2.

1 Tutorial data

Lecturer : dr. Putri Rizki Amalia Badria

Moderator : Rivaldy Pratama
Secretary : Mala Soleha
Day/Date : Monday, 13 November 2017
Wednesday, 15 November 2017

Rules :
1. All members are required to issue income
2. raise your hand if you want to ask
3. talk politely and well-mannered
4. have a permission if you want to go out

2.2 Scenario
Iwan, 20 years old, came to the hospital with chief complaint of pain in his
right ankle since 2 hours ago. Complaints caused by right foot twisted in
and fell when playing futsal. Complaints accompanied by swelling and
more pain hen moved. Iwan complains he can’t walk because of pain on his
ankle.
Phisical examination :
General situation : Compos mentis; respiratory rate 22x/min; pulse rate 102
x/min;
Blood Pressure : 130/80 mmHg, Temperature 37ºC
Spesific circumstances
Height: 160 cm, Weight: 57 kg

Head : conjungtiva anemis (-), icteric sclera (-)

Thorax : Cor or Heart normal

Abdomen: Flat, hepar and lien not palpable

Upper extremity: normal

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 Lower extremity:

- Left: normal
- Right: regio ankle dextra:
Look:
- Asymmetrical, sollen on the lateral part
- Hematoma
- Open wound (-), Actie bleeding (-)

Feel: Tenderness (+), crepitation (-), palpable tension on the lateral

ankle skin

Move: pain hen the right ankle is moved inside.

ROM: ankle joint is limited

Pulsation of artery dorsalis pedis (+)

Supporting Investigation:

Laboratory: Hb: 11.4gr%, Leukocytes 9000/mm3

Radiological Examination: Anke dextra AP/Lateral: no visiblr fracture,

visible swelling of soft tissue in the lateral

2.3. Terms Clarification

1. Pain : The feeling of distress, suffering or agany caused
by stimulation of specialized nervi endings.
2. Ankle : The joint between leg and foot, from full extension
to full flexion
3. Twisted : Trauma of the joint causing the tearing of some
supportive ligamen fiber or muscle

4. Swelling : Transient abnormal enlargement of a body part

area not due to cell proliferation
5. Hematoma : a localized collection of extravasated blood usually
cloted in an organ space or tissue
6. Tenderness : Feeling that very sensitive by pressure or by touch
7. Fracture : The breaking of a part, especially bone

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 8. Crepitation : A dry sound like that of grating the and of a
fractured bone
9. ROM : The range of motio of a joint full of

2.4. Problem Identification

1. Iwan, 20 years old, came to the hospital with chief complaint of pain in his
right ankle since 2 hours ago. Complaints caused by right foot twisted in
and fell when playing futsal.
2. Complaints accompanied by swelling and more pain hen moved. Iwan
complains he can’t walk because of pain on his ankle.
3. Phisical examination :
General situation : Compos mentis; respiratory rate 22x/min; pulse rate 102
x/min;
Blood Pressure : 130/80 mmHg, Temperature 37ºC
Spesific circumstances
Height: 160 cm, Weight: 57 kg

Head : conjungtiva anemis (-), icteric sclera (-)

Thorax : Cor or Heart normal

Abdomen: Flat, hepar and lien not palpable

Upper extremity: normal

Lower extremity:

- Left: normal
- Right: regio ankle dextra:
Look:
- Asymmetrical, sollen on the lateral part
- Hematoma
- Open wound (-), Actie bleeding (-)

Feel: Tenderness (+), crepitation (-), palpable tension on the lateral

ankle skin

Move: pain hen the right ankle is moved inside.

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 ROM: ankle joint is limited

Pulsation of artery dorsalis pedis (+)

4. Supporting Investigation:
Laboratory: Hb: 11.4gr%, Leukocytes 9000/mm3
Radiological Examination: Anke dextra AP/Lateral: no visiblr fracture,
visible swelling of soft tissue in the lateral

2.5. Problem Priority

Number 1 : Iwan, 20 years old, came to the hospital with chief complaint of
pain in his right ankle since 2 hours ago. Complaints caused by right foot
twisted in and fell when playing futsal, It can disturb his activity and caused
more complication.

