Orthopedic Case - Trauma

FIFIT ERVITA HASIRUDDIN

K1A1 11 007
 IDENTITY
Name : Mr. I
Age : 16 years old
Address : Lrg. Mata Air
Occupation : Student
Admission : April, 12th 2018
Doctor in charge : dr.Benny Murtaza, Sp. OT
 HISTORY TAKING
(12.00 a.m)

• Chief complain : Wound at little finger of the left hand

• Anamnesis : Since four hours ago due to crushed by planer machine (blunt object)
• Mechanism of trauma : Patient was practice in his school, suddenly the planer fall and hit his
little finger of the left hand.
• History of trauma :
 Unconsciousness (-), nausea (-), vomiting (-)
Consumption : alcohol (-), drugs (-)
 Previous medication : (-)
 Active hand : right hand
 PRIMARY SURVEY
(11.50 a.m)
A
Clear, Cervical Spine Control

RR 18x/min regular, spontaneous B

thoracoabdominal type, symmetrical
C BP 120/80 mmHg
Pulse = 78x/min, regular, strong

GCS 15 (E4M6V5), isochoric pupil, D

Ø : 2,5mm/2,5mm, light reflex +/+

E T = 36.50 C (axillary)
 SECONDARY SURVEY
Generalized Status

The patient was compos mentis, moderate

illness, normal nutrition state.
 Vital Sign
BP = 120/80 mmHg,
Pulse = 78x/m, regular, strong lift.
RR = 18x/m, regular, spontaneous thoracoabdominal type.
Temperature = 36,5oC/axillary
Status Present
Head : Within Normal Limit
Face : Within Normal Limit
Eyes : Within Normal Limit
Nose : Within Normal Limit
Mouth : Within Normal Limit
Ears : Within Normal Limit
Neck : Within Normal Limit
Chest : Within Normal Limit
Abdomen : Within Normal Limit
Upper Limb : Localized
Lower Limb : Within Normal Limit
 LOCALIZED STATE
Left Hand Region (5th Digiti)
Inspection : deformity (+), hematoma (-), swelling (-) lacerated wound
(+) with size 1x1 cm
Palpation : tenderness (+),
ROM : active and passive movement of left PIP and DIP digiti V joint
are limited due to pain
NVD : sensibility was good, pulse of left ulnaris artery is palpable,
CRT <2”
Clinical Finding
PLANNING
• Routine Blood
• X-ray Left Manus AP/Oblique
X-Ray Finding
 Diagnosis
Traumatic Amputatum of 5th Digity Distal Phalanx of
Left Manus
DD/
• Compartement Syndrome Left Manus
• Muscle Contusio Left Manus
 MANAGEMENT
Non-Pharmalogical Pharmalogical
 Bed Rest • IVFD RL
 Immobilization • Analgesic
 Elevation • H2 Receptor Agonist
 Consult Orthopedist
Thank You