Case Presentation

Female 5 Years Old with Closed Fracture 1/3 Medial of Left Femur

Arranged by: Melisa Esti Wahyuni G0007209

Tutor: dr. Tangkas Sibarani, SpOT, FICS

Clinical Department of Orthopaedic & Traumatology Sebelas Maret University Hospital of Dr. Moewardi/ Orthopaedic Hospital of Prof. Dr. Soeharso Surakarta 2012

LEGALY SHEET

Case presentation entitled Female 5 Years Old with Closed Fracture 1/3 Medial of Left Femur is arranged to fulfill the requirement of clinical department of Orthopaedic & Traumatology Sebelas Maret University Hospital of Dr. Moewardi/Orthopaedic Hospital of Prof. Dr. Soeharso, by:

Melisa Esti Wahyuni

G0007209

Has been approved by the case presentation tutor of the Orthopaedic Hospital of Prof. Dr. Soeharso on February, 2012.

Tutor

dr. Tangkas Sibarani, SpOT, FICS

CASE PRESENTATION

I. Anamnesis 1. Identity Name Age Sex Address Occupation Medical record Hospitalized : Nabila : 5 years old : Female : Jotang 03/01 Kendal :: 00212870 : February 8th, 2012

Date of examination: February 8th, 2012

2. Chief complain Pain in her left upper leg

3. Present illness Alloanamnese with her parent Yesterday, at 2 pm, patient played with her friend and suddenly a motorcycle crushed her. She fell down and the tire of motorcycle crushed her upper leg. She couldnt move her left leg and felt pain. Then her parents brought her to the Kendal hospital. In that hospital, patient took a radiograph examination and diagnosed with closed fracture 1/3 medial of left femur. Kendal hospital sent her to the Orthopaedic Hospital of Prof. Dr. Soeharso, in order to get more treatment.

4. Past history Hospitalization: one year ago, with burn injury in right upper leg. There are no other disease history.

Extremity Motoric: upper extremity (5/5), lower extremity (5/x) Sensoric: upper extremity (+/+), lower extremity (+/+)

Local Status L: swelling (+), deformity (+), skin intact F: The temperature of the skin in left upper leg is warmer than around and right upper leg, probe pain (+) M: ROM of coxae articulation and genu articulation are limited because of pain

LLD 2 cm

III. Assesment I Closed fracture 1/3 medial of left femur

IV. Additional Examination X-ray of left upper leg in AP and Lateral position: The x-ray of female 5 years old, was taken on February 8th, 2012 in Orthopaedic Hospital of Prof. Dr. Soeharso. There is fracture line in 1/3 medial left femur with oblique configuration.

V. Assesment II Closed fracture 1/3 medial of left femur

VI. Planning II Initial treatment: immobilitation (Skin traction 2kg), analgetic, and hospitalized Conservative treatment

VII. Prognosis Ad vitam Ad sanam : good : good

Ad fungsionam: good