2.6. Problem Analysis

1. Iwan, 20 years old, came to the hospital with chief complaint of pain in
his right ankle since 2 hours ago. Complaints caused by right foot
twisted in and fell when playing futsal.
a. What is the anatomy and fisiology of inferior extremities ?

Answer:

Skeleton:

Os coxae, Os femur, Os patella, Os tibia, Os fibula, Ossa tarsal

(Os talus, Os calcaneus, Os naviculare, Os cuboideum, Os

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cuneiforme mediale, Os cuneiforme intermedium, Os cuneiforme
laterale), Ossa metatarsi I-V, Ossa digitorum.

Anterior muscle:

M. iliopsoas (M. iliacus, M. psoas major), M. tensor fascies latae, M.

sartorius, M. pectineus, M. adductor longus, M. gracilis, M. quadriceps
femoris (M. vastus lateralis, M. rectus femoris, M. vastus medialis), M.
fibularis, M. gastrocnemius, M. tibialis anterior, M. soleus, M. extensor
digitorum longus, M. extensor hallucis longus.

Posterior muscle:

M. gluteus medius, M. gluteus maximus, M. semitendinosus, M.

biceps femoris, M. gracilis, M. semimembranosus, M. gastrocnemius, M.
soleus.

There are so many ligament in articulation talocruralis.

In posterior there are some type of ligament : lig. tibiofibulare, lig.

talofibulare posterior, lig. talocalcaneus posterior, lig. calcaneofibulare,
lig. talocalcaneum mediale, lig. collalaterale mediale. In laterale there
some type ligament: lig. collaterale mediale, lig. Talofibulare anterius,

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lig. tibiofibulare anterior, lig. calcaneofibulare, lig. talocalcaneum
laterale, lig. talocalcaneum interoseum.

Articulation in lowwer limp :

Articulatio coxae, Articulatio genus (Articulatio femerotibialis and

Articulatio femoropatellaris, Articulatio talocruralis, Articulatio
calcaneocuboidea, Articulatio subtalaris, talocalcaneonavicularis,
Articulatio cuneonavicularis, Articulatio cuneocuboidea, articulationes
intercuneiformes, Articulationes metatarsophalangeae, Articulationes
interphalangeae pedis.

Nerves in lowwer limp diveded into two part:

 Plexus lumbalis : branches of motoric that goes to M. iliopsoas

and M. quadratus lumborum(T12-L4), N. iliohypograsticus
(T12,L1), N. ilionguinalis (T12,L1), N. genitofemoralis (L1, L2),
N. cutaneus femoris lateralis (L2, L3), N. femoralis (L2-L4), N.
obturatorius (L2-L4).

 Plexus sacralis: branches of motoric that goes to muscles

pelvitrokanterik lateralis(L4-S2), N. gluteus superior (L4-S1), N.
gluteus inferior ( L5-S2), N. ischiadicus (L4-S3), N.

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 cutaneusfemoris posterior (S1-S3), branche of cutaneus that goes
to skintuber ischiadicum (S5-Co1), N. pudendus (S2-S4), Nn.
Splanchinici pelvici (S2-S4), branches of motoric that goes to
pelvis (S3,S4)

 Fisiology:
 Femur Bone
 Femur bone is the largest body part and the strongest bone in the
human body. It connects the hips and knees. Thigh bone consists of
the head and neck in the proximal and two condylus on the distal. The
head of the femur will form the joints on the other proximal hips of
the trochanter major and the minor trochanter into a place of muscle
attachment. In the posterior proximal part there is a glutea tuberosity
with a rough surface where gluteus maximus is attached. Nearby there
is a section of aspera line where the biceps femoris muscle attached.
One of the important functions of the femoral head is where the
production of red blood cells in the bone marrow. At the distal end of
the femur there is a condylus that will make the condylar joint with
the knee. There are two condylus namely condylus medialis and
condylus latelaris. Between the two condylus there is a pause called
fossa intercondylaris.

 Tibia bone
 The Tibia is a bone thicker than the long bones in the lower leg. It is
also called shin bone. The end of its on becomes "medial" and "lateral
condyle," which has a concave surface and is united with the condyle
from femur.
 Tibia supports the lower leg bones and stretches parallel to the other,
the smaller bone (fibula) attached by the ligaments. The front of the
tibia, or tibial tuberosity, lies just below the skin and can be easily felt.

