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CHAPTER I

INTRODUCTION

1.1 Background
Neuro-Musculoskeletal system are the seventh block in the 3rd semester
competency-based curriculum in medical faculty of Muhammadiyah
Palembang University . Learning in this block is very important to learn in
medical faculty of Muhammadiyah Palembang University.
On this occasion, a case study tutorial of scenario A which presents
cases that related to the Neuro-Musculoskeletal .
Iwan, 20 years old, camoe to hospital with chief complaint of pain in his
right ankle since 2 hours ago. Complaints caused by right foot twisted in and
fell when playing futsal. Complaints accompanied by swelling and more pain
when moved. Iwan complaints he can’t walk because of pain on his ankle.
Physical examination:
General situation : compos mentis ; respiratory rate 22x/min ; pulse rate
102x/min ; blood pressure 130/80 mm Hg; temperature 37.0℃
Spesific examination:
Height : 160 cm , Weight: 57 kg
Head : conjungtiva anemis (-), icteric sclera (-)
Thorax : Cord an pulmo are normal
Abdomen : flat, hepar and lien not palpable
Upper extremity : normal
Lower Extremity:
- Left : normal
- Right : region ankle dextra :
Look :
- Asymmetrical, swollen on the lateral part
- Hematoma
- Open wound (-), active bleeding (-)

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Feel : Tenderness (+), crepitation (-) palpable tension on the lateral ankle
skin
Move : pain when the right ankle is moved nside.
ROM : ankle joint is limited
Pulsation of artery dorsalis pedis (+)
Supporting investigation :
Laboratory : Hb: 11,4 gr %, Leukocytes 9,000/mm3
Radiological Examination : Ankle dextra AP/Lateral: no visible fracture,
visible swelling of soft tissue in the lateral

1.2 Purpose
the purpose of this case study tutorial report are:
1. As a group task report which is a competency-based curriculum learning
system in the medical faculty of Muhammadiyah Palembang.
2. Can solve cases given in a scenario by group analysis and learning
methods
3. The purpose of the tutorial learning method is reached

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CHAPTER II
DISCUSSION

2.1 Data Tutorial


Tutor : dr. Ahmad Azhri, S.Ked., DAHK.
Moderator : Zadi Oktariansyah
Desk Secretary : Nabilah Apriliani
Bord Secretary : Nunung Mirawati
Monday, 13 November 2017
Time 8.00 – 10.30 a.m .
Wednesday , 15 November 2017
Time 8.00 – 10.30 a.m

The Rule of Tutorial : 1. Deactivate the phone or condition the phone in


silence.
2. Raise your hand when going to argument.
3. Get permission when going out of the room.
4. It is prohibited to bring food or eat in the room
during the discussion process is in progress.

2.2 Scenario
Iwan, 20 years old, camoe to hospital with chief complaint of pain in his
right ankle since 2 hours ago. Complaints caused by right foot twisted in and
fell when playing futsal. Complaints accompanied by swelling and more pain
when moved. Iwan complaints he can’t walk because of pain on his ankle.
Physical examination:
General situation : compos mentis ; respiratory rate 22x/min ; pulse rate
102x/min ; blood pressure 130/80 mm Hg; temperature 37.0℃
Spesific examination:
Height : 160 cm , Weight: 57 kg

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Head : conjungtiva anemis (-), icteric sclera (-)
Thorax : Cord an pulmo are normal
Abdomen : flat, hepar and lien not palpable
Upper extremity : normal
Lower Extremity:
- Left : normal
- Right : region ankle dextra :
Look :
- Asymmetrical, swollen on the lateral part
- Hematoma
- Open wound (-), active bleeding (-)
Feel : Tenderness (+), crepitation (-) palpable tension on the lateral ankle
skin
Move : pain when the right ankle is moved nside.
ROM : ankle joint is limited
Pulsation of artery dorsalis pedis (+)
Supporting investigation :
Laboratory : Hb: 11,4 gr %, Leukocytes 9,000/mm3
Radiological Examination : Ankle dextra AP/Lateral: no visible fracture,
visible swelling of soft tissue in the lateral

2.3 Terms of Clarfication


1.Pain : Is it the filling of being hurt that is caused by lunes or
injuries
2.Ankle : Articulation / joint that connects tarsus and lower leg
3.Hematome : Local clothing of blood in organ, space/ tissues
4.Palpable Tension : A feel of tension in muscle of lateral ankle
5.Asymmetrical : Having no balance or symmetry
6.Fracture : Solving a particular part of the bone

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7.Swelling : An abnormal enlargement of a part of the body
8.Tenderness : Very sensitive to touch or press
9.Crepitation : Is a sound when someone make a fraction from two
point of broken bone
10. ROM : Range of motion

(Dorland, 2009)

2.4 Problems Identification


1. Iwan, 20 years old, camoe to hospital with chief complaint of pain in his
right ankle since 2 hours ago.
2. Complaints caused by right foot twisted in and fell when playing futsal.
3. Complaints accompanied by swelling and more pain when moved. Iwan
complaints he can’t walk because of pain on his ankle.
4. Physical examination:
General situation : compos mentis ; respiratory rate 22x/min ; pulse rate
102x/min ; blood pressure 130/80 mm Hg; temperature 37.0℃
Spesific examination:
Height : 160 cm , Weight: 57 kg
Head : conjungtiva anemis (-), icteric sclera (-)
Thorax : Cord an pulmo are normal
Abdomen : flat, hepar and lien not palpable
Upper extremity : normal
Lower Extremity:
- Left : normal
- Right : region ankle dextra :
Look :
- Asymmetrical, swollen on the lateral part
- Hematoma
- Open wound (-), active bleeding (-)

