Patient Identity

Name
: Munardi
Age
: 27 years old
Address
: Ds.Prada Kec.Syiah
Kuala.Banda Aceh
Occupation
: Entrepreneur
MR
: 987881
Hp
: 08126929471
Patient came: 10.00 AM

Chief Complaint
Pain and difficulty moving of the right hand

Present illness history

The patient came to RSUDZA with a chief complaint
pain and difficulty moving of the right hand since 1
hour ago. The patient was cutting glass with cutter knife
, suddenly the glass hit his right hand. There was no
trauma at the other part of body

 Physical examination

Primary Survey

Airway : Clear
Breathing
: Spontaneous, 20 breaths/min.
Circulation
: BP: 110/90 mmhg, Pulse : 96
beats/min
Disability
: GCS E4 V5 M6 : 15
Exposure
:

L/S at the right forearm

L : Wound (+) size 4 x 2 cm , bone exposed
(-),
tendon exposed (+)
F : Pain (+), NVD (-)
M : ROM free

 Secondary survey There was no trauma at

other part of body

Assessment
Ruptured of the flexor tendon at the Zone V at the right
hand.

Management

Stop oral intake

IVFD RL 20 drips/min

Inj Cefotaxim 1 g

Inj Ketorolac 30 mg

Inj Tetagam 250 IU

Laboratory examination

Laboratory result
Hemoglobin
: 14,0 gr/dl
White Blood Count
: 12.700 mg/ ul
Platelets
: 204.000/ul
Hematocrit
: 39 %
CT/BT
: 8/2
Blood glucose ad random : 99 mg/dl

Diagnose
Ruptured of the flexor tendon at the Zone V of the right
hand.
(ICD X M66.20)

Consult to orthopedic division

Debridement + Exploration and Repair tendon
emergency

Operation Report
Patient in supine position with general anasthesia
Asepsis, antisepsis and drapping procedure
Performed debridement with NaCl 0,9 %,
povidonie iodine and H2O2
Exploration at the old wound, there was total
ruptured of the flexor digitorum superficialis
tendon, palmaris longus tendon
Performed sutured flexor digitorum superficialis
tendon, palmaris longus tendon with non
absorbable 2-0 by Kessler modified procedure
Performed irrigated with Normosaline
Wound operation closed by primary suture
Performed backslab and Kleinert procedure

Post operative diagnose

Ruptured of the flexor digitorum superficialis tendon
and palmaris longus tendon at the Zone V of the right
hand (ICD X M66.20)

Date

22-1-2014 pain
POD 1
(-)

Vital sign
Blood pressure :
120/80 mmhg
HR : 100 beats/
minute
RR:20
breaths/minute
Temperature:
36,9c

Ruptured of the
flexor digitorum
superficialis
tendon and
palmaris longus
tendon at the Zone
V of the right hand
(ICD X M66.20)

IVFD RL 0,9% 20
drips/minutes
Inj.Ceftriaxon 1gr/12hours
Inj. Ketorolac 30 mg / 8
hours
Inj.Ranitidin 25 mg/12
hours