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 The tibial tuberosity is the area on the bone where the muscles tendon
and attach.
 The upper end of the femur joins to form the knee joint, and the lower
end is part of the ankle joint. On the inside of the ankle, the tibia
widened and the stick out to form a large protruding bone called the
"medial malleolus." On the outside of the ankle is a bulge called
"lateral maleolus," sometimes called the ankle bone, and is an area
most common for sprained ankles.
 The lateral meniscus of the knee is a thick, crescent-shaped piece of
cartilage that serves as a cushion. Located between the joints where
the femur and tibia articulate on the outside of the knee. Similarly, the
medial meniscus lies in the joints on the inside of the knee. The
menisci is essential for absorbing shock from the knee, as well as
providing lubrication and stabilization.

 Fibula Bone
 The fibula is long, slender on the side of the tibia. The edges expand
slightly above the "head" and lower "lateral malleolus." Fill the lateral
fibula head just below the condyle; but does not enter the knee joint
and does not bear any weight. The ligaments that join the fibula to the
front of the fibula are called "antibody tibiofibular ligaments," and
"posterior tibiofibular ligaments" joining them behind the knee. The
lateral malleolus is joined to the ankle by the "anterior talofibular
ligament," and "posterior talofibular ligament." This ligament forms a
bulge at the ankle side
b. What is the meaning there’s a complaint about pain in his ankle since 2
hours ago?

Answer: feel pain from 2 hours ago means that there is acute pain on
ankle. it is a sudden injury that can caused by hypermobile of ankle,
clash by something hard, bad coordination of muscle and joint, or etc.

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 the Acute pain is felt from 1 second to less than 6 months. The pain
shows that there is an inflammatory process which are indicated by
character like rubor, kalor, dolor, and tumor (Nugroho, B. 2013).

c. What is the clasification of pain?

Answer : 1. Pain according to duration

a. Acute Pain: Take place in a short time (< 6 Months), will be healed
by itself without any treatment.
b. Chronic Pain: Take place in a long time (> 6 Months), the pain will
be constant, and will be feeled with heavy intensity.

2. Pain according to source

a. Nosiseptif Pain: Caused by sensitivity of nosiseptor peripheral that

contact with skin, bone, joint, muscle.
b. Neuropatic Pain: Result from injury or abnormality on peripheral
nerves or central. Hard to be healed.

3. Pain according to location

a. Supervicial Pain: Caused by skin stimulus. Short time and

localized. For example caused by syringe.
b. Referred Pain: The pain itself will be feel in other location from the
source. Its because some organs dont have receptors of pain.
c. Viseral Pain: caused by stimulation of organs internal. Diffuse and
will be spread into some area.

d. What is the movement of inferior extremities?

Answer:
a. Aduksi and Abduksi
b. Flexions and Extensions
c. Inversions and eversions

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 Flexions and extensions on knee joints, inversions and eversions on
the soles of the feet, abduksi and aduksi toes, abduksi and aduksi the
hip joint ( anatomy snell )
e. What is the Patophysiology?

Answer: physical activity → ankle movement of emphasis turns

suddenly → foot are not support perfectly → many bone stabilizer on
the lateral side so it make the pressure of foot be inverted → foot in
inversion position → ligamentous for eversion are not strong enough to
retain the inversion forces → structure of ligaments are stretch beyond
normal → torn of lateral complex ligaments → inflammatory process
→ release bioactive chemicals → stimulate nerves on site of injury →
pain (Sumartiningsih, 2012).

f. How to measure range of pain?

a. Answer : Numerical Rating Scale
b. Visual Analogue Scale
c. Verbal Rating Scale (Sudoyo, 2014).
g. What is the relation betweem his age and twisted right ankle when
playing futsal with his complaint?

