CHAPTER II

CASE REPORT

I. IDENTITAS
Nama : Mr.S
Age : 35 yo
Gender : Male
Address : Kaliwungu 03/05 Kendal
Job : employee
Religion : Islam
At Hospital : 26 October 2016
Room : Kenanga
No. CM : 512409

II. ANAMNESIS
A. Symptom : Pain of the right forearm
B. Present History :
The man came to the poli orthopedi with his family after fell while falled
from motorcycle. While the incident of patient falls to the right, He was
collided with a motorcycle in front of his before he fell. He complained
that his right forearm felt pain if he moved. He told that every he moved
like flexi and extention he keep on pain.

PRIMARY SURVEY
- Airway: patent, clear
- Breathing: good, 24x/m
- Circulation & Hemorragic : BP: 120/70 mmHG, N: 84x/m
- Dissability: Alert, GCS 15
- Expossure: Normal, nothing lession
 Medical History :
 History of similiar injury : Nothing
 History allergy drug and food : Nothing
 History of long cough : Nothing

C. Family Medical History :

 History of similiar symptom : Nothing
 History of heart disease : Nothing
 History of diabetics militus : Nothing

D. Personal History, Social, and Environment

 Patient used health insurance BPJS

III. PHYSICAL EXAMINATION

GCS : 15
VITAL SIGN :
 HR : 84 x/m
 RR : 24 x/m
 to : 36o c
 HP : 120/70 mmHG
 Weight : 65 kg

Status Generalis

1. Skin : Turgor (N)

2. Head : Mesocephal, Wound (-)
3. Eyes : Anemis -/-, Icteric -/-
4. Ear : Discharge -/-
5. Nose : Deviation septum -/-, discharge -/-
6. Mouth : Blooding (-)
 7. Neck : Simetris, Trachea deviation (-)
8. Thorax : Normochest, simetris

COR

Inspeksi : ictus cordis (-)

Palpasi : Ictus cordis palpable at SIC V, 2 cm medial to the

linea mid clavicularis sinistra, pulsus the sternal (-), pulsus
epigastrium (-)
Percussion : heart border
Bottom left: SIC V, 2 cm medial linea mid clavicularis sinistra
Top left : SIC II linea sternalis sinistra
Top right : SIC II linea sternalis dextra
Waist heart: SIC III linea parasternalis sinistra
Impression : configuration of the heart normal
Auscultation : heart sound I-II regular, gallop (-), murmur
(-)
Pulmo :
Anterior Posterior
I: Statis: normochest(+/+), simetris I: Statis: normochest(+/+), simetris
(+/+), retraction (-/-). Dinamis: simetris (+/+), retraction (-/-).Dinamis: simetris
Pa: statis: simetris (+), nothing Pa: statis: simetris (+), nothing
widening between the ribs, retraction (- widening between the ribs, retraction
/-), sterm fremitus dx=sin (-/-), sterm fremitus dx=sin
Pe: Sonor (+/+) Pe: Sonor (+/+)
Aus: vesicular (+/+), ronchi (]-/-), Aus: vesicular (+/+), ronchi (-/-),
wheezing (-/-) wheezing (-/-)
 Back : kifosis and lordosis (-)

Abdomen :
Inspection : normal, massa (-)
Palpation : Supel, pain (-), hepar and lien are not papble
Percussion : tympani (+)
Auscultation : bowel (+) Normal

Eksremity:

Superior Inferior
Akral -/- -/-
Oedem +/- -/-
Capillary refill <2 “ <2”
Lession -/- -/-
Hematom -/- -/-

IV. LOCALIS STATUS

right Forearm :

Move :
 Active :
- Extention : (+)
- Flexion : (-)
- Endorotation : (-)
- Exorotation : (-)
 Pasif :
- Extention : (+)
- Flexion : (-)
 - Endorotation : (-)
- Exorotation : (-)

