CASE REPORT

I. DATA BASE ( October 9th 2008 )

1.1 Identity

Name : Miss. K
Sex : Female
Age : 21 y.o.
Address : Surabaya
Occupational : Merchant (distributor of snack at DTC Wonokromo)
Religion : Moslem
Ethnic : Javanese
Marital status : Single
Sport recreational : Jogging

Reffered from Orthopaedic out patient clinic with contusio genu dextra susp. ACL lesion.

1.2 Chief complaint : Nyeri lutut kanan

1.3 History of present illness

 Pain at the right knee since 2 weeks ago after she got traffic accident
(motorcycle vs motorcycle ) and fell down with right knee on bending position (she
forgot how the injury was occurred). After that she went to RSI Hospital and was
prescribed for analgesic drug.
 Pain was increased by walking activity, climbing stairs, knee bending position and
relieved by taking a rest.
 She also felt that her right knee was locking when walking and unstable on the front
and behind direction.
 There was no numbness and tingling sensation.
 She still able to do activity of daily living but she felt pain while squatting and
praying.
1.4 History of past illness
- History of trauma + ( 2 weeks ago ).

1.5 History of family

She is the youngest girl of 3 brother. Her father was already death. Her mother has a rent car.
She covered by her own source.

1.6 Physical Examination

 General Status

- Compos mentis, independent ambulation, antalgic gait, right handed

dominant.
- Vital Sign : BP 120/70 mmHg HR 84 x/minutes
RR 20 x/minutes
- Height : 152 cm Body Weight : 49 kg
BMI : 21,21 kg/m2 (Normal BMI)
 Head and Neck : No anemia, icterus, cyanosis & dyspneu .
 Thorax : Cor : S1-S2 normal sound, murmur -, gallops –
Pulmo : wheezing -/- , ronchi -/-.
 Abdomen : Meteorismus -,
Hepar / lien : unpalpable
 Upper Extrimities : No abnormality detected.
 Lower Extrimities : see on the local status.

1.7 Physiatric Examination

1.7.1 Musculoskeletal Status
Cervical ROM MMT
Flexion F (0-450) 5
Extension F (0-450) 5
Lateral Flexion F/F (0-450) 5/5
Rotation F/F (0-600) 5/5
Trunk ROM MMT
Flexion F (0-800) 5
Extension F (0-300) 5
Lateral Flexion F/F (0-350) 5/5
Rotation F/F (0-450) 5/5
Shoulder ROM MMT
Flexion F/F (0-1800) 5/5
 Extension F/F (0-800) 5/5
Abduction F/F (0-1800) 5/5
Adduction F/F (0-450) 5/5
Ext. Rotation F/F (0-450) 5/5
Int. Rotation F/F (0-550) 5/5
Elbow ROM MMT
Flexion- Extension F/F (0-1500) 5/5
Forearm supination F/F (0-800) 5/5
Forearm pronation F/F (0-800) 5/5
Wrist ROM MMT
Flexion F/F (0-800) 5/5
Extension F/F (0-700) 5/5
Radial deviation F/F (0-200) 5/5
Ulnar deviation F/F (0-300) 5/5
Fingers ROM MMT
Flexion
MCP F/F (0-900) 5/5
PIP F/F (0-1000) 5/5
DIP F/F (0-900) 5/5
Extension F/F (0-450) 5/5
Abduction F/F (0-200) 5/5
Adduction F/F (200-0) 5/5
Thumb ROM MMT
Flexion
MCP F/F (0-500) 5/5
IP F/F (0-900) 5/5
Extension F/F (0-900) 5/5
Abduction F/F (0-500) 5/5
Adduction F/F (500-0) 5/5
Opposition 5/5
Hip ROM MMT
Flexion F/F (0-1250) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-450) 5/5
Adduction F/F (0-200) 5/5
Ext. Rotation 0-800 5/5
Int. Rotation 0-800 5/5
Knee ROM MMT
Flexion - 5-120°/F 5-/ 5 pain
Extension ( N: 0-1350) 5-/ 5
Ankle ROM MMT
Plantar Flexion F/F (0-450) 5/5
Dorsi Flexion F/F (0-300) 5/5
Inversion F/F (0-350) 5/5
Eversion F/F (0-250) 5/5
Toes ROM MMT
Flexion
MTP F/F (0-300) 5/5
IP F/F (0-500) 5/5
Extension F/F (0-800) 5/5
Big Toe ROM MMT
Flexion
MTP F/F (0-250) 5/5
IP F/F (0-250) 5/5
Extension F/F (0-800) 5/5