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Feel : Tenderness (+), crepitation (-) palpable tension on the lateral
ankle skin
Move : pain when the right ankle is moved nside.
ROM : ankle joint is limited
Pulsation of artery dorsalis pedis (+)
5. Supporting investigation :
Laboratory : Hb: 11,4 gr %, Leukocytes 9,000/mm3
Radiological Examination : Ankle dextra AP/Lateral: no visible fracture,
visible swelling of soft tissue in the lateral

2.5 Problems Analysis


1. Iwan, 20 years old, came to hospital with chief complaint of pain in his
right ankle since 2 hours ago.
a. What is anatomy and fisiology of the extremity inferrior ?
Answer :
Ankle Bone Structure:
o Tibia
Tibia is the lower leg bone that is more medial than the fibula.
In the proximal portion, the tibia has a medial and lateral
condyle in which both are facies for articulation with the
friezing condyle. There are also facies to articulate with the
head of the fibula on the lateral side. In addition, the tibia has a
tuberosity for attachment of the ligaments. In the distal region
the tibia forms articulation with the tarsal bones and medial
malleolus (Snell, 2012).

o Fibula
The fibula is the lower leg bone that is located more laterally
than the tibia. In the proximal part, the fibula articulates with
the tibia. While in the distal, the fibula forms lateral malleolus
and facies for articulation with the tarsal bones (Snell, 2012).

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o Tarsal
The tarsal is the 7 bones that form the articulation with the
fibula and the tibia in the proximal and with the distal
metatarsal. There are 7 tarsal bones, namely calcaneus, talus,
cuboid, navicular, and cuneiform (1, 2, 3). Calcaneus acts as a
standing bone (Snell, 2012).

Gambar 2.1 Ankle and foot joint sebagai stabilisasi pasif


Sumber: Atlas anatomi (Atner, 2002)

 Foot Joints:
o Distal Tibio Fibular Joint
The distal tibio fibular joint is a syndesmosis joint with a small
motion freedom. Reinforced anterior and posterior tibiofibular
ligaments and membrane interroseum. Arthokinematic and
osteokinematic are shear motions in very small sagittal plots

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and angular motion in the frontal plane as opening and closing
forks (Kisner and Colby, 2012).

o Ankle Joint (Talo Crural Joint)/Rear Foot


Talocrural, or tibiotalar, functionally talocrural joint can be
considered as a synovial hinge joint, formed by the cruris (tibia
and fibula) and os. Talus, medial malleolus, and lateral
malleolus. Movements that occur dorsal flexion and plantar
flexion. Arthrokinematic and osteokinematiknya is the
movement of the neutral position consists of motion of the
sagittal field 28 ° - 30 °.
Plantar flexion or (ROM: 40-500) loose-packed position, dorsal
flexion (ROM: 20-300), close-packed position. Traction against
the talus always directed distally. Translations for dorsal
motion of flexion towards the posterior and plantar motion of
flexion towards the anterior. 1 ° transverse motion (internal
rotation) 9 ° and movement (external rotation), and 4 ° frontal
inversion and 2 ° movement of eversion (Kisner and Colby,
2012).

o Subtalar Joint (Talo Calcaneal Joint)/Rear Foot


Subtalar joint is a type of joint joint joint, formed by os. Talus
and Calcaneus. Arthrokinematic and osteokinematik is a
movement that occurs in the form of adduksi (valgus) and
abduction (varus), which ROM both are hard end feel. The
larger the position of the foot in plantar flexion, the greater the
slope should be. Reinforced by talocalcaneal ligaments.
Subtalar joint biomechanics are essential in ankle stability,
especially inversion and eversion movements in an effort to
keep the feet stable under the center of gravity (Kisner and
Colby, 2012)

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o Midtarsal joint (Mid foot) / Inter Tarsal Joint
Midtarsal joint (Mid foot) / Inter Tarsal Joint consists of (Barr,
2005):
a. Talo calcaneo navicular joint, has a complex joint basin,
including joint joint type of joint. Reinforced by a
plantar calcaneonavicular ligament.
b. Calcaneo cuboid joint, is a joint plan, along with
talonavicularis to form a transverse tarsal (mid tarsal
joint). Reinforced ligament spring, dorsal talo navicular
ligaments, bifurcatum ligaments, Calcaneo cuboid
ligaments, Plantar calcaneocuboid ligaments.
c. Cuneo navicular joint, navikular jointed with
cuneiforme I, II, III, shaped concave. Cuneiforms of
plantar sections are smaller, along with cuboids forming
a transverse arc. Main motion; plantar - dorsal flexion.
When plantar flexion occurs cuneiform sideways to
plantar.
d. Cuboideocuneonavicular joint, the main joint is
cuneiform II-cuboid in the form of a joint plan. The
most important motion is inversion and eversion. When
cuboid inversion translates to medial plantar to
cuneiform III.
e. Intercuneiforms joint, with navicular forming transverse
arc when inversions occur arc additions.
Arthrokinematiknya in the form of translational motion
between os. tarsal Joint.
f. Cuneiforms I-II-III jointed with metatarsal I-II-III,
cuboid jointed with IV-V metatarsal, Metatarsal II to
proximal so jointed also with Cuneiforms I-III, so that
the joint is most stable and its motion is very small.
Arthrokinematiknya traction motion Metatrsal to distal

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o Metatarso phalangeal dan Inter phalangeal Joint (Fore Foot)
a. Metatarso phalangeal Joint.
A convex-shaped metatarsal distal forms an ovoid-hinge
joint with motion: flexion-extension and abduction-
adduction. Maximally lose pack position (MLPP) =
Extension 110, close pack position (CPP) = full extension.
Motion motion in the direction of angular motion, traction
always direction distal direction axis longitudinal phalang.
Front legs function for mobility, especially for the process
of putting the feet while walking. At the time of running the
possibility of motion of flexion and extension, as well as on
the joints of the toes (interphalangeal) another.

b. Proximal and Distal Interphalangeal Joint


Proximal phalang caps are convex and the distal base of
concave-shaped phalanges form hinge joints. The
movement is flexion-extension. Maximally lose pack
position (MLPP) = Flex 100, close pack position (CPP) =
full extension Motion movement in the direction of angular
motion, traction always toward distal direction of axis
longitudinal axis phalang.