V. SUPPORTING EXAMINATION
1. X- Foto Rontgen Regio antebrachii dextra 2 position AP/Lateral

2. Laboratory (26-10-2016)
Hematologi Hasil Reference value
Hemoglobin 12,7 gr/dL 11,5-16,5
Leukosit 10,2 10^3/uL 4,0-10,0
Trombosit 290 10^3/uL 150-500
Hematokrit 40,2 % 35,0-49,0
Protombin Time (PT) 11,5 s 11,3-14,7
APTT 33,2 s 27,4-39,3
VI. ASSESMENT
Dx. Clinic:
Close Fracture radius ulna dextra.
VII. INITIAL PLAN
a. Ip Terapeutik
Medical treatment
- Infus RL 20 tpm
- Inj. dexketoprofen 2x50 mg
- Inj. Cefazolin 2x1
- Inj. Ranitidine 3x50 mg
b. Ip. Operatif
ORIF
c. Ip. Monitoring
General situation, Vital sign, the result of supporting examination
d. Education
- Describes of the disease and the prognosis to the family
- Explain the possible complication that can happen to
family
VIII. PROGNOSIS
 Quo ad vitam : ad bonam
 Quo ad sanam : ad bonam
 Quo ad fungsionam : dubia ad bonam
 CHAPTER I
INTRODUCTION

The forearm consists of the radius and ulna which are connected by the

proximal and distal radioulnar joints, the interosseous membrane and several

muscles. Forearm rotation, consisting of pronation and supination, is a rotatory

motion of the radius around the ulna in combination with subtle translation1. The

longitudinal axis of the forearm is considered to pass through the centre of the radial

head proximally and through the ulnar fovea at the base of the ulnar styloid distally.

Fractures of the forearm present unique management problems. In these

particular diaphyseal fractures, perhaps more than any others, the combination of

anatomical reduction and skeletal stability with mobility of the extremity is

necessary to produce excellent functional results. Of all diaphysial fractures, only

the forearm requires anatomical reduction and stable internal fixation, in order to

maintain full function of the hand. 10–14% of all fractures occur in the forearm.

The incidence of forearm shaft fractures does not increase with age

A fracture that occurs can be about adults or children, a Fracture on the

forearm in children approximately 82% in distal radius bone area of the

metaphysical, and distalulna fracture while in the area of diafisis which occur

frequently as invoice type green-stick. Radius fractures can occur in

the proximal 1/3, 1/3 middle or distal 1/3.

 CHAPTER III
CONTENTS REVIEW

3.1 Anatomical of Bone

3.1.1 Bone can be classified into five groups based on its shape:
a. Long bones (femur, humerus) consisting of a long thick stem, called the
diaphysis and two ends, called the epiphysis. Next to the proximal
epiphysis are metaphysical. Among the epiphysis and metaphysis are
growing cartilage area, called the epiphyseal plate or growth plate. Long
bones grow because of the accumulation of cartilage in the epiphyseal
plate. Cartilage is replaced by bone cells produced by osteoblasts and
bone lengthening. The stem is formed by dense bone tissue. Formed
from spongi epiphyseal bone (cancellous or trabecular). At the end of
the teen years depleted cartilage, epiphyseal plates fuse, and the bones
stop growing. Growth hormone, estrogen, and testosterone stimulates
the growth of long bones. Estrogen, along with testosterone, stimulates
the fusion of the epiphyseal plate. Stem a long bone has a cavity called
the medullary canal. Medullary canal contains the bone marrow.
b. Short bones (carpals) irregularly shaped and the core of cancellous
(spongy) with an outer layer of dense bone.
c. Short flat bone (skull) consists of two layers with an outer layer of solid
bone is bone concellous.
d. Irregular bone (vertebrates) is the same as the short bones.
e. Sesamoid bone is a small bone, which is located around the bone adjacent
to the inventory and supported by tendons and facial tissues, for example
the patella (knee hood).
3.2 Fracture Definition
A fracture is any break in a bone, including chips, cracks, splintering,
and complete breaks.
Two Basic Types Of Fracture:
1. Closed Fracture (Simple fracture):
Occurs when a bone is broken but there is no penetration extending
from the fracture through the skin.
2. Open Fracture: (Compound fracture)
Is a fracture in which there is a wound over the fracture site, with or
without bone protruding through it.

