Bedah Orthopaedi, Urologi, Urologi, Digestive, Digestive, Onkologi Onkologi Batch Agustus 2018 Contributor: dr. And Andre reas as W. Wic Wicak akson sono o dr. Rizky Atmagusta
dr. Ani Anindy ndya a K. Zah Zahra ra dr. Benedictus Anindita S.
ORTHOPAEDIC SURGERY
Initial management for Trauma
Adjuncts :
Primary Survey :
ABG
- Airw Airway ay - Bre Breath athing ing - Circu Circulation lation - Dis Disabi ability lity
EKG
Seconda Sec ondary ry Survey Survey :
Gastric Gast ric & Urina Urinary ry Cathe Catheters ters
Head to toe exam
X-ray
AMPLE history
FAST/DPL
- Exposure/Enviro Exposure/Environmental nmental
Immobilization
Reassess
Reassess
FRAKTUR •
• •
Suatu kondisi DISK DISKONTINUIT ONTINUITAS AS STRUKT STRUKTUR UR TULA TULANG NG yang dapat bersifat komplit komplit / inkompli inkomplitt. Fraktur Fraktur terjadi akibat akib at adanya adanya gay gaya a yang yang melebihi elastisitas elastisi tas tulang. tulang . Deskripsi Deskripsi Frakt Fraktur ur : Hubungan dengan jaringan jaringan sekitar (open/closed) (open/closed) – Hubungan Orientasi (transverse (transverse,, oblique, oblique, spiral) spiral) – Orientasi volar, metaphysis, metaphysis, diaphysis, epiphysis epiphysis middle/ middle/shaft, shaft, dll) – Lokasi (dorsal, volar, Nama tulang tulang – Nama
Cont Contoh oh : Closed Fracture oblique 1/3 media media os. Clavicula Clavicula Sinistr Sinistra a
Manajemen Fraktur – “4R”
RECOGNITION
REDUCTION
RETENTION
REHABILITATION
Manajemen Fraktur – “4R”
RECOGNITION
REDUCTION
RETENTION
REHABILITATION
RECOGNITION •
Anamnesis –
– – – – – – –
History of trauma? (Remember (Remember : fractur fracture e is not alway alwayss at the site site of injury) Age Mecha Mechanis nism m of injury? injury? Localized Localized pain, aggrav aggravate ated d by movement movement Deformi Deformity ty,, decreased function “Heard the bone break” “Feel the ends of the bone grating” Previus Previus musculosk musculoskelet eletal al abnormality
Physical Examination Airway – Breathing – Circulation
LOOK LOOK (Inspectio (Inspection) n) Symetrici Symetricity ty right-left right-left Swelling, wound, deformity (angulation, rotation, shortening), abnormal movement, movement, discolor discoloration ation (ecchymoses) (ecchymoses) Bone expos exposur ure e Posture Posture and colour colour of distal distal extremity extremity FEEL (Palpati (Palpation) on) Localiz Localized ed tenderness tenderness Distal Distal neurologic neurological al status (S&M), pulsation Aggravatio Aggravation n of pain and muscle spasm during even the slightest slightest passive movement movement
Feeling and listening the crepitus unnecessary -> Xray Diagnosis more
reliable
Move
Active Acti ve mov moveme ement nt ROM
Imaging – Imaging – X-ray “Rule of Two” Two Two views views
Differ Different ent point point of view. view. Ex: Anteroposterior and lateral
Two Two joint jointss
Joints proximal and distal the fracture must must be included included
Two limb limbss
X-rays of the uninjured limb are needed for comparison
Two Two injuri injuries es
Two occasio occasion n
Search for the possibility of another injury. injury. Severe force often causes injuries at more than than one one level. Ex : pelv pelvic ic and and spin spine e frac fractu turre Pre and pos post treatment
KLASIFIKASI FRAKTUR Skin and Soft Tissue Integrity
Amount of Displacement
Orientasi Garis Patahan Tulang Tulang