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Gambar 2.2 Persendian kaki kaki
Atlas Anatomi Manusia (Sobotta, 2010)

 Arcus of Feet
There are two arcus, Longitudinal Arc and Transverse Arc
(Bonnel et al., 2010):
o Longitudinal Arc: is the continuum of the calcaneus and the
metatarsal caput.
o Transverse Arc: proxikmal section restricted os. Cuboideum,
lateral cuneiforme, mid cuneiforme and medial cuneiforme are
more concave and distal to the more flat metatarsalia.
 Fascia
Ankle and foot is a fascia superficialis dorsum pedis located in
the distal portion of the retinaculum musculorum extensoren
inferius. This fascia forms a fascia cruris and extends distally into
the extensorisal aponeurosis of the fingers. In the proximal
portion attached to the retinaculum musculorum extensor superior
and forming the crossing with the retinaculum musculorum

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extensorum inferius can only be seen in slow dissection and the
lateral part of the proximal crus is often absent. Next to the
tendons of the musculus extensor digitorum longus which is a
dense, rigid, and rigidly attached layer of fascia dorsum pedal
fascia tissue (Kisner and Colby, 2012).

 Ankle Ligament Structure


Ligaments are elastic structures and as passive stabilizers in the
ankle and foot joint. Ligaments that often injure the ligament of
the lateral complex of the foot include: anterior talofibular
ligament which serves to resist movement toward the plantar
flexion, posterior talofibular ligament which serves to
withstand movement to the inverse, calcaneocuboideum
ligaments are functioning to resist movement towards the
plantar flexion, ligaments talocalcaneus which serves to resist
movement to inversion and calcaneofibular ligaments that
serve to resist movement to inversion to make the foot joints
locked to a certain extent so that the formation of stability in
the legs and cervical ligaments. There is also a plantar
cuneonavicular ligament, plantar cuboideonavicular ligament,
plantar intercuneiform ligament, plantar cuneocuboid ligament
and interrosea ligament of intermediate cuneocuboideum
ligament and interrosea intercuneiform ligament. In the
ligaments between tarsal and metatarsal there are dorsal
tarsometatarso ligaments, plantar tarsometatarso ligaments and
interrosea cuneometatarsal ligaments. Among the metatarsal
ossa there are metatarsal ligaments of dorsal and plantar
interrosea located on the metatarsal basis (Chook and Hegedus,
2013).

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Gambar 2.3 Sruktur ligamen sebagai stabilisasi pasif.
Sumber: Atlas anatomi (Sobotta, 2010)

 Muscle and Ankle and Foot Tendons


Muscles act as joint movers, also act as active components of
stabilizers that maintain joint and bone integrity during
movement. The tendon is the end of the inherent muscle there
is bone. its function is to connect various organs of the body
such as muscles with bones, bones with bones, also provide
protection against organs (2006). M. soleus and M.
gastrocnemius, its function is to plantar pedis flexion, this
muscle is in innervation by N. tibialis L4-L5. its function for
supination (adduction and inverse) and pedal flexion plantar.
The anterior M.tibialis and posterior M.tibialis, these muscles
are in the innervation by N. peroneus (fibularis) profundus L4-
L5, its function for dorsal flexion and supination (adduction
and inverse) pedis.

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M. peroneus longus and M. peroneus brevis, is the most
powerful pronator to prevent occurrence of lateral ankle sprain,
this muscle is innervated by N. peroneus (fibularis)
superficialis L5-S1. Its function is for pronation (abduction and
eversion) and pedicular flexion plantar, not only on the
ligaments, other tissues such as the tendon can be injured, the
tendons are often injured in the ankle sprain is the peroneus
longus and brevis tendons that function against the movement
of eversion in the foot (Farquhar, et al 2013).

Gambar 2.4 Struktur otot dan tendon ankle (atlas anatomi)


Sumber: Sobotta (2010)

b. What causes of pain ?


Answer :
1. Due to tissue stretching caused by edema that resulting in
increased local stresses that can cause pain.

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2. The expulsion of chemicals or mediators of pain such as
prostaglandins, bradykinin, which can stimulate peripheral
nerves around inflammation so that become pain.
(Hertel, 2002).

Synthesis :

Pain is a protective mechanism intended to raise awareness that


there has been or will be tissue damage. Unlike other
somatosensory modalities, pain is accompanied by motivated
behavior responses (eg withdrawal or defense) as well as emotional
reactions (eg crying or fear). Also unlike other sensations,
subjective perceptions of pain may be influenced by past or present
experiences.