This type of fracture is more serious than closed fractures because the
risks of contamination and infection are greater. Fractures are further
classified according to their appearance on x-ray:
Types of fracture
a. Green stick fracture
Usually occurs in children whose bones are still pliable (like green
sticks). A break occurs straight across part of the width of the bone,
perpendicular to the long axis
b. Transverse Fracture
Cuts across the bone at right angles to its long axis often caused by direct
injury
c. Oblique Fracture
The fracture line crosses the bone at an oblique angle
d. Comminuted Fracture:
The bone is fragmented into more than two pieces
e. Impacted Fracture:
The broken ends of the bone are jammed together
f. Spiral Fracture:
Usually results from twisting injuries.The fracture line has the
appearance of a spring
This type of fracture of the radius and ulna fracture:
• Fracture of the Radius Kaput
Fracture of the radius kaput is often found in adults but it is almost
never found in children. This fracture is sometimes feels pain when the
forearm is rotated, and painon the lateral side of the
elbow press gave instructions to mendiagnosisnya.
• Fracture of the neck of the Radius
Fall on the outstretched hand can force the elbow into valgus and
encourage kaputradius at kapitulum. In adults kaput radius can be
cracked or broken, whereas in children's bones are more likely to experience
a fracture in the neck radius. After the fall, the boy complained of pain in
the elbow. On this there is the possibility of fracturepain kaput press
on radius and pain when the arm is rotating.
• Fracture of Radius Diafisis
If there is pain, local press should do x-ray examination
• Fracture of the Distal Radius
Distal Radius fractures are divided into:
1. Galeazzi Fracture
Fracture of Galeazzi Fracture on i.e. 1/3 of the distal radius, accompanied
by joint dislocation of the distal radio-ulna. The distal fragment is
experiencing shifts and angulasi to the dorsal direction. Dislocation about
the ulna toward the dorsal and medial. This fracture due to a fall with his
hands outstretched and the forearm in pronation, or circumstances occur
due to blow directly on the dorsolateral part of the wrist.Galeazzi fracture is
much more common than the Monteggia fracture. The ends of the bottom
of the ulna that stands out is the
striking markings. Necessary examination for nerve lesions ulnaris,
which often happens.

2. Colles Fracture
This fracture due to a fall with his hands outstretched. Fracture of
the distal radius occurs in corpus, usually of about 2 cm of the articular
surface. The distal fragment is shifted towards the dorsal and proximal,
showing a picture of deformities "fork-dinner" (dinner-fork). The
possibility can be accompanied by a fracture of
the ulna styloideus prosesus on. Fracture of distal part of radius (up to 1
inch from the ends of the distal) and angulasi to the dislocated posterior to
the posterior, and distal to the pragmen radial deviation. Can
be kominutiva. It can be accompanied by a
fracture prosesus stiloid ulna.Collees fracture can occur after a fall, so that
can cause fracture at the lower end of radius with distal fragment of
posterior shift
3. Smith's Fracture.
These fractures due to falls on the back of the hand or blow directly on the
back of the hand. The patient's wrist injury, but there were no
deformities. Fracture of distalpart of radius with dislocation of
the distal fragment or angulasi towards the ventralradius diviasi with the
hand that gives an overview of deformities "spade Garden"
(garden spade).