Special Special Type Type Of Fract Fractur ure e
Frakt raktur ur Pedi Pediat atri rik k GREENSTICK
INKOMPLIT
TORUS/BUCKLING
KOMPLIT
BOW
FRAKTUR PEDIATRIK
Green Greenst stic ick k Frac Fractu ture re
•
Suatu kondisi kondisi fraktur inkomple inkomplete te pada tulang, dimana garis fraktur
Tor Torus / Buckle Fract Fracture ure
•
Suatu kondisi fraktur yang diakibatkan oleh gaya yang menekan pada aksis longitudinal tulang
Bow Bow Fracture
•
tekanan n longitudinal yang melebihi kemampuan Fracture yang terjadi karena karena adanya tekana
Fraktur Lempeng Epifisis Salter-Harris Fracture
Fraktur Colles VS Fraktu Frakturr Smith Smith
CD-VS
Frak raktur Coll Colles es •
•
ang berj berjar arak ak ≤ 2,5 Fraktur pada distal tula lan ng radius yang cm dari pergelangan tangan yang disertai dengan perrgeseran fr pe fra agm gme en di disstal pa pattah aha an ke arah DO DOR RSAL
Dinner ner fo fork rk def deform ormity ity ” Deformitas = “Din
CD-VS
Frakt Fraktur ur Smith Smith (Rever (Reverse sed d Colles) Colles) •
•
Fraktur pada distal tulang radius yang ang berj berjar ara ak ≤ ½ - 1 inchi dari pergelangan tangan yang disertai dengan perrges pe eser eran an fr frag agme men n dis isttal pa pattah ahan an ke ar arah ah VENTRAL pade de / gar ard den sp spad ade e deformity ” Def Deformit ormitas as = “House spa
MU-GR
Frakt raktur ur Clav Clavic icul ula a Mechanism of Mechanism Trauma
Evaluation
Fall on the PE: PE: Swelling, shoulder , direct ten tenderness, tenting blow to clavicle, fall skin, skin, deform deformity ity on outstretched hand
Classification • •
•
1/3 media media (69% (69%)) 1/3 lateral/distal (28%) 1/3medial/prox i mal mal (3 %)
Treatment •
• •
Media & Proximal (undisplaced) closed treatm treatment ent closed ( Arm Arm Sling) Distal ORIF Severely shortened, open, tented, neurovascular injury ORIF
Arm Sling
Figure Figure of 8 - bandage bandage
Frak Fraktu turr Terbuka •
antarra tulang tulang yang yang fraktu frakturr Adanya hubungan anta dengan dengan dunia luar luar melalui melalui luk luka trauma traumatik tik –
•
Luka Luka besar tanpa tereksp tereksposn osnya ya tulang yang yang fraktur fraktur ≠ frakt fraktur ur terbuk terbuka a
Kontamina Kontaminasi si dan risik risiko o inf infeksi eksi tinggi
Gustilo-Anderson Classification
•
•
•
crushing, I luka kecil (< 1 cm) , bersih, cedera jaringan lunak minimal tanpa crushing, fraktur fraktur non-ko non-kominut minutif if II luka 1-10 cm, tanpa hilangnya kulit penutup luka (skin ( skin flap), flap), ceder cedera a jaring jaringan an lunak tidak banyak, moderate crushing, crushing, moderate moderate commin comminuti ution on III luka laserasi luas (> 10 cm), cm) , kerusakan kulit dan jaringan lunak luas, high energy injury injury.. – –
IIIA laserasi luas, namun tulang yang fraktur fraktur masih dapat ditutup oleh jaringan jaringan lunak IIIB periosteal fraktur ur tidak dapat ditutup tanpa flap tanpa flap jaringan jaringan periosteal stripping stripping ekstensif, frakt
Manajemen Manajemen Frakt Fraktur ur Terb Terbuk uka a ATL TLS S (initia (initiall trauma trauma survey & resuscita resuscitation) tion) • Safe Safe the life then safe safe the limb
Penceg Pe ncegahan ahan inf infeks eksii • Antibiot Antibiotik ik profila profilaks ksis is (IV, lokal), lokal), profila profilaks ksis is tetan tetanus, us, debridemen debridemen luka
Stabilis Sta bilisasi asi fr frakt aktur ur • Interna Internall or external external