There are three categories of pain receptors: mechanical


nociceptors that respond to mechanical damage, such as puncture,
impact, or pinching. Thermal nociceptors that respond to excessive
temperatures, especially heat, and polymodal nociceptors that
respond equally to all types of destructive stimuli, including
chemical irritants removed from the injured tissue. No nociceptors
have a special structure, they are all naked endings. Because of its
benefits for survival, nociceptor does not adapt to persistent or
repetitive stimuli. On the other hand, all nociceptors may be
sensitized by prostaglandins, which greatly increase the receptor
response to disturbing stimuli (feels more painful when there is
prostaglandin). Prostaglandins are a group of specific fatty acid
derivatives that act locally after removal
(Sherwood, 2014)

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c. How is the pathophysiology of pain ?
Answer :

Physcal trauma

Reduced oxygen caused damaged tissue

Release of histamine by mast


cells

Increased local capillary


permeability

plasma protein scome out of


the capillaries

Accumulation of plasma proteins

localized edema

Local stretching in edema tissue

pain

There’s a physical trauma that reduced oxygen caused damaged


tissue,so release of histamine by mast cells, then Increased local

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capillary permeability, plasma protein scome out of the capillaries,
accumulation of plasma proteins occur, there’s a localized edema,
then local stretching in edema tissue, and he fell pain in his ankle

(Sherwood, 2014).

d. What causes of pain in this case ?


Answer :
In this case pain is caused by injury on his right ankle, it causes the
tearing of the ligaments. ankle sprain is an injury to one or more
ligaments in the ankle, usually on the outside of the ankle.
Ligaments are bands of tissue—like rubber bands—that connect
one bone to another and bind the joints together. In the ankle joint,
ligaments provide stability by limiting side-to-side movement.
Sprained ankles often result from a fall, a sudden twist, or a blow
that forces the ankle joint out of its normal position. Ankle sprains
commonly occur while participating in sports.
(American College of Foot and Ankle Surgeons, 2005).

e. What kind of pain ?


Answer :
a. Classification of pain based by location (Sulistyo, 2013):
 Supervicial or cutaneous Pain
Supervicial is a pain caused by skin stimulus
characteristics of pain lasted briefly and localized. Pain
usually feels as a sharp sensation.
 Viceral Pain
Viceral is a pain that ocurs due to the stimulation of
internal organs
 Referred Pain

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Refered is amcommon phenomenon is a visceral pain
because many organs don’t have pain receptors.
Characteristics of pain can be felt in parts of the body
separate from the source of pain and can be felt with
various characteristics.
 Radiation
Radiation is widespread pain sense from the initial
place of injury to other parts of body.

b. Classification of Pain Based on Awitan (Tamsuri,2007):


Based on the time of the incident, the pain can be classified as
acute pain and chronic pain.
 Acute Pain
Acute pain is a pain that occurs within a time or
duration of 1 second to less than six months, whereas
chronic pain is pain that occurs in more than six
months. Acute pain may be viewed as limited and
useful pain to identify any injury or disease in the body.
Injuries or diseases that cause acute pain can heal
spontaneously or with treatment. For example, a
pricked finger usually heals quickly. In more severe
cases such as limb fractures, treatment is needed to
reduce pain as well as bone healing.
Patients in acute pain exhibit a measurable neurologic
response caused by sympathetic stimulation known as
autonomic hyperactivity. These changes include
tachycardia, tachypnea, increased peripheral blood
flow, increased blood pressure, and the release of
catecholamines. Local muscle strength may also occur,
in an involuntary attempt to keep the injured area
motionless.

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 Chronic Pain
Chronic pain is a continuous pain for 6 months or more.
This pain lasts beyond the estimated healing time and
often can not be attributed to specific causes or injuries.
Chronic pain is different from acute pain and shows
new problems. In chronic pain syndrome can be caused
by disease factors or pathologic processes are persistent.
But chronic pain is also the disease itself. The client
becomes anxious and frustrating. Chronic pain affects
all aspects of the client's life
Patients with chronic pain have no or less demonstrated
autonomic hyperactivity but exhibit symptoms of
irritability, loss of spirit, and impaired ability to
concentrate. This chronic pain often affects all aspects
of the life of the sufferer, causing distress, emotional
turmoil, and disrupting physical and social function .
Chronic pain generally arises irregularly, intermittently,
or even persistent. This pain causes mental and physical
fatigue.
Chronic pain is divided into two chronic non-malignant
and malignant pain. Non-malignant chronic pain is a
pain caused by a non-progressive or healing tissue
injury , may occur without obvious causes such as low
back pain, and pain based on chronic conditions, eg
osteoarthritis While malignant chronic pain called
cancer pain has an identifiable cause of pain that occurs
due to changes in the nerves, this change may occur due
to suppression of nerves due to metastasis of cancer
cells and the influence of chemicals produced by cancer
itself.

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Most cancer pain sufferers do not come from pain
experience. And some have psychological pain that
comes from the malignancy process. Anyway, a lot
experience pain in the late stages of the disease, and is
generally associated with metastasis. About 60 to 80%
of hospitalized cancer patients suffer from severe pain.

c. Pain Classification by Location (Tamsuri,2007):


 Superficial Pain
Superficial pain usually arises from skin stimulation
such as in lacerations, burns, and so on. The pain lasts
briefly, is localized, and has a sharp sensation.
 Somatic Pain
Somatic pain is a pain that occurs in the bone muscles
and other support structures, generally dull pain and
stimulated by stretching and ischemia.
 Viseral Pain
Viseral pain is a pain caused by damage to internal
organs.
 Painful Spread
Painful spread (radiation) is a sensation of pain that
extends from the sensation of origin to the surrounding
tissue. Pain can be intermittent or constant.
 Pain Fantom
Pain fantom is a special pain felt by clients who have
amputations.
 Reaction Pain
Reaction pains are pain caused by visceral pain that
radiates to other organs, so that pain is felt in some
places and locations.