4. Fracture of plate Epifisis

Epifisis Plate fracture is a fracture of the long bone in the region at the tip
of the bone at the joint dislocations and ligament tears
Classification according to the Salter-
Harris classification embraced and divided into5 types. Most common
is type II, with the metaphysical fragments seen in triangulardorsal.
Klasifikasi Salter Harris
-Type I
Total epifisis plate separation occurs in the absence of a
fracture in the bone, the growth plate cells still attached to
the epifisis epifisis. This fracture occurs due
to shearing force and often occur in the newborn and in
children that young. Treatment with closed reduction is
easy because there are still intact and the
periosteum bondingintak. The prognosis is usually good
when direposisisdengan fast.
-Type II
A type of fracture that is often found. The fracture line through all
the epifisis plateand turning the metaphysical and will form
a triangular-shaped metaphysical fragments is called a sign
of Thurson-Holland. Growth of cells on the epifisis plate is also
still attached. The trauma which produce this type
of fracture usually occurs in children. The periosteum suffered a
tear in the area konveks but remain intact in the
areakonkaf. Treatment with repositioned as soon as possible not so
hard unless when repositioning late to do action operation. The
prognosis is usually good, depending on the damage to the blood
vessels.
-Type III
Epifisis plate type III fracture is a fracture of the intra-
artikuler. Fracture lines beganpassing joints surface plate epifisis pl
ate epifisis along the line then. This type of fracture is intra-
artikuler and are usually found on the distal tibia epifisis. Because
of this fracture are intra-artikuler and needed an
accurate reduction then we recommend that you do open
surgery and internal fixation using pins are delicate.
 -Type IV
This type of fracture is also an intra-artikuler fracture through
the joint surfaces of the cutting epifisis and all layers of epifisis and
continues on a portion of the metaphysical. This type of fracture of
the lateral condyle fractures such as humeri in children. Treatment
with internal fixation and open operations are done because the
fracture is unstable due to the pull of muscles. The prognosis was
ugly when the reduction is not done.
-Type V
Type V fracture is a fracture due to destruction of epifisis that are
forwarded on epifisis plate. Usually occurs at the joints of
the body that is the underpinning of the ankle joint and the knee
joint. Diagnosis is difficult because radiologik cannot be seen.The
prognosis is ugly because it can damage part or all of the
growth plate.
5. Monteggia Fracture
This type of fracture caused by pronation forearm imposed when a
fall or a blow directly on the proximal third of
the dorsal with anterior angulasi accompanied with anterior dislocation of
radius kaput.

CT scans used to detect the location of a complex fracture structure and

determine whether the fracture is a fracture of
the compression fracture or burst fracture, dislocation. Usually
 with this fracture of the MRI scan will be more clearly evaluate soft
tissue trauma, damage to ligaments and the presence of bleeding.

3.3 Procces of Fracture

a. Direct
fracture occurs at the site of trauma. Direct pressure on the bone and
fracture in the area of pressure. Ex : direct hit over the bone
b. Indirect
Trauma occurs when trauma doesn’t directly delivered to areas farther
from the fracture. Usually the soft tissue remains intact. Ex: after falling
on outside stretched hands
c. Force of Powerful Muscle Actions
For example, violent cough may cause rib fracture
d. Aging and bone disease
Can increase the risk of fractures (pathologic fractures), with bones
breaking even minor accidents
e. Twisting Forces
Such injuries are often seen in football and skiing accidents where a
person's foot is caught and twisted with enough forces to fracture a leg
bone

3.4 Treatment of Fracture

a. Recognition or recognition is doing the correct diagnosis so that it
will help in the treatment of fractures due to treatment planning can
be prepared more perfect .
b. Reduction or repositioning is retake actions fracture fragments as
closely as possible to its original condition or status or circumstances
normal layout .
c. Retention or fixation or immobilization is action to maintain or hold
the fracture fragments during healing .
 d. Rehabilitation is an act with the intention that section who suffer
these fractures can be back to normal .

The 4 AO principles, in their basic form, have governed the society’s approach to
fracture management for decades. They are as follows:

1. Anatomic reduction of the fracture fragments: For the diaphysis, anatomic

alignment ensuring that length, angulation, and rotation are corrected as
required; intra-articular fractures demand anatomic reduction of all
fragments.
2. Stable fixation, absolute or relative, to fulfill biomechanical demands
3. Preservation of blood supply to the injured area of the extremity and respect
for the soft tissues
4. Early range of motion and rehabilitation

Open reduction and internal fixation (ORIF)

The objectives of ORIF include adequately exposing the fracture site, while
minimizing soft tissue stripping and obtaining a reduction of the fracture. Once a
reduction is achieved, it must be stabilized and maintained.

Treatment:

 Nonoperative
o functional fx brace with good interosseous mold
 indications
 isolated nondisplaced or distal 2/3 ulna shaft
fx (nightstick fx) with
 < 50% displacement and
 < 10° of angulation
 outcomes
 union rates > 96%
  acceptable to fix surgically due to long time to
union
 Operative
o ORIF without bone grafting
 indications
 displaced distal 2/3 isolated ulna fxs
 proximal 1/3 isolated ulna fxs
 all radial shaft fxs (even if nondisplaced)
 both bone fxs
 Gustillo I, II, and IIIa open fractures may be treated

with primary ORIF

 outcomes
 most important variable in functional outcome is to
restore the radial bow
o ORIF with bone grafting
 indications
 cancellous autograft is indicated in radial and ulnar
fractures with bone loss
 bone loss that is segmental or associated with open
injury
 comminution >1/3 length of shaft
 nonunions of the forearm
o external fixation
 indications
 Gustillo IIIb and IIIc open fractures
o IM nailing
 indications
 poor soft-tissue integrity
  not preferred due to lack of rotational and axial
stability and difficulty maintaining radial bow
(higher nonunion rate)
3.7 Bone Healing

