CASE REPORT

Saturday , January 17th 2015

Team On Duty:
dr.
dr.
dr.
dr.
dr.
dr.
I.

dr. Hendra K (Chief)

Rynaldi (Coordinator)
Tomi
(Report editor)
Aswad
(Medical report)
Mohan
(Medical report)
Andri Feisal
(documentation)
Rahmad (documentation)

Patient Identity
Name
Age
Sex
Address
MR
Fathers Phone
Body Weight
Time Arrived

:
:
:
:
:

Yossi Perdana Putra

10 years old
Male
Ujong Kalak, Johan Pahlawan, Kab. Sigli
1 03 68 41
: 082368193863
: 21 kg
: 11.44 PM

II.

Chief Complain:
Pain and difficulty moving of the left leg

III.

Present illness history

The patient was referred from Sigli district hospital to Zainoel Abidin
emergency room with a chief complain pain and difficulty moving of
the left leg for 2 days. Initialy, he was playing with his friends and
suddenly his friend kicked him and he fell. There was no history of
unconsciousness, nausea and vomiting.
Physical examination

IV.

Primary Survey
A
: Clear
B
: Spontaneous, 22 breaths/min
C
: Blood Pressure: 120/70 mmHg, Pulse: 80 beats/min
D
: GCS 15, E4M6V5, isochoric pupil 3mm/3mm, light reflex
(+/+)
Exposure
L/S at the left hip region
L
: Symmetrical, hematoma (-), slight flexion, internal rotation,
adduction
F
: Pain (+), NVD (-)
M
: ROM limited at hip

Secondary survey

 Head and neck

In normal limit
Thorax
In normal limit
Abdominal
In normal limit
Pelvic region
L/S at the left hip region
L : Symmetrical,hematoma (-), slight flexion, internal rotation,
adduction
F: Pain (+), NVD (-)
M: ROM limited at hip
Upper extremity
in normal limit
Right lower extremity
in normal limit
V.

Assessment:
Posterior dislocation of the left hip

VI.

Management
Immobilization
IVFD RL 10 drips/mnt
Ketorolac injection 10 mg
Laboratory examination
Radiology examination

VII.

Laboratory result
Haemoglobin
: 12,0 gr/dl
White Blood Count : 16,700 /ul
Platelets
: 319.000 /ul
Hematocrit
: 35 %
CT/BT
: 7/2
Radiology result :
Pelvic AP
Posterior dislocation of the left hip

VIII.

Diagnose
Posterior dislocation of the left hip joint
Consult to orthopedic surgery division
Close reduction emergency

IX.
X.

XI.

XII.

Operative report
Performed close reduction with Bigelows Manuver
The left hip joint dislocation was release
Performed skin traction
Post Operative Diagnosed
Posterior dislocation of the left hip joint (ICD 10 CM S73.012)

Follow up

Date

19/1/2015 Pain (-) General Condition:

POD 1
Good
BP
: 100/70
mmhg
P
: 86
beats/minute
RR
: 20
breath/minute
T
: 37 C
L/S at the pelvic
region
L: symetrical
F: Pain (-)
L/S at the left Femur
L : Skin traction (+)
F: Pain (-)
M: Limited

A
Posterior
dislocation of the
left hip joint (ICD
10 CM S73.012)

Post close
reduction
(ICD 9 CM 79.75)

IVFD RL 10
drips/mnt
Inj
Metamizol
e Sodium
500 mg/8
hours

Performed skin
traction