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d. Classification of Organ Based Pain (Tamsuri,2007):
 Organic Pain
Organic pain is pain caused by damage (actual or
potential) organ.
 Neurogenic Pain
Neurogenic pain is pain due to neuronal disorders, eg in
neuralgia and may occur acutely or chronically.
 Psychogenic Pain
Psychogenic pain is pain due to various psychological
factors, usually occurs when psychogenic effects such
as anxiety and acute arise in the patient.
e. Classification Pain Based on Nature (Gillenwater et al, 1996):
 Incidental is a pain that arises at any time and
disappears. This incident occurred in patients suffering
from bone cancer.
 A steady pain is a pain that arises and persists and is felt
for a long time. In acute kidney distention the capsule
and ischemic is one of the most common types of pain.
The constant level of pain in obstruction and distension.
 Proximal pain is a pain that is felt high intensity and
strong. The pain usually lasts ± 10-15 minutes, then
disappears, then reappears. This pain occurs in patients
with Carpal Tunnel Syndrome.

f. Classification of Pain Based on Light Weight (IASP, 1979):


 Mild Pain
Mild pain is an environment that arises with its intensity
mild In mild situations usually patients can objectively
communicate well.
 Medium Pain

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Pain was moderately ill with intensity medium. While
the patient is being objectively hissing, grinning, can
indicate where the illness can be describe it, can follow
the command.
 Pain Weight
Severe pain is a pain that arises with that intensity
weight. On the patient's painful objective pain
sometimes unable to follow orders but still response to
action, may indicate the location of pain, can not
describe it, can not be overcome with over long breath
position.

f. What is the meaning of chief complaint of pain in his right ankle since
2 hours ago ?
Answer :
The meaning he complaint of pain in his right ankle since 2 hour
ago is Iwan was twisted when playing futsal. Twisted motion can
cause injury to the ligaments. A ligament is soft tissue which
connects bone to bone Palpable pain should raise suspicion of an
asteocondraltalar dome lesion. The lesion result from direct trauma
between the talus and fibula (anteriolatreral lesion) or between the
posteromedial talus and tibia (postmedial lesion). Trauma causes of
occurrence of tissuedamage. Tissue demage lead to an
inflammatory response which is an adaptive response of the body
to eliminate damage tissues.Inflammation can be acute or chronic,
acute inflammation is rapid in onset and of short duration lasting
from a few minutes to as long a few days. While the cronic
inflammation may be more insidiousis of longer duration (days to
years). So pain happen because inflammation mediator cause by
injury.
(Robbins, 2015)

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g. What is the relation between age and gender in this case ?
Answer :
There’s nothing relation between age and gander because
complaints caused by trauma and can occur in male or female at
any age. There’s the relation between activity and complaint is in
every physical activity, aspecially sport activity can cause injuring
one of part of body which usually injury is on joint of ankle. Injury
at the ankle are usually caused by movement to the outher (lateral)
or the innes (medial) side of the sudden ligament. When the
ligamentum muscle fibers for eversoon are not strong enough to
resist, the ligamentum fibers from lateral will depressed and
become inverse. It will causes sprain on the outher side. Sprained
ankles often result from a fall, a sudden twist cor a blow that forces
the ankle joint one of its normal position.
Ankle sprains commonly occur while participating in sports
wearing inappropriate shoes, or walking or running or anunever
surface.
Sometimes ankle sprain occur because of weak ankles, a condition
that some people are born with.
Previous ankles or foot injuries can also weaker the ankle and lead
to sprains.
The sign and symtoms of ankle sprain may include
1) Paint or soreness
2) Swelling
3) Bruising
4) Difficulty walking
5) Stiffness in the joint

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2. Complaints caused by right foot twisted in and fell when playing
futsal.
a. What is the meaning complaints caused by right foot twisted in and
fell when playing futsal ?
Answer :
that means was the ankle got ligament injury caused by blunt
trauma.

b. What kind of trauma ?


Answer :
Traumatic classification based on trauma trauma and traits:
1. Mechanical trauma
a. Blunt trauma, due to injury:
 Bruises → discontinuity of blood vessels and tissues
under the skin without damage to skin tissue.
 Standing prominent → blood collection in the blood
vessel network is damaged.
 The shape of the wound → resembles a related object.
 Bruise → occurs in the epidermis - friction with a
rough surface.
 Blisters press: the direction of violence perpendicular
to the surface of the body, the depressed epidermis
burrows inward.
 Scratch sliding → the direction of hardness tilted
angle, epidermis pushed and collected at the end of
motion of the object.
 Strain abrasions → epidermal discontinuities due to
stretching which is in accordance with the skin line.
 Tear wounds → occur in the underlying tissue
epidermis due to the violence that extends beyond the
skin tissue elasticity.

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b. Sharp trauma, due to injury:
 Iris ulcers → inside the wound is smaller than the
length of the cut wound.
 Stab wound → inside the wound is larger or deeper
than the length of the wound.
 Cut wound → in the wound is more or less the same
as the length of the wound.

c. Firearms
 The skin around the wound is burning or black from
smoke.
 Hair around scorched wounds.
 Clothes that cover burnt wounds.
 Black and tattoo tattoos more outside the wound.

2. Physical trauma
a. Hot temperature (burns)
 Eritem with the characteristics of intact epidermis,
restlessness, heal without leaving sikatriks.
 Vesicles, bulls and bleps with high albumin or NaCl.
 Coagulativa necrosis characterized by dark brown
black color and healed by leaving sikatriks (litteken).
 Carbonization (already becoming charcoal).
b. Cold trauma (hypothermia and frostbite
Hypothermia)
Pale skin due to red vasoconstriction due to
vasodilation due to paralysis of the vasomotor center.

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 Skin turns into a blackish red, swollen (skin blister),
itching and pain. Then arise irreversible superficial
gangrene.