Answer: According to research by The Electronic Injury National

Surveillance System (NEISS) in America shows that ankle sprain is
influenced by gender, age, and involvement in sports. Men aged between
15-24 year olds have higher rates of sprain ankle, and female ages The
30-year-old has a higher rate of sprain ankle. Half of all ankle sprain
(58.3%) occurs during athletic activities, with basketball (41.1%),
football (9.3%), and soccer (7.9%). This can prove that the highest
percentage of ankle sprain is during exercise (Martin et al., 2013).
h. What is the impact of twisted ankle?

Answer: Impact of twisted ankle: ligament damage can lead to

decreased movement and instability, resulting in easy occurrence of

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 bone sprain and bone inflammation, accumulation of collagen fibers,
the emergence of fibous tissue, causing decreased tissue elasticity,
healing inhibited. If this condition lasts long disturbance of stability to
ligament laxity (passive stability) and decreased neuromuscular
function (active stability). In muscle will decrease motor recruitment
muscle and non activation at golgi body so happened happened
sensorimoto deficit, while at ligament destructive mechanoreptor which
result proprioceptive decrease. The decreased proprioceptive will be
followed by decreased reflexes in the ankle.
i. What is the possible illness in this case?

Answer: Chronic ankle sprays that last a long time and are not
handled properly or do not make improvements will cause disability.
Foot and ankle disability is characterized by an inability to perform
movement and functional activity. The presence of conditions of chronic
ankle sprain itself causes the patient to feel uncomfortable in carrying out
his daily activities resulting in foot and ankle disability. If this is not in
good intervention it will be an increase foot and ankle disability in
chronic ankle sprain. The disrupted functionality of the foot and ankle
functionality includes standing activity, walking normally, light to heavy
work, response with homework, squats, up and down stairs, and personal
care / maintenance, daily living, recreation and sports activities. Such
activity may be disrupted and its function decreases it is named disability
(Barr and Harrast. 2005).

j. How the mechanism of iwan’s trauma?

Answer: Answer: ankle movement of emphasis turns suddenly → foot
are not support perfectly → many bone stabilizer on the lateral side so it
make the pressure of foot be inverted → foot in inversion position →
ligamentous for eversion are not strong enough to retain the inversion
forces → structure of ligaments are stretch beyond normal → torn of
lateral complex ligaments → inflammatory process → vasodilatation of

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 blood vessel in the area of injury → permeability of vascular increased
→ many blood fluids send to the site of injury → seeps out from
capillary to interstitial space → swelling

Ligament damage → movement and instability decreased →

neuromuscular function decreased → motor muscle recruitment
decreased and nonactivation of the Golgi body → deficit of
sensorimotor → when move there is spasm muscle → pain when
moved

Ligament damage → movement and instability decreased →

accumulation of collagen fibrous → arise fibrous tissue → elasticity of
tissue decreased → ankle hypomobile → pain when moved

Ligament damage → stimulates nerves → proprioceptive decreased →

ankle reflex decreased → ankle joint is limited.
k. How does ankle injury heals it self?

Answer:
1. Telling the victim to rest
2. Do not panic Acting nimble but still in a state of calm because of
calmness will help to be able to act right and right.
3. Watch for signs of shock If the victim shows signs of shock, the
victim is stretched out by putting the head lower than the rest of the
body.
4. Do not move the victim in a hurry, Don’t move from its place before
it can be ascertained the degree of severity of injury suffered (Cava, Cs.
1995).
l. What are syntoms of ankle injury?

Answer: Usually people feel pain in their ankle, then it will caused
swelling. The swelling itself can cause limited of range of motion.
Swelling will be turned into bruising. The affected area will be tender to
touch and usually unstable.

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2. Complaints accompanied by swelling and more pain hen moved. Iwan
complains he can’t walk because of pain on his ankle.
a. What is the meaning there are complaints about swelling and more pain
when moved?
Answer: The meaning of the swelling and getting more painful when
moving is because there is a scretch or tear in the ligament of their
ankle. More movement that will move the ligament that already tear,
will caused more tear and it can cause tear or scretch on syndesmosis
which will make the ligament is hard to heal.
b. What is the pathophysiology of swelling?

