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PATIENT IDENTITY

Name
Age
Sex
Date of admittance
MR Number

: MNA
: 30 years old
: Male
: 19th April 2015
: 708978

HISTORY

Chief Complaint
History of illness

: Pain at the left knee.


: Patient suffered from the knee pain since 2 day before

admitted to the Wahidin Sudirohusodo Hospital due to accident.


Mechanism of Trauma: The patient was riding a motorcycle and suddenly felt to the
left side which his knee directly hitting the road and cannot stand up well after the

accident.
History of unconsciousness (-), nausea (-), vomit (-).

PHYSICAL EXAMINATION
PRIMARY SURVEY

Airway
Breathing
Circulation
Disability
Environment

: Patent
: RR=20x/min, symmetrical, spontaneous, thoracoabdominal type
: BP=130/80 mmHg, P=82x/minute regular and strong
: GCS 15 (E4M6V5), light reflex +/+, isochoric pupil 2.5/2.5 mm
: Axillary temperature of 36.5oC

SECONDARY SURVEY
Left Knee Joint

Inspection : Deformity (+), swelling (+), hematoma (+), excoriated wound (+) at
Palpation
ROM
NVD

anterior aspect of knee which same level as patella


Tenderness
(+), Patellar Tapping(+), Ballotement sign (+)
:
: Active and passive motions of knee joints is limited due to pain.
: Sensibility is good, pulsation of dorsalis pedis artery is palpable,
Capillary refill time < 2.

Left Leg Region

Inspection : Deformity (+), swelling (+), hematoma (+)


Palpation : Tenderness (+)
ROM
: Active and passive motions of knee joints are limited due to pain.
Active and passive motions of ankle joints is good.

: Sensibility is good, pulsation of dorsalis pedis artery is palpable,

NVD

Capillary refill time < 2.


LEG LENGTH DISCREPANCY (LLD)
Right
93 cm
93 cm
0 cm

ALL
TLL
LLD

Left
80 cm
80 cm

CLINICAL PICTURE

Figure 1: Anterior view of left knee

Figure 2: Lateral view of left knee

Figure 3: Lateral view of left knee


LABORATORY FINDINGS
TEST

RESULT

WBC
RBC
HGB
HCT
PLT
HbsAg
CT
BT

11.6 x 103 /uL


5.29 x 106 /uL
16.0 g/dL
47 %
215 x 103 /uL
Negative
800
300

RADIOLOGICAL FINDINGS

Figure 4: Knee X-ray at AP and lateral aspect shows fracture of tibial plateau

Figure 5: Tibia and fibula X-ray at AP and lateral view shows fracture of tibial plateau
DIAGNOSIS
Closed fracture of left tibia plateau
Hemarthrosis left knee joint
MANAGEMENT
IVFD Ringer Lactat
Analgetic
Antibiotic
Apply long leg back slab at left lower limb
Elevation of left lower limb
Plan for ORIF

RESUME

A male, 30 years old suffered from the knee pain since 2 day before admitted to the
Wahidin Sudirohusodo Hospital due to accident.

From physical finding there are swelling, deformity, hematoma, excoriated wound at
anterior aspect of knee which same level as patella, tenderness, positive patellar
tapping and Ballotement sign at the left knee joint, active and passive motions of the
knee joints are limited due to pain and distal neurovascular within normal range.

From physical finding there are swelling, deformity, hematoma and tenderness at the
left leg region, active and passive motions of the knee joints are limited due to pain
and distal neurovascular within normal range.

From radiological findings at both knee and tibia x-rays, there is fracture at tibial
plateau.

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