3. Chemical trauma
a. Strong acids → coagulate protein → dry corrosive
wounds,paper like permanent paper.
b. Strong base → forming sapling reaction → wet, slippery
cuts → damage to the inside.
(Bengmark S. 1998 )

Synthesis :
1. Vulnus Laceratum
This type of wound is caused by a collision with a blunt object,
with uneven cuts and wound hemorrhage and increased
risk of infection.
2. Vulnus Excoriation
The cause of injuries due to accidents or falls that cause blisters
on the surface of the skin is an open wound but affected only
the coolies.
3. Vulnus Punctum
The cause is a sharp pointed object or something into the skin, an
open wound from the outside looks small but inside may be
severely damaged, if the abdomen / thorax is called vulnus
penetrosum (penetrating wound).
4. Vulnus Contussum
Cause: hard object collision. This wound is a closed wound, as
a result of damage to the soft tissue and rupture of blood
vessels causing pain and bleeding (hematoma) when small it
will be absorbed by the surrounding tissue if the organ in the
collision can cause serious consequences.

26
5. Vulnus Scissum / Insivum
The cause of this type of wound is a sharp incision or needle is
an open wound resulting from therapy for invasive action,
sharp cut edges and slippery.
6. Vulnus Schlopetorum
The cause is a shot, a grenade. On the edge of the wound looks
blackish, can be irregular sometimes found corpus alienum.
7. Vulnus Morsum
The cause is an animal or human bite, the likelihood of a large
infection of a wound form depends on the shape of the tooth.
8. Vulnus Perforatum
This type of wound is a penetrating wound or a broken wound.
Causes due to arrows, spears or infectious processes that extend
beyond the serous membranes / epithelial tissue organs.
9. Vulnus Amputatum
Cut wounds, beheaded with the cause of large / heavy sharp
objects, saws. The wound forms a circle according to the cut
organ. Bleeding is great, the risk of infection is high, there are
symptoms of limb pathom.
10. Vulnus Combustion
Causes due to thermis, radiation, electrical or chemical Skin
tissue damaged by various degrees ranging from blisters (bull -
carbonization / burn). Pain and / or anesthesia.
(Hendriati, 2010).

c. What is the trauma in this case ?


Answer :
Trauma in this case is mechanical trauma

27
3. Complaints accompanied by swelling and more pain when moved.
Iwan complaints he can’t walk because of pain on his ankle.
a. What is cause of swell ?
Answer :
Swell is cause by increased capillary ermeability, increased blood
and fluid flow yo the injury tissue so that plasma proteins can get
out of the blood vessels into the interstitial space .
(corwid 2008)

b. How is pathophysiology of swellow ?


Answer :
Physical activity → ankle movement and pressure turns suddenly
→ foot are not support perfectly → many bone stabilizer on the
lateral side so it makes the pressure of foot be inverted → foot in
inversion position → ligamentous for eversion are not strong
enough to retain the inversion forces → structure of ligaments are
stretch beyond its normal → rupture of lateral complex ligaments
→ inflammatory process → vasodilatation of blood vessel in the
aite of injury → permeability of vascular increased → many blood
fluids send to the site of injury → blood plasma seeps out from
capillary to interstitial space → swelling (Sumartiningsih, 2012).

c. What is the relation between complaints accompanied by swelling and


more pain when moved?
Answer :
Sprain is an injury that occurs in the joint, with the occurrence
stretching or tearing on the ligament, this happens because sudden
excessive stress, or excessive use on the joints that wrap the
adjacent bones as in the rotating motion. Sprain can cause it to
happen dislocation is a state of joint shift so that occurs deviation
between the two bones forming joints. As a result joint stability

28
may be impaired on ligament damage weight. When the ankle joint
sprained, it will be followed by inflammation process around the
ankle. Light sprays are usually accompanied by partial hematomas
ligament fibers break, while in sprain is effusion fluid that causes
swelling and on the entire weight sprain broken ligament fibers so
they can not be moved usually with severe pain, swelling and
bleeding in the joints (Ulfah, M., 2013).

4. Physical examination:
General situation : compos mentis ; respiratory rate 22x/min ; pulse
rate 102x/min ; blood pressure 130/80 mm Hg; temperature 37.0℃
Spesific examination:
Height : 160 cm , Weight: 57 kg
Head : conjungtiva anemis (-), icteric sclera (-)
Thorax : Cord an pulmo are normal
Abdomen : flat, hepar and lien not palpable
Upper extremity : normal
Lower Extremity:
- Left : normal
- Right : region ankle dextra :
Look :
- Asymmetrical, swollen on the lateral part
- Hematoma
- Open wound (-), active bleeding (-)
Feel : Tenderness (+), crepitation (-) palpable tension on the
lateral ankle skin
Move : pain when the right ankle is moved nside.
ROM : ankle joint is limited
Pulsation of artery dorsalis pedis (+)

29
a. What is the interpretation of the physical examination?
Answer :

Interpretation

General Situation Pulse Rate : 102 x/min Takikardi


Specific Circumtances: Look: Abnormal
Right Lower Extremity -Assymetrical, swollen
on the lateral part
-Hematoma

Feel: Tenderness (+), Abnormal


palpable tension of the
lateral ankle skin
(Backley, 2006).

b. How the abnormal phatophysiology of the physical examination?


Answer :
 Pain when moved, ROM limited
Exercise → Blunt Trauma → Plantar invertion → Ligament
over stretching → Torn ligament → Pain → Imobilization →
Decreased of muscle strength → ROM limited → difficult to
walk (Calatayud, et al., 2014).

 Assymetris, Swelling on the lateral part:

Exercise → Blunt Trauma → Plantar invertion → Ligament


over stretching → Blood capiler disconnected →
Acummulation of plasma in insterstitial → Swelling →
Assymetris (Calatayud, et al., 2014).

