CHAPTER II

CASE REPORT

I. IDENTITAS
Nama : Mr.S
Age : 29 yo
Gender : Male
Address : Kebonagung
Job : employee
Religion : Islam
At Hospital : 17 August 2016
Room : Kenanga
No. CM : 528.119

II. ANAMNESIS
A. Symptom : Pain of the right forearm
B. Present History :
The man came to the IGD with his family after fell while played futsal.
While the incident of patient falls to the right, He was collided with his
friend before he fell. He complained that his right forearm felt pain if he
moved. He told that every he moved like flexi and extention he keep on
pain.

PRIMARY SURVEY
- Airway: patent, clear
- Breathing: good, 24x/m
- Circulation & Hemorragic : BP: 120/80 mmHG, N: 80x/m
- Dissability: Alert, GCS 15
- Expossure: Normal, nothing lession
 Medical History :
 History of similiar injury : Nothing
 History allergy drug and food : Nothing
 History of long cough : Nothing

C. Family Medical History :

 History of similiar symptom : Nothing
 History of heart disease : Nothing
 History of diabetics militus : Nothing

D. Personal History, Social, and Environment

 Patient used health insurance BPJS

III. PHYSICAL EXAMINATION

GCS : 15
VITAL SIGN :
 HR : 80 x/m
 RR : 24 x/m
 to : 36o c
 HP : 120/80 mmHG
 Weight : 70 kg

Status Generalis

1. Skin : Turgor (N)

2. Head : Mesocephal, Wound (-)
3. Eyes : Anemis -/-, Icteric -/-
4. Ear : Discharge -/-
5. Nose : Deviation septum -/-, discharge -/-
6. Mouth : Blooding (-)
 7. Neck : Simetris, Trachea deviation (-)
8. Thorax : Normochest, simetris

COR

Inspeksi : ictus cordis (-)

Palpasi : Ictus cordis palpable at SIC V, 2 cm medial to the

linea mid clavicularis sinistra, pulsus the sternal (-), pulsus
epigastrium (-)
Percussion : heart border
Bottom left: SIC V, 2 cm medial linea mid clavicularis sinistra
Top left : SIC II linea sternalis sinistra
Top right : SIC II linea sternalis dextra
Waist heart: SIC III linea parasternalis sinistra
Impression : configuration of the heart normal
Auscultation : heart sound I-II regular, gallop (-), murmur
(-)
Pulmo :
Anterior Posterior
I: Statis: normochest(+/+), simetris I: Statis: normochest(+/+), simetris
(+/+), retraction (-/-). Dinamis: simetris (+/+), retraction (-/-).Dinamis: simetris
Pa: statis: simetris (+), nothing Pa: statis: simetris (+), nothing
widening between the ribs, retraction (- widening between the ribs, retraction
/-), sterm fremitus dx=sin (-/-), sterm fremitus dx=sin
Pe: Sonor (+/+) Pe: Sonor (+/+)
Aus: vesicular (+/+), ronchi (]-/-), Aus: vesicular (+/+), ronchi (-/-),
wheezing (-/-) wheezing (-/-)
 Back : kifosis and lordosis (-)

Abdomen :
Inspection : normal, massa (-)
Palpation : Supel, pain (-), hepar and lien are not papble
Percussion : tympani (+)
Auscultation : bowel (+) Normal

Eksremity:

Superior Inferior
Akral -/- -/-
Oedem +/- -/-
Capillary refill <2 “ <2”
Lession -/- -/-
Hematom -/- -/-

IV. LOCALIS STATUS

right Forearm :
Look : hematom (+). Oedem (+)
Feel : pain (+) at right hand, warm (-), pulsasi (-),
Move :
 Active :
- Extention : (+)
- Flexion : (-)
- Endorotation : (-)
- Exorotation : (-)
 Pasif :
- Extention : (+)
- Flexion : (-)
 - Endorotation : (-)
- Exorotation : (-)

V. SUPPORTING EXAMINATION
1. X- Foto Rontgen Wrist joint dextra 2 position AP – Lateral

Before ORIF :
After ORIF :
 2. Laboratory (17-8-2016)
Hematologi Hasil Reference value
Hemoglobin 12,5 gr/dL 11,5-16,5
Leukosit 10,5 10^3/uL 4,0-10,0
Trombosit 280 10^3/uL 150-500
Hematokrit 39,2 % 35,0-49,0
Protombin Time (PT) 11,4 s 11,3-14,7
APTT 33,4 s 27,4-39,3

VI. ASSESMENT
Dx. Clinic:
Close Fracture radius distal dextra.
VII. INITIAL PLAN
a. Ip Terapeutik
Medical treatment
 - Infus RL 20 tpm
- Inj. dexketoprofen 2x50 mg
- Inj. Cefazolin 2x1
- Inj. Ranitidine 3x50 mg
b. Ip. Operatif
ORIF
c. Ip. Monitoring
General situation, Vital sign, the result of supporting examination
d. Education
- Describes of the disease and the prognosis to the family
- Explain the possible complication that can happen to
family
VIII. PROGNOSIS
 Quo ad vitam : ad bonam
 Quo ad sanam : ad bonam
 Quo ad fungsionam : dubia ad bonam
 CHAPTER I
INTRODUCTION

