Dokumen.tips Laporan Kasus Bedah Orthopedi

8/18/2019 Dokumen.tips Laporan Kasus Bedah Orthopedi

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LAPORAN KASUS BEDAH ORTHOPEDI

SEORANG LAKI-LAKI 55 TAHUN DENGAN FRAKTUR REGIO CRURIS

SINISTRA DISTAL TERBUKA GRADE IIIB, DISLOKASI SENDI

THALLOCRURAL SINISTRA

Disusun oleh :

Tjues Aryo Agung ! G"A ##$ %5&

Pembimbing :

'r! An'ry R! (no)o, S*!OT

BAGIAN ILMU BEDAH

FAKULTAS KEDOKTERAN UNIERSITAS DIPONEGORO

SEMARANG

!"##

#


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LAPORAN KASUS BEDAH ORTHOPEDI

I$ IDENTITAS PENDERITA

N++ : Tn!

.en(s /e0+(n : L+/(-0+/(

Uur : 55 )+1un

A0++) : 2enggung, Ken'+0

2e/erj++n : 2e)+n(

Ag++ : Is0+

Su/u : .+3+

+su/ Ru+1 S+/() : 4 e( #%%

No C : ""%#"#

II$ DAFTAR MASALAH

No +s+0+1 A/)(6 T+ngg+0 No +s+0+1 2+s(6 T+ngg+0

%! Fr+/)ur reg(o

7rur(s s(n(s)r+ %8&

'(s)+0 )er9u/+

gr+'e IIIB

%#-#5-#%% %!

!

Sus*! Ker+)()(s

s+3+1(/+

Sus*! 2

%#-#5-#%%

%#-#5-#%%

III$ DATA DASAR

A$ DATA SUB%EKTIF

An&mnesis

Au)o+n+nes(s 'eng+n *en'er()+, '+n +00o+n+nes(s '+r( C *+s(en )+ngg+0 %#

e( #%% *u/u0 %5!## IB '(9+ngs+0 A&!

Ke0u1+n U)++ : ruju/+n RSUD Tugu 'eng+n *+)+1 )u0+ng /+/( /(r(

%


3/12

R(3+y+) 2eny+/() Se/+r+ng :

; " j+ SRS *+s(en e9+n)u )e)+ngg+ny+ ene9+ng *o1on s++)

9er+ng/+) /e s+3+1! S++) *o1on j+)u1, /+/( /(r( *+s(en )erjer+) )+0( )+9+ng '+n

)er)+r(/ o0e1 9+)+ng *o1on /e +r+1 9er0+3+n+n '+n )er9en)ur /er+s /e 9+)+ng

*o1on y+ng j+)u1! 2(ngs+n


4/12

Res*(r+)ory R+)e : % 8en()

Su1u : &4,% oC

Ku0() : s+3o +)+ng, /u0() /er(ng =, /orne+ /+n+n /eru1!

H('ung : n+*+s 7u*(ng


5/12

S3e00(ng - 8 - - 8 >

A/r+0

D(ng(n

- 8 - - 8 -

Capillary

Refill

8 8

2u0s+s(

+r)er(

>8> > 8 >

Sens(9(0()+s > 8 > > 8 > enurun

o)or(/ :

- Ger+/ > 8 > > 8 Su0() '(n(0+( /+ren+

nyer(!

- Ke/u+)+n 5 8 5 5 8 Su0() '(n(0+( /+ren+

nyer(

Ter0(1+) UKK 9eru*+ 9er7+/ 3+rn+ *u)(1 '( *er)eng+1+n reg(o 9r+71((

+n)er(or, s(s(/ =, 1(*es)es( =

($ STATUS LOKALIS

Reg(o 7rur(s s(n(s)r+

Ins*e/s( : )+*+/ )u0+ng =, *us =, '+r+1 =, oe'e+ =, 'e6or()+s

=, +ngu0+s( =, *een'e/+n =, eoro)+s(


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I* T : In6us RL # )*

Gen)+(7(n 5# g (!

Ce6+?o0(n & % gr (!

Ke)oro0+7 & g (!

R+n()('(n & g (!

Konsu0 9+g(+n +)+ '+n /u0() /e0+(n

2ro FSE '+n free flap

I* : /e+'++n uu, )+n'+ ()+0, s)+)us 0o/+0(s

I* E : - enje0+s/+n /e*+'+ *en'er()+ '+n /e0u+rg+ *en'er()+ 9+13+

*en'er()+ eng+0+( *+)+1 )u0+ng )er9u/+

- enje0+s/+n )en)+ng *er0uny+ 6o)o ron)gen un)u/ e0(1+)

*+)+1 )u0+ngny+

- enje0+s/+n +/+n *er0uny+ '(0+/u/+n o*er+s( un)u/

e0+/u/+n re*os(s( '+n e+s+ng 6(/s+)or e/s)ern+!