1.7.2 Neurological Status

 Deep tendon reflex : BPR++/++ TPR++/++
KPR++/++ APR++/++
 Pathologic reflex : Babinski -/- Hoffmann Tromner -/-
 No sensory deficit.
1.8 Local Status : R. Knee dextra
Inspection : Swelling (+), redness (-),Deformities (-), atrophy of quadriceps (-)
Palpation : Warmth (+), Tender point at medial tib. Plateu.

Diameter Dextra Sinistra

Patella 35,5 cm 34 cm
VMO (above superior 40,5 cm 40,5 cm
margin of patella)
Quadriceps (10 cm above 39 cm 39 cm
superior margin of patella)

1.9 Special Examination :

Anterior drawer test : +/-
Lachman test : +/-
Posterior drawer test : -/-
Valgus stress test : +/-
Varus stress test : -/-
Mc.Murray test : -/-
Appley compression test : -/-
 Appley distraction test : -/-
VAS : 6

 Barthel Index

Activity Score
Feeding 10
Bathing 5
Grooming 5
Dressing 10
Bowels 10
Bladder 10
Toilet use 10
Transfers 15
Mobility 15
Stairs 5
TOTAL 95 ( Slightly dependent )

1.10 Supporting Examination

MRI examination : Nop 5 th 2008

Horizontal tear meniscus Total rupture ACL at

lateralis posterior horn femoral attachment.
 Joint effusion Bone bruise at lateral
tibia plateu

II. Diagnosis : Rupture of ACL dextra + Collateral Med. Lig Dextra + Lateral
Meniscus
Functional diagnosis :
 Impairment : Right ACL, collateral medial ligament and lateral meniscus
rupture with instability of the right knee.
 Disability : cannot praying in a proper position due to the knee pain.

III. Problem list :

- Surgical : Rupture of ACL dextra + Collateral Med. Lig dextra + Lateral
Meniscus
- Medical : -
- Rehabilitation Medicine :
R1 (Ambulation) : antalgic gait
R2 (ADL) : cannot praying in proper position
R3 (Communication) : -
R4 (Sociological) :-
R5 (Psychological) : worried about her right knee function
R6 (Vocational : disturbing her job as a merchant.
R7 (Others) : - Pain at the right knee ( VAS 6 ).
- Limitation ROM genu dextra.
- Instabilitas genu dextra.
- Inflammatory sign +.
IV. Goal :
A. Short term goal :
 Reduce inflammation and pain
 Maintain range of motion
 Maintain muscle strength and prevent atrophy
 Achieve function of the right knee as good as possible.
B. Long term goal
  Pain free knee on activity of daily living and sport activity
 Prevent the secondary knee osteoarthritis.

V. Planning
1. Surgical : ACL reconstruction ( from orthopaedic department )
2. Medical : Mefenamic acid 500 mg 3 dd 1.
3. Rehabilitation Medicine
R1 (Ambulation), R2 (ADL), R6 (Vocasional), R7 (Other)
 PDx : -
 PTx :
 Icing genu dextra 20 minutes / session.
 High TENS at tender point ( medial tib plateu ) genu D
with frequency 170 Hz, intensity 45 mA, duration 15`.
 Isometric strengthening exercise quadriceps dextra as frequent as
possible.
 Active NWB ROM exercise genu D minimal 3 times/day @ 10
repetition.
 Straight Leg Raising (SLR) exercise.
 Bandaging of the right knee
 PMx : Clinical sign, symptoms, VAS and ROM knee
 PEx : Health education and home exercise program.

 Icing genu dextra at home with 3-4 session/day, @ 20 minutes/session

 Bandaging of the right knee

 ADL modification with praying in a sitting position.

 Make the exercise regularly.

R3 (Communication) :-
R4 (Sociological) :-
R5 (Psychological) :
 PDx :
 PTx : give psychological support to the patient
 PMx : Psychological condition
 PEx : - Education about her disease
- Encourage her to do exercise more.