Syaridin Bin Amran / M / 39 YO

Open Segmental Fracture of The Left Femur Grade 3A

Alta Dislocation of Left Patella due to Rupture of Left Patellar Ligament
Close Fracture of Left Head Fibula
Multiple Vulnus Laceration
Crush Syndrome

Performed :
Debridement Emergency + OREF
(Saturday, April 27th 2024)
History
Chief Complain : Pain and difficult to move the left thigh
The patient came with complaints of pain in the left thigh accompanied by
injuries that occurred around 6 hours before admission to ED RSUDZA. The
complaint was experienced due to the patient's left thigh being crushed by the
excavator arm. According to the patient, his left thigh was stuck for 5 minutes.

History of loss of consciousness : (-)

History of past illness / treatment : (-)
History of food / drug allergy : (-)
 General State
• Primary Survey • Head
A: Clear
B: Spontaneous RR 20x/min, SatO2 • Eye : Pupil isochor equal 2mm/2mm, sclera normal,
98% on room air conjunctiva normal
C: TD 122/85mmHg HR 89 x/min, • Nose : normal
D: E4M6V5 (GCS 15) • Lips : normal
• Jaw : normal
• Ears : normal
• Neck : Lymph node normal, trachea in the middle
• Chest : Vesicular, rh -/-, wh -/-, heart sound
normal
• Abdomen : Symmetrical , soepel, tenderness (-), mass
(-), tympanic, shifting dullness (-),
peristaltic (+) normal
• Genitalia : Male, no abnormalities
• Extremity : By local state
• Skin : skin papulae/nodule (-)
L/S ar Left Thigh
L : deformity(+) angulation, swelling (+),
bruise(+), open wound (+),
F : Pain VAS 6-7, NVD within normal limit
M:
• AROM hip joint limited due to pain
• AROM knee joint limited

L/S ar Left Knee Joint

L : deformity(+) angulation, swelling (+),
bruise(+), open wound (+),
F : Pain VAS 4-5, NVD within normal limit
M:
• AROM knee joint limited due to pain
• AROM ankle joint in normal limit
Diagnosed:
• Open Segmental Fracture of The Left Femur Grade 3A
• Alta Dislocation of Left Patella due to Rupture of Left Patellar Ligament
• Close Fracture of Left Head Fibula
• Multiple Vulnus Laceratum
• Crush Syndrome

Post Debridement Emergency + OREF of Left Femur

Planning:
• Fluid therpy
• Inotropic therapy : Norepinefrin 2 cc / hour
• Antibiotic therapy
• Adequate analgetics
• Evaluation of serum CK, K+, lactic acid, AST, ALT, LDH, Ureum & Creatinine
THANK YOU