 Takikardi, Hematoma:

30
Exercise → Blunt Trauma → Plantar invertion → Ligament
over stretching → Blood capiler disconnected → Hematoma
→ Decreased of Hb → Vasokontriction → Takikardi
(Calatayud, et al., 2014)

5. Supporting investigation :
Laboratory : Hb: 11,4 gr %, Leukocytes 9,000/mm3
Radiological Examination : Ankle dextra AP/Lateral: no visible
fracture, visible swelling of soft tissue in the lateral
a. What is the interpretation of supporting investigation?
Answer :
interpretation of laboratory examination.

Physical
HB Leukosit
Laboratory
11,4 mg/dl 9.000/mm3
14,0 – 18,0 5000 -
Normal
mg/dl 10.000/mm3
interpretation Abnormal normal

interpretation of radiology examination.


I
Radiological Examination Interpretation
n
nAnkle dextra AP/Lateral: Abnormal
Visible swelling of soft tissue in
the lateral
(
(Backley, 2006).

31
b. How the abnormal phatophysiology of the supporting investiation?
Answer :
Exercise → Blunt Trauma → Plantar invertion → Ligament over
stretching → Blood capiler disconnected → Hematoma →
Decreased of Hb (Calatayud, 2014).

6. How to diagnose ?
Answer :
 Anamnesis
Pain in his right ankle since 2 hours ago. Complaints caused by
right foot twisted in and fell when playing futsal. Complaints
accompanied by swelling and more pain when moved. Iwan
complains he can’t walk because of pain on his anckle.
 Physical examination :
General Situation : puls rate 102x/minute blood pressure
130/80 mmHg,
Spesific examination:
Lower extremity : Right : Regio ankle dextra :
Look :
- Asymmetrical, swollen on the lateral part
- Hematoma
Feel : Tendernees (+) , creptitation (-), Palpable tension on the
lateral ankle skin
Move : Pain when the right ankle is moved inside
ROM : ankle joint is limited
Laboratory : Hb : 11,4 gr%
Radiological examination : Ankle dextra AP/ Lateral : Visible
swelling of soft tissue in the lateral.

32
7. What is the differential dignose ?
Answer :

The Name Of The


Explanation
Differential Diagnosis

pain, swelling, bruising, limited ROM


Sprain
(Range of Motion)
pain, swelling, muscle spasms, limited
Strain
ROM (Range of Motion)
bruising, swelling, deformity, bone
Fracture in the maleolus
pain
the inability of the muscles to move,
Achilles Tendon Rupture
tenderness, swelling, bruising
(Backley, 2006).

8. What is supporting examination ?


Answer :
Plain Radiographic Imaging
The use of radiographs in patients with ankle injuries is guided by
the Ottawa Ankle Rules. These rules state that an ankle
radiographic series is required only if the patient has pain in the
malleolar zone and any of the following 3
 Bone tenderness at the posterior edge or tip of the lateral
malleolus (ie, the lower 6 cm of the fibula)
 Bone tenderness at the posterior edge or tip of the medial
malleolus (ie, the lower 6 cm of the tibia)
 Inability to bear weight immediately after the injury and in the
emergency department

33
The Ottawa Ankle Rules state that a foot radiographic series is
required only if the patient has any pain in the midfoot zone and
any of the following 3 findings:
 Bone tenderness at the base of the fifth metatarsal
 Bone tenderness at the navicular bone
 Inability to bear weight immediately after the injury and in the
emergency department

The Ottawa Ankle Rules are contingent upon the patient presenting
within 10 days of the injury. Although they were not originally
intended for patients younger than age 18 years, a meta-analysis of
12 studies showed that the Ottawa foot and ankle rules can be
reliably used to exclude fractures in children older than age 5
years. The studies included a total of 3,130 patients and identified
671 fractures, resulting in a prevalence of 21.4%. Demonstrating a
pooled sensitivity of 98.5% and a missed fracture rate of 1.2%, the
report indicated that the Ottawa foot and ankle rules are useful
(level 2 evidence) for excluding fractures in children. Another
study suggests they may be useful for children as young as 2 years.
Radiographic studies of the ankle should include the following
views:
 An anteroposterior (AP) film with the ankle in 5-15° of
adduction
 A true lateral film
 A 45° oblique film with the ankle in dorsiflexion (ie, Mortise
view)

Stress-View Radiographic Imaging


Stress radiographic films may provide further assessment for ankle
stability; however, patient cooperation may be limited, depending
on the severity of the injury. Stress-view exams include the talar

34
tilt and anterior drawer tests. Because of muscular guarding due to
patient pain, the accuracy of these tests is dramatically increased
with the use of local anesthesia. Compare the stress views with
those of the uninvolved ankle in both tests. Other variables in
determining the reliability of these tests include the degree of
patient relaxation and cooperation, the amount of force used, the
angle of ankle flexion, and the amount of laxity in the uninvolved
side. (See Clinical Presentation.)
Computed Tomography Scanning
Computed tomography (CT) scanning may be indicated if imaging
of soft tissues is warranted or if bone imaging beyond radiography
is indicated. CT scanning is useful for evaluating osteochondritis
dissecans and stress fractures. In complex injuries, 3-dimensional
CT scanning may be useful.
MRI
MRI may be a useful evaluation when a syndesmotic or high ankle
sprain is suspected or if osteochondrosis or meniscoid injury is
suspected in patients with a history of recurrent ankle sprains and
chronic pain. However, caution must be used when evaluating the
findings on MRI since a study of asymptomatic patients revealed
that approximately 30% had findings consistent with abnormal
anterior talofibular ligaments and peroneal muscles.
Arthrographic Imaging
Ankle arthrograms may be useful for determining capsular damage
and the number of ankle ligaments damaged; however,
arthrography is indicated only if surgery is needed, and the criteria
for surgery to repair double lateral ligament complete tears are still
under debate. Staples found that arthrograms provide the most
preoperative information.
Ankle arthrograms are not indicated in every patient considered for
surgical treatment. Marked clinical instability in a young individual

35
with great physical demands being considered for surgery requires
an ankle arthrogram.