- enje0+s/+n engen+( /o*0(/+s( +3+0


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Fr+/)ur +)+u *+)+1 )u0+ng +'+0+1 )er*u)usny+ /on)(nu()+s j+r(ng+n )u0+ng, )u0+ng

r+3+n sen'(, )u0+ng r+3+n e*(6(s(s, 9+(/ y+ng 9ers(6+) )o)+0 +u*un y+ng *+rs(+0!

Tr+u+ y+ng enye9+9/+n )u0+ng *+)+1 '+*+) 9eru*+ )r+u+ 0+ngsung, )e/+n+n

0+ngsung *+'+ )u0+ng '+n )erj+'( 6r+/)ur *+'+ '+er+1 )e/+n+n, '+n )r+u+ )('+/

0+ngsung, )r+u+ '(1+n)+r/+n /e '+er+1 y+ng 0e9(1 j+u1 '+r( '+er+1 6r+/)ur! A/(9+)

)r+un+ 9erg+n)ung *+'+ jen(s )r+u+, /e/u+)+n, +r+1ny+ '+n uur *en'er()+!

B$ KLASIFIKASI FRAKTUR

K0+s(6(/+s( 6r+/)ur '(9+g( enj+'(:

%! enuru) +'+ )('+/ny+ 1u9ung+n +n)+r+ *+)+1+n )u0+ng 'eng+n 'un(+ 0u+r!

- Fr+/)ur )er)u)u*

Fr+/)ur y+ng )('+/ e*uny+( 1u9ung+n 'eng+n 'un(+ 0u+r!

- Fr+/)ur )er9u/+

Fr+/)ur y+ng e*uny+( 1u9ung+n 'eng+n 'un(+ 0u+r e0+0u( 0u/+ *+'+

/u0() '+n j+r(ng+n 0un+/!

! enuru) e)(o0og(s

- Fr+/)ur )r+u+)(/

Terj+'( /+ren+ )r+u+ y+ng )(9+-)(9+!

- Fr+/)ur *+)o0og(s

Terj+'( /+ren+ /e0e+1+n )u0+ng se9e0uny+ +/(9+) /e0+(n+n *+)o0og(s

*+'+ )u0+ng +u*un '( 0u+r )u0+ng, (s+0ny+ )uor, (n6e/s( +)+u

os)eo*oros(s!

- Fr+/)ur s)res

Terj+'( /+ren+ 9e9en 0++ +)+u )r+u+ r(ng+n y+ng )erus-enerus *+'+

su+)u )e*+) )er)en)u, (s+0ny+ 6r+/)ur *+'+ )u0+ng )(9(+ +)+u e)+)+rs+0 *+'+ )en)+r+ +)+u o0e1r+g+3+n y+ng ser(ng 9er0+r( +)+u 9+r(s-9er9+r(s!

&! enuru) /o*0() )('+/ny+ g+r(s 6r+/)ur

- Fr+/)ur /o*0()

A*+9(0+ g+r(s *+)+1 y+ng e0+0u( se0uru1 *en+*+ng )u0+ng +)+u e0+0u(

/e'u+ /or)e/s )u0+ng se*er)( y+ng )er0(1+) *+'+ 6o)o!

- Fr+/)ur )('+/ /o*0()

"


8/12

A*+9(0+ g+r(s *+)+1 )('+/ e0+0u( se0uru1 *en+*+ng )u0+ng,

se*er)(:

Hairline fracture

Greenstick fracture

Buckle fracture

@! enuru) g+r(s 6r+/)ur

- Tr+nsers+0

- O90(/

- S*(r+0

- Ko(nu)(6

- Ku*u-/u*u

- Segen)+0

- De*res(

5! enuru) 9ergeser +)+u )('+/ 9ergeserny+ 6r+gen-6r+gen 6r+/)ur

- Fr+/)ur undisplaced :

G+r(s *+)+1 /o*0() )e)+*( /e'u+ 6r+gen )('+/ 9ergeser!

- Fr+/)ur displaced :

Terj+'( *ergeser+n 6r+gen-6r+gen 6r+/)ur!

($ FRAKTUR TIBIA DAN FIBULA

#$ F)e*uensi

Fr+/)ur )(9(+ eru*+/+n 6r+/)ur y+ng *+0(ng ser(ng '+r( seu+ 6r+/)ur )u0+ng

*+nj+ng! Kej+'(+n )+1un+n 6r+/)ur )er9u/+ )u0+ng *+nj+ng '(*er/(r+/+n %%,5 *er

%##!### or+ng, 'eng+n @# )erj+'( '( e/s)re()+s (n6er(or! Fr+/)ur '( e/s)re()+s

(n6er(or *+0(ng 9+ny+/ +'+0+1 6r+/)ur y+ng )erj+'( *+'+ '(+6(s(s )(9(+!

!$ Mo)+&li+&s ,&n Mo)bi,i+&s

An7++n /e1(0+ng+n +nggo)+ ger+/ 9+3+1 '+*+) )erj+'( se9+g+( +/(9+) '+r(

)r+u+ j+r(ng+n 0un+/ 9er+), g+nggu+n neuro+s/u0+r, 7e'er+ +r)er( *o*0()e+0,

s(n'ro /o*+r)een, +)+u (n6e/s( se*er)( g+ngren +)+u os)eoye0()(s! Ce'er+ +r)er(

4


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*o*0()e+0 +'+0+1 7e'er+ ser(us y+ng eng+n7+ e/s)re()+s 9+3+1 '+n 9(+s+ny+

ser(ng )er+9+(/+n!

