Good morning dr Agus, dr. Andri Primadhi, dr.

Herry herman,

Good morning candidates and all residents

This is morning case report, Saturday November twenty six, two thousand and twenty two,

Night shift

There was one patient to be reported

-------------------------

Male, nineteen years old

Mr. Hari Firmansyah / 19 y.o. / Employee / 0002092841

Chief complaint: Wound at left arm and pain at right thigh

Primary survey:

A: Clear without C-spine control

B: Shape and movement was symetrical for both hemithorax, RR : nineteen x/mnt, Saturation : 100%

C: BP: one hundred and twenty over seventy mmhg, HR: one hundred and ten times per mnt,
bimanual pelvic compression test was stable

D: GCS: 15 E4M6V5, pupil isokor, diameter 3mm/3mm , light reflex +/+

E:

Burn injury 4% at upper body region

Burn injury 1% at right upper extremity

Swelling and burn injury 6% at left upper extremity

Burn injury 0,5% at genital area

Burn injury 4,5% at left lower extremity

Swelling at right thigh

HT: Eleven hours prior to the hospital admission, when the patient was installing electrical cables in
Tasikmalaya city, using stairs. The patient was lost his balance and fell from 5 meter height, with his
left arm holding a high-voltage electric cable and his right thigh hitting the ground first. After the
accident, the patient complained burns at his left arm and pain at right thigh. The patient then taken
to SMC Tasikmalaya Hospital, got wound cleansing and then referred to the Plastic Surgery division
Hasan Sadikin Hospital.

Secondary survey:

At chest region :

L: superficial dermal to full thickness burn injury 4% total burn surface area TBSA eschar melingkar (–)

F : tenderness +

At right arm :

L: deep dermal to full thickness burn injury 1% TBSA, eskar melingkar (-), shiny skin (-)

F : tenderness +, distal sensibility normal compared to the other side, CRT<2”, pain out of proportion
(-)

M : ROM within normal limit

At left arm :

I: mid dermal - full thickness burn injury 6% TBSA, eskar melingkar +, swelling +, shiny skin +

F : tenderness +, distal sensibility decreased compared to the other side, radialis artery pulsation was
absent, CRT>2”

M : ROM limited due to pain and contracture

At pelvic region :

L : I: mid dermal - full thickness burn injury 0.5%, eskar melingkar

F : tenderness +

M : ROM limited due to pain

At right thigh :

L: swelling +, deformity (-), wound (-)

F: tenderness +, distal sensibility normal compared to other side, CRT <2 Sec

M: ROM limited due to pain

At left thigh :

I: mid dermal to full thickness burn injury 4.5% TBSA, eskar melingkar (-), deformity (-), shiny skin (-)

F : tenderness +, distal sensibility normal compared to the other side, CRT<2”

M : ROM within normal limit

Limb length discrepancy : 1 cm

TL: 84 cm / 83 cm

AL: 86 cm / 85 cm

Clinical Diagnosis:

- Susp closed fracture at right proximal femur

- Electrical burn injury sixteen percentt at upper body, right upper extremity, left lower extremity, and
genital area

- Compartement syndrome at left forearm due to electrical burn injury

Xray examination :

Cervical :

This is Cervical lateral x ray of male 19 y.o. there is no identity with no marking side

A= Acceptabilities:

- Patient name, age, marking,

- Lordosis, C1-Upper pole T1,

- Check orientation, position and side description (Left, right, erect, ap, pa)

Acceptence : we can see vetebrae body of C1 to Upper body of T1

A Alignment: there was no disruption of

• Anterior vertebral body line

• Posterior vertebral bodyline

 • Spinolaminal line

• Posterior spinosus line

Bone : Vertical body height of all segment was equal

C = Cartilage = There was no irregularity of Upper and lower end plate

Disc = Intervertebral disc space of all segment was equal

No Vacuum disc phenomenon

S : Soft tissue = • Retropharyngeal space at C2 0,64 mm

(Children and, adult 7 mm)

• Retrotracheal Space at C6 1,43 mm

(Children 14 mm, adult 21 mm)

Thorax xray

This is Thorax AP view x ray of male 19 y.o.

A= Airway:

• No Trachea deviation

No increasing of Broncovascular marking

B = No bone discontinuity at Clavicle, vertebrae, Sternum

C = Cardiothoraxic ratio less than 50%

D : Diaphragma:

• Meniscus sign (level at 10th costae)

• Costophrenic angle was sill sharp for both hemithorax

Pelvic

There was no disruption of pelvic line

- Ilioischial line

- Iliopectineal line

- Shenton Line

- teardrop

- antrior wall
- Acetabular roof

- Posterior wall

There was bone discontinuity at right intertrochanter femur comminutive displaced

Femur

- There was bone discontinuity at right intertrochanter femur comminutive displaced

Working diagnosis:

- Closed fracture at right intertrochanteric femur comminutive displaced Evans unstable , AO

Classification 31A2

- Electrical burn injury 16% at upper body, right upper extremity , left lower extremity, and genital area

- Compartement syndrome at left forearm due to electrical burn injury

Management:

Analgetic, antibiotic, tetanus prophylaxis

Fluid resuscitation 4000cc /24 hours

Plastic Surgery Division:

Performed:

• Debridement and fasciotomy at emergency theatre

Orthopaedic & Traumatology Department:

Performed :

• Immobilization with skin traction

Plan to :

• Closed reduction and internal fixation with Cephalomedullary nail electively