Morning report

Fracture os fibula 1/3 distal

grade III b et dislocation os tibia
sinistra

Erwin Syahputra
Anamnesis
Identity
Name : Ny. ER
age : 24 years old
Entry date : Agustus 16 2017
No. MR : 963262

Chief complaint
Ilness in the lower extremity post traffic accident 1 hours ago
 Primary Survey
Airway and Cervical Control
• Objective : patient can answer questions well,
there is no lesion on the neck and
supraclavikula
• Assessment : airway clear
• Action : give okxygen 10 L/minutes with NRM,
and give pulse oximetri
• Evaluasi : pulse oximetri 97%
Breathing and ventilation
• Objective : there is no lesion on the chest,
jugular venous distension (-), trachea
deviation (-), symetrical chest, breath sound
(+/+).
• Assesment : ventilation and lung
development is good
• Action : conttinue Oksigen dan evaluation
with pulse oximetri
• Evaluasi : pulse oximetri 97%
Circulation and hemorage control
 Objective :
HR 82 x/s
BP 132/85 mmHg
RR 20 x/s
CRT < 2 s
 Assessment : good circulation
 Action : give IVFD RL 20 tpm, cateter urine and
aplication of splint
 Evaluasi : urine inisial 200 cc
Disability and mini neurologi

 Objective : GCS 15
Pupil isokor diameter 2mm/2mm
direct and indirect light reflex (+/+)

 Assessment : good neurological mini

examination result
Exposure

•Objective : temperature 36,5 ̊C

•Assesment : good exposure
•Action : open the whole clothes and blanket the
patient
 Secondary Survey
Trauma mechanism
• 1 hours before admission patient got an trafic
accident motorcycle and car, patient fall from the
motorcycle with the left foot first, and the left foot
stuck in the sprocat. After the accident patient
aware and fell ill on the left foot. nausea (-),
fomited (-), breathles (-).
 AMPLE
Allergy : Allergy drugs (-)
Medication : patients are not taking any
drugs and alcohol.
Past illness : -
Last meal : 5 hours before falling
Event : there was a wound on the left leg
and lesion on the arms
Past illness history
Trauma history (-)

Family history (-)

 Physical examination
Generalized state
General appearance: Medium sickness
Consciousness : Composmentis cooperative
GCS : 15

Vital Sign
HR : 82 x/minutes
BP : 132/85 mmHg
T : 36,5˚C
RR : 20 x/minutes
 PHYSICAL EXAMINATION

head & neck : within normal limits

Toraks : within normal limits
Abdomen : within normal limits
Extremities : localized status
Localized state
 Localized state
extremities

•Look
there are deformity on the left foot and bone out of the soft
tissue
• Feel
pain (+), sensory (+), CRT < 2 s
• Move
the patient can not move the foot because she fell pain
Working diagnosis
• Dislocation os tibia sinistra and open fracture
1/3 distal os fibula sinistra
 Adjunct

• Routine blood test

• RO thoraks, RO extremities
Routine blood test (16-08-2017)

HGB : 14,8 g/dL

HCT : 46,9 %
WBC : 10.770/uL
PLT : 271.000/uL

PT : 15,2 sec
INR : 1,16
APTT : 26,1 sec
 RO thoraks

• RO thoraks with
normal limits
RO extremities

• There is a fracture of
the third of the distal
os of fibula sinistra
• There is a dislocation
in the os tibia sinistra
• Swelling (+)
Diagnosis
• Dislocation os tibia sinistra
• Open fracture 1/3 distal os fibula sinistra
grade III b
 assesment
• Non Farmakologi:
IVFD RL 20 tpm
Catheter urine
Splint
Cervical coller

• Farmakologi:
 Inj. Ceftriaxone 2x1 gr
 Inj. Ketolorac 3x30 mg
 Inj. ATS
 Operative :
ORIF
 Fracture is a discontinuitas of bone.

 Dislocation is a bone slips out of a joint.

Etiologi

 Trauma
 Osteoporois
 overuse
 Types of fractures

• closed fractures
• compound fractures
(open fractures)
• Comminuted fracture
 ORIF
 Is an open reduction internal fixation
(ORIF) refers to a surgical procedure
to fix a severe bone fracture, or
break.

This is a two-part surgery:

◦First, the broken bone is reduced or
put back into place.
◦Next, an internal fixation device is
placed on the bone to hold it together.
This can be done with screws, plates,
rods or pins
Thanks