Bone Scanning
A bone scan can detect subtle bone abnormalities (e.g., stress
fracture, osteochondral defects). A bone scan can also detect
syndesmotic disruption.
(Young, 2017)

9. What is working diagnose ?


Answer :
Working diagnose of this case is ankle sprain.
Ankle sprain is an injury to one or more ligaments in the ankle,
usually on the outside of the ankle. Ligaments are bands of
tissue—like rubber bands—that connect one bone to another and
bind the joints together. In the ankle joint, ligaments provide
stability by limiting side-to-side movement .
(American College of Foot and Ankle Surgeons, 2005).

10. What is governance ?


Answer :
1. Using PRICE methods, (protection, rest, ice, compression and
elavation)
 Protection, In Conditions where’s the patient should keep the
moderate feet from the disorder can exacerbate the injury.
 Rest, In Condition,s do not perform any activity or reduce the
activity of the injured foot.
 Ice, ice use on the injured foot to reduce swelling, it is given
for 15 - 20 minutes every 2 hours for 2 days or until swelling is
reduced.

36
 Compression, build a useful compress to stop excessive blood
flow at the time.
 Elevation, conditions where the area must be higher than the
heart. This serves to reduce blood flow in the area of the
injured and also to reduce the swelling.

2. In pharmacological therapy, can be given acetominophen (ibu


profen with a dose of 200-800 mg or use Aspirin 500-1000 mg).
and then to reduce the pain can be given NSAID ( mefenamat
acid ).

3. Rehabilitation:
 Avoid exercises that cause pain or swelling
 Rotate the ankle for 10-15 times for 2-3 times a day
 The Achilles tendon is stretched at a 30-second level at each
foot position (fingers) inward, fingers outward, straight ahead,
doing for 3-4 times a day
 Lifting the toes for 10 times, 1-3 sets, for 3-4 times a day
 weight / body support between edera and can not stand on the
ankle, this movement can be done for 20 minutes until severely
free from illness. The activity is carried out for 2-3 times a day
 Work on stretching by proprioceptive neurofacilitator (PNF) at
the ankle with the help of spouse / other person for 2-3 times a
day
 Followed by a forward motion going forward with a short step.
(priyoniadi, Bambang 2005.)

4. Conservative Therapy
Physical therapy during the recovery phase is aimed at the patient
regaining full range of motion, strength, and proprioceptive
abilities, and may include the following :

37
 Strengthening exercises : starts with isometric exercises, then
adnvances to use of elastic bands or surgical tubing
 Proprioception rehabilitation : starts with single-leg-stance
exercise in a single plane, then progresses to multiplanar
exercises
 Other exercises : uses a balance or tilt board, then advances
to functional drills, jogging, sprinting, and cutting, and then
progresses to figure-of-eight and carioca drills

5. Surgery
In most patients, there is no improved outcome with operative
repair of third-degree anterior talofibular ligament tears and
medial ankle ligament tears.
(Young, 2017).

11. What is complication ?


Answer :
Complications associated with ligament reconstruction include
wound healing problems, infection, sural nerve injury and failure
of ligament healing.
(American Orthopaedic Foot and Ankle Society, 2012).

12. What is prognose ?


Answer :
Quo Ad Vitam : Bonam
Quo Ad Functionam : Dubia ad bonam
Quo Ad Sanationam : Bonam

Synthesis :
Prognosis lateral ligament reconstruction. Very good functional
results have been reported in approximately 90% of patients

38
undergoing Brostrom/Gould ligament reconstruction, with
radiographic evidence of less residual laxity. The results are less
satisfactory in patients who have generalized hypermobility of the
joints or long-standing ligamentous insufficiency (>10 years), as
well as in those who have undergone previous ankle joint ligament
surgery. Anatomic repair using the original ligament is technically
simple, giving rise to few complications, and producing short- and
long-term satisfactory functional results.
(Maffulli dan Longo. 2010).

13. What is KDU ?


Answer :
3A. Not an emergency
Doctor graduates are able to make clinical diagnoses and
provide preliminary therapy in non-emergency settings. Doctor
graduates are able to determine the most appropriate referral for the
next patient's treatment. Doctor graduates are also able to follow up
after returning from referrals (KKI, 2012).

14. What is NNI ?


Answer :

Whatever it be wherein ye differ, the decision thereof is with


Allah. such is Allah my Lord: In Him I trust, and to Him I turn.
(QS: As- Syurah : 30)

39
“what comes to you of good is from God, but what comes to you of
evil, is from yourself” (An-Nisa: 79)

From Abu sa’iddan, Abu Hurayrah, They heard the RassulAllah


S.A.W says : “ No believer is struck by a calmamity of pain, wich
is not healed, tired, painful and anxieties are overthrown but his
sins are forgiven” (HR Muslim: 2573)

Content :
From the hadith can be taken the lesson that every disaster is a
reeporoach from Allah SWT for the sins we have committed and
calamity to introspection our self for be better, to be
rahmatanlilalamin.

2.6 Conclution
Iwan, 20 years old, complaint of pain in his right ankle and
accompanied by swelling and more pain when moved because of sprain at
causa exercise.

40
2.7 Scema of Synthesis

Exercise

Mechanic trauma

Injury on ligament of his


right ankle

Right ankle sprain

Pain Swelling Hematoma

41
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