Answer: physical activity → ankle movement of emphasis turns

suddenly → foot are not support perfectly → many bone stabilizer on
the lateral side so it make the pressure of foot be inverted → foot in
inversion position → ligamentous for eversion are not strong enough to
retain the inversion forces → structure of ligaments are stretch beyond
normal → torn of lateral complex ligaments → inflammatory process
→ vasodilatation of blood vessel in the area of injury → permeability of
vascular increased → many blood fluids send to the site of injury →
seeps out from capillary to interstitial space → swelling
(Sumartiningsih, 2012).

c. What can caused swelling?

Answer :
d. What is the meaning of iwan complaint that he cant walk because of
pain his ankle?

Answer: The meaning he can’t walk because he had functio leasa which
caused by the pain in the ankle, probably because the ligament is torn
apart. So there wil be aupture on the anterolateral capsul go to ankle
stability will lose and he can’t walk properly, it sign of grade ankle

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 sprain usually caused by sudden laterale movement or mediale
movement of ankle. Inversion twisting is the typical of leg sprain, this is
caused by there is so many bone in the laterale so the pressure in the
laterale become inverse, if there is enough power, twisting ankle can
spread to medial maleolus tolose stability and cleating a pressure point
that inverse the ankle, when the ligament for eversion not strong enough
to hold inversion power, then the laterale ligamentwill torn apart.
Usually there isone or two ligament injury, which is anterior
talofibulare ligament and calcaneus fibular ligament. When the
ligament torn apart, there is sign of swelling, bruise and there is pain

(Sumartiningsi S. 2012).

3. Phisical examination and Spesific examination

a. What is the interpretation of abnormal physical examination?
Answer: Pulse rate 102 x/min : Takikardia
Right: regio ankle dextra:
Look:
- Asymmetrical : abnormal
- Swollen on the lateral part : inflammation react
- Hematoma : internal bleeding
Feel: Tenderness (+) :
Move: pain hen the right ankle is moved inside : abnormal
ROM: ankle joint is limited : abnormal

b. What is the patophysiology of abnormal physical examination?

Answer:

 Pulse rate 102x/min

Ankle and foot hypermobile → injury → sprain ankle → vasodilatation of

blood vessel → many blood send to the injury area → circulation disorders
→ supply o2 decreased → compensate body to take more o2 → pulse rate
102x/min

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  Hematoma

Ankle and foot hypermobile → injury → sprain ankle → vasodilatation of

blood vessel → more blood flows to local microcirculation → capillaries
filled with blood rapidly → visible to surface skin → hematoma

 Pain when moved

Ligament damage → movement and instability decreased →

neuromuscular function decreased → motor muscle recruitment decreased
and nonactivation of the Golgi body → deficit of sensorimotor → when
move there is spasm muscle → pain when moved

Ligament damage → movement and instability decreased → accumulation

of collagen fibrous → arise fibrous tissue → elasticity of tissue decreased
→ ankle hypomobile → pain when moved

 Ankle joint is limited

Ligament damage → stimulates nerves → proprioceptive decreased →

ankle reflex decreased → ankle joint is limited (Chan K, 2011).

4. Supporting Investigation:
a. What is the interpretation of abnormal Supporting Investigation?
Answer: visible swelling of soft tissue in the lateral : abnormal
swelling of soft tissue in the lateral part means there’s an inflammation
react in ligamentum calcaneofibulare or ligamentum talofibulare
anterior.
b. What is the patophysiology of abnormal Supporting Investigation?

Answer: injury causes the body to respond with inflammatory signs

such as rubor, tumor, heat, dolor and fuctiolaesa (decreased function).
The blood vessels at the site will dilate (vasodilatation) in order to send
more nutrients and oxygen in order to support healing. Dilation of blood
vessels is what causes the location of the injury looks red (rubor). A
large amount of blood fluid is injected at the site of the injury will leak

15
 out of the bloodstream into the interstitial tissues and cause swelling
(tumor). With the support of many nutrients and oxygen metabolism at
the site of injury will increase with the rest of the metabolism of heat.
This condition causes the location of the injury to be hotter than other
locations. Inflamed tissue swelling causes an increase in nerve endpoint
pressure at the locale. So that the rubor, tumor, heat or dolor will reduce
the function of joints at the site of injury known as the termolesolesa.

c. What is the preparation X-ray?