Nerus *er(neus 7oun(s eny(0+ng '( s+*(ng 7o00u '+r( 6(9u0+! S+r+6

(n( ren)+n )er1+'+* 7e'er+ '+r( *+)+1 7o00u 6(9u0+, )e/+n+n s*0(n), +)+u se0++

*er9+(/+n 9e'+1! H+0 (n( '+*+) eng+/(9+)/+n drop foot '+n /e0+(n+n sens(9(0()+s!

Delayed union, nonunion, '+n +r)1r()(s '+*+) )erj+'(! D( +n)+r+ )u0+ng *+nj+ng, )(9(+

+'+0+1 y+ng *+0(ng uu '+r( 6r+/)ur nonunion!

-$ Di&gnosis

- An+nes(s

e/+n(se )r+u+ '+n /ej+'(+n y+ng enyer)+(ny+ e0(*u)( 3+/)u

)erj+'(ny+, jen(sny+, 9er+) r(ng+n )r+u+, +r+1 )r+u+ '+n *os(s( *+s(en +)+u

e/s)re()+s y+ng 9ers+ng/u)+n! R(3+y+) )r+u+ +)+u *+)+1 )u0+ng se9e0uny+,

r(3+y+) *eny+/() )u0+ng, os)eo*oros(s +)+u *eny+/() *enye9+9 os)eo*oros(s

se9e0uny+! 2en'er()+ 9(+s+ny+ '+)+ng /+ren+ +'+ny+ nyer(, *e9eng/+/+n,

g+nggu+n 6ungs( +nggo)+ ger+/, 'e6or()+s, /e0+(n+n ger+/ '+n /re*()+s(!

- 2eer(/s++n F(s(/

Lo/+0(s:

D()eu/+n )+n'+-)+n'+ /0(n(s *+)+1 )u0+ng

Ins*e/s(:

• E/s*res( 3+j+1 /+ren+ /es+/()+n

• De6or()+s y+ng 9eru*+ *e9eng/o/+n, )er*u)+r, *een'e/+n

• A*+/+1 )er'+*+) 0u/+ *+'+ /u0() '+n j+r(ng+n 0un+/

• Ger+/-ger+/ y+ng +9nor+0

• Ke+'++n +s/u0+r(s+s(

2+0*+s(:

• Kre*()+s(, )er+s+ 9(0+ 6r+/)ur '(ger+//+n! 2eer(/s++n (n( se9+(/ny+ )('+/

'(0+/u/+n /+ren+ '+*+) en+9+1 )r+u+

• Te*er+)ur

• Nyer( )e/+n '+n nyer( su9u

• 2+0*+s( +r)er( '( se9e0+1 '(s)+0 6r+/)ur


10/12

• 2engu/ur+n )ung/+( )eru)++ *+'+ )ung/+( 9+3+1

• Sens(9(0()+s

2erger+/+n:

• Fungs(o0+es+! Se9er+*+ j+u1 g+nggu+n 6ungs(, ger+/ y+ng )('+/ +*u

'(0+/u/+n, ru+ng 0(ng/u* ger+/ sen'(


11/12

2+'+ 6r+/)ur )er)u)u* '(us+1+/+n un)u/ e0+/u/+n re*os(s( )er)u)u*! Se'+ng

un)u/ 6r+/)ur )er9u/+ 1+rus '(0+/u/+n se7e*+) ung/(n, *enun'++n 3+/)u '+*+)

eng+/(9+)/+n /o*0(/+s( (n6e/s(!

/$ Kom0li*&si

• S1o/ 1eor+g(

• S1o/ neuro+s/u0+r

• In6e/s(

• E9o0(s+s(

• De6or()+s *er+nen

1$ F)&*+u) Te)bu*&

K0+s(6(/+s( :

I! Lu/+ 9ers(1, *+nj+ng % 7


12/12

REFERENSI

%! .ong D, Sj+su1('+j+) R! 2+)+1 Tu0+ng '+n D(s0o/+s(! D+0+ :

Bu/u Aj+r I0u Be'+1! EGC! .+/+r)+, %$$4 : %%&!

! R+sj+' C1+(ru''(n! 2eng+n)+r I0u Be'+1 Or)1o*e'(! B(n)+ng

L+u*+)ue : Ujung *+n'+ng,%$$ :@-5#%

&! +r/ E B+r+)?, D! T(9(+ +n' F(9u0+ Fr+7)ureon0(neJ #%#! 7()e' %# e( #%%J!

A+(0+90e 6ro 1))*:88ee'(7(ne!e's7+*e!7o8+r)(70e8"@-oer(e3

%%

Dokumen.tips Laporan Kasus Bedah Orthopedi

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