FINDING

Xray Antebrachi Sinistra AP/Lat

 DIAGNOSE
Close Fracture Distal Os
Ulnaris Sinistra
DIFFERENTIAL DIAGNOSE

Neurovascular Injury
Muscle Contusio
Subluxation wrist joint
 MANAGEMENT
Non- Pharmacological
Pharmacological • IVFD
• Rest • Analgetic
• Immobilization injection
• Education • Antibiotic
(hygiene and injection
nutrition) • PPI
Consult : Ortopedic injection
Surgeon
THANK YOU