Professional Documents
Culture Documents
FACULTY OF MEDICINE
HASANUDDIN UNIVERSITY
CASE REPORT
DECEMBER 2015
Case study:
Mild Head Injury GCS 15 (E4M6V5) + Closed fracture Right 2nd Metacarpal base
+ Open Fracture of the Left 1/3 Middle Tibia grade IIIA + Open Fracture of the
Left 1/3 Middle Fibula grade IIIA + Open Fracture of the left 1st Metatarsal Shaft
grade IIIA + Open Chipped Fracture of left Posterior Talus Process grade IIIA
BY:
Fathin Hanina BT Khairul Parman
C 111 10 853
RESIDENT:
dr. Fahroni C. Winata
dr. Nur Rahmansyah
SUPERVISOR:
dr. Notinas Horas, M.Kes, Sp.OT
Submitted in Fulfilment of The Requirement for Clinical Rotation at
Department of Orthopaedics and Traumatology
Faculty of Medicine
Hasanuddin University
2015
APPROVAL SHEET
This case report entitled Mild Head Injury GCS 15 (E4M6V5) + Closed fracture
Right 2nd Metacarpal base + Open Fracture of the Left 1/3 Middle Tibia grade IIIA
+ Open Fracture of the Left 1/3 Middle Fibula grade IIIA + Open Fracture of the
left 1st Metatarsal Shaft grade IIIA + Open Chipped Fracture of left Posterior Talus
Process grade IIIA prepared by
Name
: Hasanuddin University
Resident I,
Resident II,
PART I
CASE REPORT
I.
Patients Identification
II.
Name
Age/ Date of Birth
Gender
Medical Record No
Date of Admission
:A
: 24 years old (21/09/1991)
: Male
: 73 47 50
: 28/11/2015
History Taking
III.
Physical Examination
Airway
Breathing
Circulation
Disabilaty
Exposure
: T= 36.8 C (Axillary)
Palpation
: Tenderness (+)
Dorsal View
ROM
NVD
Lateral view
Medial view
ROM
NVD
Dorsal view
Medial view
Lateral view
Plantar view
V.
Laboratory Findings
RESULT
NORMAL VALUE
WBC
RBC
HGB
HCT
PLT
Clotting time
Bleeding time
Ureum
Creatinin
SGOT
SGPT
Natrium
Potassium
Chloride
25.10
4.35
12.6
37.8
314
800
300
33
0.93
37
41
141
3.3
111
4,00-10,00 103/mm3
4,00-6,00 106/mm3
14,0-18,0g/dl
43,0-56,0%
150-400 103/mm3
4-10menit
1-7menit
10-50mg/dl
<1,3mg/dl
<38 U/L
<41 U/L
136-145mmol/l
3,5-5,1mmol/l
97-145mmol/l
HBsAg
Non-reactive
Non-reactive
10
Lateral cervical
AP Thorax
11
AP Pelvic
12
13
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Resume
Male, 24 years old with wound on left lower leg after a motorcycle accident.
History loss of consciousness (+) vomit (+) diagnosed with mild head injury
GCS 15 + closed fracture right 1 st metacarpal base + open fracture 1/3 middle
of left tibia + open fracture 1/3 middle of left fibula + open chipped fracture
of the posterior left talus process + open fracture of the 1st left metatarsal
shaft with LLD 1cm. NVD are normal.
VIII. Diagnosis
1. Mild Head Injury GCS 15 (E4M6V5)
2. Closed fracture Right 2nd Metacarpal Base
3. Open Fracture of the Left 1/3 Middle Tibia grade IIIA
4. Open Fracture of the Left 1/3 Middle Fibula grade IIIA
5. Open Chipped Fracture of the Posterior Process of Left Talus grade IIIA
6. Open Fracture of the left 1st Metatarsal Shaft grade IIIA
IX. Management
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PART II
LITERATURE REVIEW
I.
Background
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II.
Hemodynamic instability
Coagulopath
Pulmonary injury
Abdominal injury
Epidemiology
Road traffic accidents are the first cause of death for <45-year old people
whereas victims are usually young and in their most productive age. In
USA, trauma accounts for 145.000 deaths per year (disabilities of threefolds this number), and in developing countries, trauma is the first cause of
death for all ages. In Egypt, there is about 7000 death toll per year caused by
trauma which is more than the casualties caused by wars. Car accidents
usually cause multiple injuries with vast inflammation and severe bleeding
that affect several organs, limbs or visceral tissues. This requires physicians
and surgeons from different specialties to cooperate in managing such cases.
Polytrauma is known as multiple injuries at the same onset that usually
affect multiple organs. This type of injury is usually severe and associate
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Early: This occurs minutes to a few hours after injury, usually as a result
of intracranial bleeding, hemopneumothorax, splenic rupture, liver
laceration, or multiple injuries with significant blood loss. These
represent correctable injuries for which immediate, coordinated,
definitive care at a level I trauma center can be most beneficial.
Late: This occurs days to weeks after injury and is related to sepsis or
multiple organ failure.(1)
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20
21
22
response
syndrome
may
induce
prolonged
cell
interactions.
Reactive
oxygen
species,
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dysfunction
syndrome.
The First and Second Hit Phenomena
Numerous studies have demonstrated that stimulation of a variety of
inflammatory mediators takes place in the immediate aftermath of trauma.
This response initially corresponds to the first-hit phenomenon. Hoch et al.
reported elevation in plasma concentrations of IL-6 and IL-8 in patients with
an injury severity score of 25 points. An immediate increase in expression
of neutrophil L-selectin was reported in patients with an injury severity
score of 16 points. Similarly, a significant (p < 0.05) increase in the
expression of the integrin CD11b was noted in more severely injured
patients. The development of multiple organ dysfunction syndrome has also
been associate with a persistent elevation of CD11b expression on both
neutrophils and lymphocytes for 120 hours, a finding that is suggestive of
neutrophil activation in the early development of leukocytemediated endorgan injury.
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DAFTAR PUSAKA
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1.
Kenneth J. K JDZ. Handbookof fractures: Lippincott Williams &
Wilkins; 2010.
2.
Hafez MA MA, Hamza H Staged Surgical Management of Multiple
Fractures in Polytrauma Patient. Int J Osteol Orthop. 2015;2(1):8-10.
3.
Giannoudis PV. Surgical Priorities in Damage Control
in
Polytrauma. J Bone Joint Surg 2003(85-B):478-83.
4.
Willmott. H. Trauma and orthopaedics at a glance: John Wiley &
Sons, Ltd.; 2016.
5.
Craig S. Roberts H-CP, Alan L. J, Arthur L. M, Jorge L. R and Peter
V. G. Damage Control Orthopaedics. The Journal of Bone and Joint
Surgery. 2005;87-A(2).
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