Answer:
1. EXAMINATION PROTOCOL
2. AREA:ANKLE
3. VALID REASONS FOR EXAMINATION
Acute ankle injury – adopt Ottowa guidelines below:
Ottawa guidelines
 An ankle x-ray is required only if there is pain in the mallleolar zone
and any one of the following
 Bone tenderness along the distal 6cms of the posterior edge of the
fibula or tip of the lateral malleolus
 Bone tenderness along the 6cm posterior edge of the tibia or tip of the
medial malleolus
 Inability to bear weight for 4 steps both immediately and in the
emergency department
 Suspected inflammatory arthropathy on presentation
4. STANDARD PROJECTIONS
Anteroposterior
Lateral
5. ADDITIONAL PROJECTIONS
Mortice View
Axial Calcaneum (Reynolds, 2015).

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5. If the Complaint are collected
a. How to diagnose in this case?

Answer: Anamnesis

Complaint of pain in his right ankle since 2 hours ago, swelling and more
pain when moved, he can’t walk becouse of pain on his ankle.

Physical diagnostik

Lower extremity:

Right: regio ankle dextra

Look:

- Asymmetrical, swollen on the lateral part

- Hematoma

Feel :

- Tenderness (+), palpabel tension on the lateral ankle skin

Move :

Pain when the right ankle is moved inside

ROM:

Ankle joint si limited

Pulsation of artery dorsalis pedis (+)

Suporting investigation

Radiological examination : Ankle dextra AP/Lateral: no visible fractur,

visible swelling of soft tissue in the lateral.

b. What are the differential of diagnose in this case?

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Answer:

1. Ankle Sprain Injury

2. Fracture
c. What is the Support examination needed in this case?

Answer: Nothing, because supporting examination is complated.

d. What is the working diagnose in this case?

Answer: Ankle Sprain Injury
e. What is the treatment in this case?

Answer: With the RICE method (Rest/break: stop activity immediately)

Excessive activity on the affected part will trigger further complications,
Ice is the use of ice: When the injury will cause swelling and
vasodilatation, giving cold compress/ice will constrict the blood vessels
thus reducing swelling, compression/emphasis: on parts of injuries can
be bandaged/bandaged, and elevation/elevation), cessation of sport
activity for 2 to 3 weeks. When experiencing pain is given anti-pain such
as Ibuprofen and anti-inflammatory drugs. Prevention: by warming up
before exercising and cooling after exercising, practicing regularly,
obeying the rules of the game and not having anatomical abnormalities

f. What complications can occur in this case?

Answer:

1.ankle become chronically unstable

2. early arthritis in ankle joints (Sumartiningsih, 2012).
g. What is the prognosis in this case?
Answer: Dubia ad bonam
h. What is the competence of general doctor in this case?
Answer:

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4a. a doctor is able to explain and diagnose the disease as well as to
conduct the procedure independently and thoroughly
i. What is the Islamic value in this case?
Answer:

Al-Mu’minun: 14 “Then we made the semen of blood, and then a lump of

blood We made a lump of meat, and a lump of meat We made the bones,
then the bones We wrap with flesh. Then We made him another (shaped)
creature. So Glorious is Allah, the Most Excellent Creator.”

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2.7. Hypothesis

Iwan, 20 years old, complaining pain in his ankle because of ankle sprain injury.

2.8. Conceptual Sceme

Fell when playing

Futsal

Sprain

Right ankle Twisted

Swelling and pain

Swelling and pain

Can’t Walk

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 DAFTAR PUSTAKA

Sri sumartiningsi. 2012. Ankle Sprain. Semarang University: Indonesia

Snell, Richard S. 2011. Anatomi Klinis: Berdasarkan Sistem. Jakarta: EGC

Sudoyo AW, Alwi l, Simadibrata M, Setiyohadi B, Syam FA, Setiati S. 2014.

Ajar Ilmu Penyakit Dalam. Edisi VI. Jakarta: Interna Pubishing

Nugroho, B. 2013. Cedera Ankle dan Terapi Latihan. Yogyakarta: UGM

Reynolds, JH. 2015. Radiographic Standard Operating Protocols. NHS

Foundation Trust. Heft Radiology, UK.

Cava, Cs. 1995. Pengobatan dan Olahraga . Semarang : Pustaka Media

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