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CLOSED FRACTURE 1/3 DISTAL TIBIA

DEKSTRA AND CLOSED FRACTURE

DISTAL FIBULA DEKSTRA

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PATIENT IDENTITY

Name : Ny. N

Age : 50 years old

Admission : 9th

March 2012 RM number : 539117

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HISTORY TAKING

Chief Complaint : Pain at lower limbdextra

History of illness : suffered since 2 hourbefore admitted to Wahidin hospital due to

traffic accident.History of unconscious (-), nausea (-),vomiting (-)Prior treatment at Pangkajene hospital

Mechanism of trauma:patient was a carried by motorcicycle then hitby another motorcicycle from right side.Patient fell and rolled

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PRIMARY SURVEY

A :Patent

B : RR = 18 x/min, simetris, spontaneous,

thoracoabdominal type.C : PR= 80x/min regular, strong.

D :GCS 15 (E4V5M6), pupil isochors

2,5mm/2,5 mm, light reflex +/+E :T = 36,7 0C (axillar)

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SECONDARY SURVEY

Regio cruris dextra

Inspection : Deformity (+), Swelling (+),

Hematoma (+), Wound (-)

Palpation : Tenderness (+)

ROM : Active and passive motion of the knee

and ankle joints are limited due to pain

NVD : Sensibilty is good, Dorsalis pedis artery

pulse is palpable, CRT < 2 second, extended

great toe (+)

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DIAGNOSTIC IMAGING

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RESUME

A 50 years old admitted to hospital with chief

complaint pain at lower limb dextra since 2

hour before admitted to hospital due to traffic

accident.

From physical examination, local status : at

left femur region, deformity (+), swelling (+),

hematom (+), tenderness (+), range of motionis limited due to pain

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DIAGNOSE

Closed fracture 1/3 distal tibia dextra + closed

fracture fibula dextra

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Management

IVFD RL

Analgesic

Open reduction and internal fixation

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FRACTURE TIBIA

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