Distal radius fractures are one of the most common types of fractures,
accounting for around 25% of fractures in the pediatric population and up to 18%
of all fractures in the elderly age group. Although the pediatric and elderly
populations are at the greatest risk for this injury, distal radius fractures still have
a significant impact on the health and well-being of young adults. Data from the
past 40 years has documented a trend towards an overall increase in the
prevalence of this injury. For the pediatric population, this increase can likely be
attributed to a surge in sports related activities. The growth of the elderly
population and a rise in the number of active elderly are directly responsible for
the increase seen in this age group. Understanding the epidemiology of this
fracture is an important step towards the improvement of the treatment strategies
and preventative measures which target this debilitating injury.

The forearm is the part of the arm between the wrist and the elbow. The
forearm is made up of two bones: the radius and the ulna. The radius is on the
"thumb side" of the forearm, and the ulna is on the "pinky finger side."

Growth plates are areas of cartilage near the ends of the long bones in
children and adolescents. The long bones of the body do not grow from the center
outward. Instead, growth occurs at each end of the bone around the growth plate.
When a child is fully grown, the growth plates harden into solid bone. Both the
radius and the ulna have growth plates.
 CHAPTER III
CONTENTS REVIEW

3.1 Anatomical of Bone

3.1.1 Bone can be classified into five groups based on its shape:
a. Long bones (femur, humerus) consisting of a long thick stem, called the
diaphysis and two ends, called the epiphysis. Next to the proximal
epiphysis are metaphysical. Among the epiphysis and metaphysis are
growing cartilage area, called the epiphyseal plate or growth plate.
Long bones grow because of the accumulation of cartilage in the
epiphyseal plate. Cartilage is replaced by bone cells produced by
osteoblasts and bone lengthening. The stem is formed by dense bone
tissue. Formed from spongi epiphyseal bone (cancellous or trabecular).
At the end of the teen years depleted cartilage, epiphyseal plates fuse,
and the bones stop growing. Growth hormone, estrogen, and
testosterone stimulates the growth of long bones. Estrogen, along with
testosterone, stimulates the fusion of the epiphyseal plate. Stem a long
bone has a cavity called the medullary canal. Medullary canal contains
the bone marrow.
b. Short bones (carpals) irregularly shaped and the core of cancellous
(spongy) with an outer layer of dense bone.
c. Short flat bone (skull) consists of two layers with an outer layer of solid
bone is bone concellous.
d. Irregular bone (vertebrates) is the same as the short bones.
e. Sesamoid bone is a small bone, which is located around the bone
adjacent to the inventory and supported by tendons and facial tissues,
for example the patella (knee hood).
 3.1.2 Physeal anatomy

The key difference between the child's bone and that of an adult
is the presence of a physis. Physeal injuries are very common in
children, making up 15-30% of all bony injuries. The growth plate, or
physis, is the translucent, cartilaginous disc separating the epiphysis
from the metaphysis and is responsible for longitudinal growth of long
bones. The cells of the physis are arranged in columns or layers
described as the germinal or resting layer, the proliferative zone, the
hypertrophic zone and the zone of provisional calcification (Figure 10).
The proliferative zone is where the chondrocytes undergo rapid division
by mitosis and is the most metabolically active zone. Osteoblasts use
the chondrocyte columns as a scaffold for ossification in the zone of
provisional calcification. The hypertrophic zone is the weakest because
it lacks both collagen and calcified tissue. Most physeal separations
occur through this layer because it is less able to resist shearing stress

3.2 Fracture Definition

A fracture is any break in a bone, including chips, cracks, splintering,
and complete breaks.
Two Basic Types Of Fracture:
1. Closed Fracture (Simple fracture):
 Occurs when a bone is broken but there is no penetration extending
from the fracture through the skin.
2. Open Fracture: (Compound fracture)
Is a fracture in which there is a wound over the fracture site, with or
without bone protruding through it.