Management of physeal injuries

 Look for and define the exact lines of separation on good quality x-rays
using multiple views
 Occasionally views of the opposite side may help
 Classify the injury using the Salter-Harris classification
 If not readily classifiable, consider CT, MRI and urgent referral to
orthopaedics
 The majority of type I and II injuries are treated by closed reduction and
cast immobilisation
 The majority of type III and IV injuries require ORIF
 CHAPTER IV
DISCUSSION

Anamnesis :
The man came to the poli orthopedi with his family after fell while falled from
motorcycle. While the incident of patient falls to the right, He was collided with a
motorcycle in front of his before he fell. He complained that his right forearm felt
pain if he moved. He told that every he moved like flexi and extention he keep on
pain.

Physical Examination

Look : hematom (+). Oedem (+), deformitas (+), doesn't seem a

wound
Feel : pain (+) at right hand, warm (-), pulsasi (-), the artery is
palpated radial artery
Move :
 Active :
- Extention : (+)
- Flexion : (-)
- Endorotation : (-)
- Exorotation : (-)
 Pasif :
- Extention : (+)
- Flexion : (-)
- Endorotation : (-)
- Exorotation : (-)
` Therapy
Infus RL 20 tpm
- Inj. dexketoprofen 2x50 mg
- Inj. Cefazolin 2x1
- Inj. Ranitidine 3x50 mg

To treat a man with open reduction internal fixation and then reexamination
in 5-10 days to evaluate maintenance of the reduction. Open reductions with plate.
 BAB V
CONCLUSSION

 Open reduction is indicated if the fracture is irreducible (periosteum or pronator

quadratus may be interposed).. Open reduction and internal fixation with smooth
pins or screws parallel to the physis is recommended if the fracture is
inadequately reduced.
 CASE REPORT
FRACTURE REGIO ANTE BRACHII DEXTRA
Disusun untuk memenuhi sebagian tugas kepaniteraan klinik bagian
Ilmu Bedah RSUD dr. H. Soewondo Kendal

Disusun oleh :
M. Ibtisam Fauzani 012116455

Pembimbing :
dr. Wisnu Murti Sp.OT

FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2016
 HALAMAN PENGESAHAN

Nama : M. Ibtisam Fauzani

NIM : 012116455
Fakultas : Kedokteran
Universitas : Universitas Islam Sultan Agung ( UNISSULA )
Tingkat : Program Pendidikan Profesi Dokter
Bagian : Ilmu Bedah
Judul : Fracture Regio Ante Brachii Dextra

Semarang, 26 October 2016

Mengetahui dan Menyetujui
Pembimbing Kepaniteraan Klinik
Bagian Ilmu Bedah RSUD Kendal

Pembimbing,

dr. Wisnu Murti Sp.OT

 REFERENCES

1. Apley, A Grahm dan Solomon, Louis. 1995. Buku Ajar Ortopedi dan
Fraktur Sistem Apley. Edisi ketujuh. Jakarta : Widya Medika.

2. Ruedi, Thomas P dan Murphy. William M, 2000. AO Principles of Fracture

Management. New York : Thieme Stuttgart

3. Charles T Mehlman, DO, MPH Professor of Pediatrics and Pediatric

Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Director,
Musculoskeletal Outcomes Research, Cincinnati Children's Hospital
Medical Center., 2014., Growth Plate (Physeal) Fractures
http://emedicine.medscape.com/article/1260663-overview

4. CHARLES D. NEWTON., ETIOLOGY, CLASSIFICATION, AND

DIAGNOSIS OF FRACTURES.,
http://cal.vet.upenn.edu/projects/saortho/chapter_11/11mast.htm