IDENTITY

Name : Mr. A
Age : 25 years old / Male
Address: South Konawe
Admission : November 11th, 2015
DPJP : dr. Tri Tuti H, Sp. OT
 HISTORY TAKING
Chief Complain : pain at left leg

Anamnesis :

Chief Complain: Patient come to the hospital with pain at left leg
suffered since two hours before admitted to the hospital due to
traffic accident.

Mechanism of trauma: the patient was hit by a car when walked.

No body know about the detail of the mechanism of trauma

The patient is a mental retardation.

No history of unconscious, no history of nausea and vomit. Patient

was taken to Wolasi clinic to get first treatament.
PRIMARY SURVEY
A Patent

RR 18x/min regular, spontaneous

thoracoabdominal type, symmetrical B
BP 120/70 mmHg
C HR = 100 x/min regular, strong, active bleeding
at dorsum pedis region.

GCS 15 (E4V5M6), pupil

: 2.0 mm/2.0 mm, light
isochors,
reflex +/+ D
E T = 36,500 C (axillary)
GENERAL STATE
Head : normal
Eyes : normal
Mouth : normal
Ear : normal
Neck : normal
Thoraks : normal
Abdomen : normal
Ekstremitas superior : normal
Extremitas inferior : ekstremitas inferior dextra was
normal
SECONDARY SURVEY
Left leg region:
Look : Deformity (-), swelling (-), hematoma (-), wound
(+) laceration wound (10x15 cm) , bone expose
(+), muscle expose (+) at left dorsum pedis
region,
Feel : Tenderness (+) at left dorsum pedis region , at
left cruris region, crepitation (-)
Move : Active and passive movement of the knee and
ankle joints are limited due to pain
NVD : Sensibility is good, pulsation of the dorsalis
pedis are difficult to identificated. Capillary refill
time < 2
CLINICAL FINDING
RADIOLOGICAL FINDINGS
Left cruris X-ray
AP/Lat

Left Pedis X-ray

AP/Oblik
RESUME
Male 25 years old, Patient come to the hospital with chief
complain pain at left leg suffered since two hours before
admitted to the hospital due to traffic accident. Mechanism of
trauma, the patient was hit by a car when walked. No body
know about the detail mechanism, the patient is a mental
retardation. No history of unconscious, no history of nausea
and vomit. Patient was taken to Wolasi clinic to get first
treatament.
RESUME
Physical examination, general state composmentis, RR
18x/min regular, BP 120/70 mmHg, HR = 100 x/min regular,
strong, T = 36,50 C (axillary). Secondary survey in normal
ccondition. The left extremitas founded; laceration wound
(10x15 cm) , bone expose (+), muscle expose (+) at left
dorsum pedis region, Tenderness (+) at left dorsum pedis
region , at left cruris region, crepitation (-), Active and passive
movement of the knee and ankle joints are limited due to pain.
Radiological findings; oblique fracture in 1/3 proximal of left
tibia.
WORKING DIAGNOSIS
Open fracture 1/3 proximal of left tibia grade IIIa
MANAGEMENT
IVFD RL
Analgesic
Slab
Consul orthopedic
THANK YOU
LITERATURE REVIEW
Definition

Fracture is damage in the

continuity of the bone,
cartilage (joints), and
epifisis.
Incidence

Tibia fracture is the

most common in the
long bone fracture.
There is 11.5/100.000
patient in a year.
fibula
Classification
Gustilo Grade Definition
I Open fracture, clean wound, wound <1
cm in length
II Open fracture, wound > 1cm but < 10
cm in length,without extensive soft-
tissue damage, flaps, avulsions
III Open fracture with extensive soft-
tissue laceration (> 10 cm), damage,
or loss an open segmental fracture.
IIIA Type III fracture with adequate
periosteal coverage of the fracture
bone despite the extensive soft-tissue
laceration or damage
IIIB Type III fracture with extensive soft-
tissue loss and periosteal stripping and
bone damage. Ussualy associated with
massive contamination. Will often need
further soft-tissue coverage procedure.

IIIC Type III fracture associated with an

arterial injury requiring repair,
irrespective of degree of soft-tissue
injury
Clinical feature

History:
Injury, inability,
fracture is not always General sign:
in the injury site, age Shock or bleeding,
and mechanism of brain and medulla
trauma, swelling, spinalis injury
deformity, hiposthesia
and unconscious
Local sign:
Look: deformity,
swelling, hematoma,
open wound and bone
expose
Feel: tenderness and
crepitation
Move: Active and
passive movement
Diagnose

Phisical
History Examinati
n

Additional
examinati
on
Management

Closed Open
reduction reduction
Prognosis

Tibial fracture healing

depend on fracture pattern
and soft-tissue injury.