OPEN FRACTURE PHALANX DISTAL DIGITI IV MANUS DEXTRA WITH OPEN FRACTURE

PHALANX MEDIAL DIGITI II MANUS SINISTRA.

Mail, 36 years old

Job: Labor factory

B. ANNAMESIS

Main complaints: Open wound on the right hand on the fourth finger and finger to V
interrupted accompanied by open wound on the left hand on the second finger.

Current Illness History:

Patients present with open wound in the right hand on the fourth finger and finger
to V interrupted accompanied by open wound in left hand on second finger. Patients
say open sores on the hands are caused by work accidents. This has been
experienced since this morning. The wound was painful and began to be difficult to
move.

medical history :

- Patient has never had a serious accident.

- The patient denies ever suffering from Diabetes Mellitus and previous
Hypertension

- Patient has never undergone certain surgery

- Patients deny having a history of drug and certain food allergies

- The patient denies ever taking any particular medications

Family Disease History: Hypertension and diabetes mellitus is denied.

PHYSICAL EXAMINATION

impression: moderate

General situation: weak

Nutrition: good

Awareness: Compos Mentis

Vital signs:

- Temperature: 36.6 oC

- Blood pressure: 130/70 mmHg

- heart rate: 86 times / minute

- Respiratory : 24 times / minute

Localized Status:

1. Regio manus dextra and sinistra

Look: Open fracture phalanx distal digiti IV manus dextra with open fracture phalanx
medial digiti II manus sinistra.

Feel: Digiti IV pain, V manus dextra (+), tenderness digiti II manus sinistra (+), capp
refill (<2 '),

Move: Limitations of movement of flexion and extension on digiti IV, V manus dextra
and digiti II manus sinistra.

Investigation

18 april 2017
- Hb : 12,0 ( N : 14-18 gr/dl)
- Leukosit : 13.600 ( N : 4500 10.700/ul)
- Eritrosit : 4,57 ( N: 4,5-6,0 juta/ul)
- Trombosit : 205.000 ( N: 150.000-400.000/ul)
- Hematokrit : 50,5 ( N: 42-54%)
- GDS : 105 ( N: <200mg/dl)

DIAGNOSE
Open fracture phalanx distal digiti IV manus dextra with open fracture phalanx
medial digiti II manus sinistra.

MANAGEMENT

Operative:

- ORIF digiti IV manus dextra

- ORIF digiti II manus sinistra

- Amputation digiti V manus dextra

Medikamentosa:

- IVFD RL 20 tpm

- Ceftriaxone amp / 12j / iv

- Ketorolac amp / 8j / iv

- Ranitidine amp / 12j / iv

date of admittance

history of illness

Patients came with open wound in the right hand on the fourth finger and the five
finger interrupted accompanied by open wound in left hand on second finger.
Patients say open wound on the hands are caused by work accidents. This has been
experienced since this morning. The wound was painful and began to be difficult to
move.

wound

accompanied

interrupted

well nourished

moderate illnes
tenderness

Tanggal masuk

Sejarah penyakit

Pasien datang dengan luka terbuka di tangan kanan pada jari keempat dan kelima
jari terganggu disertai luka terbuka di tangan kiri dengan jari kedua. Pasien
mengatakan luka terbuka di tangan disebabkan oleh kecelakaan kerja. Ini sudah
dialami sejak pagi ini. Luka itu terasa sakit dan mulai sulit bergerak.

luka

Disertai

Terganggu

Baik gizi

Sakit sedang

Kelembutan

HEALING

According to the Path of the # Line

A disruption or break in the continuity of the structure of bone

Traumatic injuries account for the majority of fractures

a break in the continuity of a bone or cartilage.

Terms used in fracture follow-up

common causes of fractures:

Fall from a height

car accidents

Direct blow

Repetitive forces

Pathology
Signs and Symptoms

Swelling or tenderness

pain

Numbness

Bleeding

Broken skin with bone protruding

Limitation or unwillingness to move a limb

Physical Examination:

Inspection for open fractures, swelling

Deformities (angulation, rotation, shortening)

Alignment.

Range of motion (active and passive)

Neurovascular status

Radiographic studies:

3 planes: AP, Lateral and Oblique

PENYEMBUHAN

Menurut Jalur # Baris

Gangguan atau pecahnya kelanjutan struktur tulang

Cedera traumatis menyebabkan sebagian besar patah tulang

Istirahat dalam kontinuitas tulang atau tulang rawan.

Istilah yang digunakan dalam fraktur tindak lanjut

Penyebab fraktur yang umum:

Jatuh dari ketinggian

kecelakaan mobil

Pukulan langsung

Kekuatan berulang
 Patologi

Tanda dan gejala

Bengkak atau nyeri tekan

rasa sakit

Mati rasa

Berdarah

Kulitnya pecah dengan tulang menonjol

Batasan atau keengganan untuk menggerakkan anggota badan

Pemeriksaan fisik:

Inspeksi untuk fraktur terbuka, bengkak

Kelainan (angulation, rotation, shortening)

Penjajaran.

Rentang gerak (aktif dan pasif)

Status neurotoksik

Studi radiografi:

3 bidang: AP, Lateral dan Oblique