This type of fracture is more serious than closed fractures because the
risks of contamination and infection are greater. Fractures are further
classified according to their appearance on x-ray:
Types of fracture
a. Green stick fracture
Usually occurs in children whose bones are still pliable (like green
sticks). A break occurs straight across part of the width of the bone,
perpendicular to the long axis
b. Transverse Fracture
Cuts across the bone at right angles to its long axis often caused by
direct injury
c. Oblique Fracture
The fracture line crosses the bone at an oblique angle
d. Comminuted Fracture:
The bone is fragmented into more than two pieces
e. Impacted Fracture:
The broken ends of the bone are jammed together
f. Spiral Fracture:
Usually results from twisting injuries.The fracture line has the
appearance of a spring
3.3 Procces of Fracture
a. Direct
fracture occurs at the site of trauma. Direct pressure on the bone and
fracture in the area of pressure. Ex : direct hit over the bone
b. Indirect
Trauma occurs when trauma doesn’t directly delivered to areas farther
from the fracture. Usually the soft tissue remains intact. Ex: after falling
on outside stretched hands
c. Force of Powerful Muscle Actions
For example, violent cough may cause rib fracture
d. Aging and bone disease
Can increase the risk of fractures (pathologic fractures), with bones
breaking even minor accidents
e. Twisting Forces
Such injuries are often seen in football and skiing accidents where a
person's foot is caught and twisted with enough forces to fracture a leg
bone
3.4 Treatment of Fracture
a. Recognition or recognition is doing the correct diagnosis so that it
will help in the treatment of fractures due to treatment planning can
be prepared more perfect .
b. Reduction or repositioning is retake actions fracture fragments as
closely as possible to its original condition or status or
circumstances normal layout .
c. Retention or fixation or immobilization is action to maintain or
hold the fracture fragments during healing .
d. Rehabilitation is an act with the intention that section who suffer
these fractures can be back to normal .

The 4 AO principles, in their basic form, have governed the society’s approach to
fracture management for decades. They are as follows:

1. Anatomic reduction of the fracture fragments: For the diaphysis, anatomic

alignment ensuring that length, angulation, and rotation are corrected as
required; intra-articular fractures demand anatomic reduction of all
fragments.
2. Stable fixation, absolute or relative, to fulfill biomechanical demands
3. Preservation of blood supply to the injured area of the extremity and
respect for the soft tissues
4. Early range of motion and rehabilitation

Open reduction and internal fixation (ORIF)

The objectives of ORIF include adequately exposing the fracture site, while
minimizing soft tissue stripping and obtaining a reduction of the fracture. Once a
reduction is achieved, it must be stabilized and maintained.
Treatment of distal radius fractures:

Post Operative Course ORIF of Distal Radius Fractures

• A dressing and padded bandage is applied after the operation.

Sometimes a temporary plaster is also applied for support
• Keep the dressings clean and dry
• Keep the arm elevated in a sling or on pillows to reduce swelling
• Start moving any free joints immediately to prevent stiffness
• Take painkillers before the anaesthetic wears off and as necessary thereafter
3.7 Bone Healing
Management of physeal injuries

 Look for and define the exact lines of separation on good quality x-rays
using multiple views
 Occasionally views of the opposite side may help
 Classify the injury using the Salter-Harris classification
 If not readily classifiable, consider CT, MRI and urgent referral to
orthopaedics
 The majority of type I and II injuries are treated by closed reduction and
cast immobilisation
 The majority of type III and IV injuries require ORIF
 CHAPTER IV
DISCUSSION

Anamnesis :
The man came to the IGD with his family after fell while played futsal. While the
incident of patient falls to the right, He was collided with his friend before he fell.
He complained that his right forearm felt pain if he moved. He told that every he
moved like flexi and extention he keep on pain.

Physical Examination

Look : hematom (+). Oedem (+)

Feel : pain (+) at right hand, warm (-), pulsasi (-),
Move :
 Active :
- Extention : (+)
- Flexion : (-)
- Endorotation : (-)
- Exorotation : (-)
 Pasif :
- Extention : (+)
- Flexion : (-)
- Endorotation : (-)
- Exorotation : (-)

` Therapy
Infus RL 20 tpm
- Inj. dexketoprofen 2x50 mg
- Inj. Cefazolin 2x1
 - Inj. Ranitidine 3x50 mg

To treat a man with open reduction internal fixation and then

reexamination in 5-10 days to evaluate maintenance of the reduction. Open
reductions with plate.
 BAB V
CONCLUSSION

 Open reduction is indicated if the fracture is irreducible (periosteum or

pronator quadratus may be interposed).. Open reduction and internal fixation
with smooth pins or screws parallel to the physis is recommended if the
fracture is inadequately reduced.
 CASE REPORT
FRACTURE RADIUS DISTAL DEXTRA
Disusun untuk memenuhi sebagian tugas kepaniteraan klinik bagian
Ilmu Bedah RSUD dr. H. Soewondo Kendal

Disusun oleh :
Ibnu Syah 012116411

Pembimbing :
dr. Wisnu Murti Sp.OT

FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2016
 HALAMAN PENGESAHAN

Nama : Ibnu Syah

NIM : 012116411
Fakultas : Kedokteran
Universitas : Universitas Islam Sultan Agung ( UNISSULA )
Tingkat : Program Pendidikan Profesi Dokter
Bagian : Ilmu Bedah
Judul : Fracture Radius Distal Dextra

Semarang, 28 September 2016

Mengetahui dan Menyetujui
Pembimbing Kepaniteraan Klinik
Bagian Ilmu Bedah RSUD Kendal

Pembimbing,

dr. Wisnu Murti Sp.OT