ORTHOPHAEDIC SHORT

CASE
(TRAUMA)

Ade Rizky Amalia

K1A1 13 001
IDENTITY
Name : Mr. S
Age : 30 years old
Address : Pewuta Village
Occupation : Employee
Admission : February, 11th 2019
Doctor in Charge : dr. Tri Tuti, Sp.OT
 A Clear, Cervical Spine Control

B Respiratory rate 20x/m, spontaneous, thoracoabdominal type,

symmetrical, regular

C Blood Pressure 130/70 mmHg

Pulse 92 x/m, regular, strong

D Glasgow Coma Scale (E4M6V5), Isochoric

pupil, Ø 2.5 mm/2.5 mm, Light reflex +/+

PRIMARY E Temperature 36,5 OC/Axillary

SURVEI
(10.25 am)
• Chief complain : Pain at right foot on fifth finger
History Taking
Suffered since ± 4 hours ago due to traffic accident.
Mechanism of trauma :
Patient was ride a motorcycle, he was use helmet with moderate speed. Suddenly, he
felt down to the right side when he try to avoid the other motorcycle.
• There was no history of syncope, nausea and vomiting
• There was no history of drugs or alcohol consumption
• There was no previous treatment

Anamnesis
(10.30 am)
SECONDARY SURVEI (10.35 am)

GENERAL STATE Composmentis, moderate illnes, good nourish

Vital Sign
BP : 120/70 mmHg
HR : 80x/minute, regular, strong
RR : 18x/minute, regular, symmetrical
T : 36,5◦C/axillary
VAS : 4/10
 STATUS PRESENT

Head : Within Normal Limit Neck : Within Normal Limit

Face : Within Normal Limit Chest : Within Normal Limit
Eyes : Within Normal Limit Abdomen : Within Normal Limit
Nose : Within Normal Limit Upper limb : Within Normal Limit
Mouth : Within Normal Limit Lower limb : Localized state
Ears : Within Normal Limit
• Right Pedis Region

I : Deformity (+), swelling (+) at digiti -V , hematoma (+), wound (+)

Lacerated wound at digiti V, size 2 cm x 1 cm , with irregular edge, bone
expose (-), tendon expose (+)

P : Tenderness (+)

ROM : Active and passive movement at metacarpophalangeal and

interphalanx joint 5 finger limited due to pain

NVD : good sensibility, CRT <2 Seconds

LOCALIZE STATE
Clinical Finding
 Routine blood test (WBC, Hb, PLT)
Blood chemistry test (RBG, SGOT/SGPT,
ur/cr)
X-Ray Right Pedis AP/Oblique

Planning Diagnostic :
X-Ray Right Pedis AP/Oblique
 Open Fracture Fifth Finger at Right Foot

DD/
• Dislocation of interphalangs distal joint Fifth Finger at Right Foot
• Rupture Tendon Fifth Finger at Right Foot

DIAGNOSIS
 PHARMACOLOGY NON PHARMACOLOGY
• Wound care
• IVFD
• Rest
• Antibiotic injection
• Immobilization
• Analgetic injection
• Compress ice
• H2RA injection
• Elevation
• Education

Consult Orthopedic Surgeon

MANAGEMENT