CASE REPORT

Fryday, 22nd , 2016

Team on duty
dr. Nazir
dr. Tommy Rivelino
dr. Raja Raharja
dr. Aswad Affandi
dr. Arfan Asmadi
dr. Ike Yoganita
dr. Syahmardani
dr. Jufrialdi
dr. Arie Nasir
Date/hour
patient
came to
ER

Examination
hour

April 11th
2016
00.30
WIB

00.30 WIB

Laboratory
Examination
Send

Patient identity
Name
Age
Sex
Address
CM
Hp
Admission time

(Jaga 1)
(Jaga 2)
(Jaga 3)
(Jaga 3)
(Jaga 4)
(Jaga 5)
(Jaga 5)
(Jaga 6)
(Jaga 6)

00.45
WIB

Result

Radiology
Examination
Send

01.56 WIB

Hour of
Diagnostics

Date/ hour
patient out
from ER

DPJP

01.56 WIB

06.00 send
to OR

Dr. Nanta,
Sp.OT
Dr. Yoppie,
Sp.BTKV

Result
-

: M. Nur
: 29 years old
: Male
: Desa Pante Rambong Kec. Pante Bidari
Kab. Bireuen
: 1 08 79 39
: 085372046185
: 00.30 PM

Chief complain
Pain and difficulty to move the left leg
Patient illnes History
The patient was referred from Idi Rayeuek district Hospital with a chief complaint of pain
and difficulty to move the left leg since 24 hours ago. He was involved in crime, and shot
by police at his leg. There was no history of unconsciousness, nausea and vomiting.

Physical examination
Primary survey

A
: Clear
B
: Spontaneous, RR : 22 breaths/ minute
C
: Blood Pressure: 110/60 mmHg, Pulse: 90 beats/minutes
D
: GCS: 15 (E4 M6 V5), isochoric pupil +/+ , light reflex (+)
L/S at the left leg
Look : Swelling (+), deformity (+), wound (+) 10x5 cm,
bone expose (-).
Fell : Pain (+), NVD (+)
RIGHT

LEFT

Femoral Artery

++

++

Popliteal Artery

++

Tibial Artery

++

Dorsalis Pedis Artery ++

Move : ROM limited

Hard Sign

Soft Sign

Arterial bleeding

Proximity of injury to major vessel

Expanding or pulsatile
hematoma

History of significant bleeding

Presence of bruit or thrill

Small hematomas

Absent or diminished distal

pulses

Presence of neurological deficits

Distal ischemia (pain, pallor, +

paralysis, paresthesias,
pulselessness, coolness)

Secundary Servey
Head
in normal limit
Neck
in normal limit
Thorax
in normal limit
Abdomen
in normal limit
Upper extremity in normal limit

Lower extremity
L/S at the left leg

Unexplained shock/Transient
hypotension/Unexplained hypotension

Look : Swelling (+), deformity (+), wound (+) 10x5 cm,

bone expose (-),
Fell : Pain (+), NVD (+)
Move : ROM limited
VAS : Moderate
Assessments:
1. Open fracture of the left leg grade IIIC
2. Critical limb ischemic at the left leg
Management
Immobilization
Stop oral intake
IVFD RL 20 drip/ mnt
Urinary catheter
Cefazoline 1 gr inj.
Gentamicin 80 mg inj.
Ranitidin 50 mg inj.
Tetagam 250 iu IM
Ketorolac inj 30 mg
Laboratory examination
Radiology examination
Laboratory result
Hb
White blood count
Platelet
Ht
CT
BT
Ureum
Creatinin
Blood Glucose ad Random

: 6.5 gr/dl transfution

: 27.400 /ul
: 155.000 /ul
: 19 %
: 8 minute
: 3 minute
: 35 mg/dl
: 0.92 mg/dl
: 192mg/dl

Radiology examination
Left Cruris AP/Lat :
Discontinuity of bone of the upper third of the left tibia and fibula
Diagnose:
1. Open fracture of the lower third of the left tibia fibula grade IIIC
2. Critical limb ischemic
3. Anemia

Consult to Orthopedic Division :

Debridement
Above knee amputation
Operative Report
Performed debridement with normal saline, peroxide + povidone iodine
Performed mouth fish incision
Identified artery, vein and nerve
Performed muscle resection
Wound closure with 1 tube drain
Post Operative Diagnose:
1. Open fracture of the lower third of the left tibia fibula grade IIIC (ICD 10 CM S 82.87)
2. Critical limb ischemic (ICD 10 CM I99.8)
3. Anemia (ICD 10 CM D50.9)
Follow up
Date
S
th
April 25 Pain
POD I
(+)

O
BP : 130/80 mmhg
HR : 86x/minute
RR : 20x/minute

A
P
Post above Knee amputation
at the left thigh
1. Open fracture of the
lower third of the left
S/L at the lef thigh
tibia fibula grade
region
IIIC (ICD 10 CM S
L : wound operation (+)
82.87)
pus (-)
2. Critical limb
F : right arterial tibialis
ischemic (ICD 10
posterior pulse (-),cold
CM I99.8)
limb
3. Anemia (ICD 10 CM
M : ROM limited
D50.9)

Diet MB
IVFD RL 30
drip/menit
Inj. Cefazoline
1 gr/12 hour
Inj. Gentamycin
80 mg/8 hour
Inj. Ketorolac
30 mg/8 hour
Blood routin
examination
Tranfusion of
PRC