Early Ea rly sof softt tissue co cover verage age
Gustilo Type Wound Wound Size Soft Soft Tissue Tissue
I < 1 cm Minimal
Contamination
Clean Simple fx pattern with minimal comminution
Fracture Fracture Pat Pattern tern
Skin Coverage Coverage
Local cal coverage
II > 1cm Moderate Moderate contaminat ion
Moderate comminution
IIIB >10cm Extensive
IIIC >10cm Extensive
Extensive
Extensive
Extensive
Severe comminution or segmental fractures
Severe comminution or segmental fractures
Severe comminution or segmental fractures
Local coverage including
Local coverage
1st generation cephalosporin for 24 hours after closure (ex: Cefazolin Cefazolin Antibiotics “initiate as soon IV) as possible” Clindamycin or Vancomycin can also be used if allergies •
IIIA >10cm Extensive
Requires free tissue flap or rotational flap coverage
Typically requires flap coverage
1st generation cephalosporin for gram positive coverage. •Aminoglycoside (such as gentamicin) for gram negative coverage coverage in type III injuries • the cephalosporin/aminoglycoside cephalosporin/aminoglycoside should be continued for 24-72 hours after the •
Manajemen Fraktur – “4R”
RECOGNITION
REDUCTION
RETENTION
REHABILITATION
REDUCTION •
•
Menge Mengemb mbali alika kan n fragm fragmen en tulang tulang yang yang frakt fraktur ur ke alignment yang norma normall dan dan posi posisi si yang ang adek adekua uatt Closed Re Reduct duction ion –
Indikasi • • •
•
Fraktur undisplaced atau minimally minimally displa displaced ced Fraktur Fraktur yang stabil setelah reduksi reduksi Unstable fracture sebelum fiksasi internal atau atau extern external al
Open Re Reduct duction ion –
Indikasi • • •
•
Fraktur Fraktur yang tidak tidak stabil Ketika closed reduction gagal Fraktur yang melibatkan fragmen artikular yang yang besa besarr Fraktur avulsi dengan fragmen fraktur yang terpis terpisah ah jauh jauh
Manajemen Fraktur – “4R”
RECOGNITION
REDUCTION
RETENTION
REHABILITATION
Bidai / Splint •
•
Ala Alat yang ang dig diguna unakan untu untuk k meng mengim imob obil ilis isas asii bagi bagian an tubu tubuh, h, dap dapat at ber bersif sifat luna lunak k atau ataupu pun n kak kaku u (rig (rigid id)) Tujuan mengurangi nyeri, mencegah kerusakan kerusakan jaringan jaringan lebih lanjut
distal lokasi frak fraktur tur) Melibatkan 2 sendi (proksimal dan distal
RETENTION (Hol (Hold d Redu Reduct ctio ion) n) • •
•
Nama Nama lain = imobi imobilis lisasi asi Mempertahank Mempertahankan an supa supaya ya tidak terjadi displacement sete setelah lah redu reduks ksii
Meto Metode de Reten etensi si –
Contin Con tinuou uouss tra tracti ction on
–
Cast Ca st sp splin linta tage ge
–
Internal fixation
–
Extern Ext ernal al fix fixati ation on
Cont Contin inuo uous us Trac Tracti tion on •
•
Traksi raksi dilakukan pada bagian extremitas didistal fraktur Memberikan tarikan tarikan konti kontinyu nyu di sepanjang aksis tulang mempertahankan alignment tulang
•
Cocok untuk shaft fracture tipe tipe oblik oblik / spir spiral al
•
Jeni Jeniss :
Cast Cast Splin plinttage age • •
Paling sering mengunakan Plaste Plasterr of Pari Pariss ( GIPS) GIPS) Circu Ci rcula larr Ca Cast st –
Apabila Apabila terlalu kencang encang tight cast (vascular compression) dan pressure dan pressure sore • •
•
Tight cast nye yeri ri dif difus us Pressure sore pada daerah penonjolan tulang yang tertutup gips. nyeri lokal pada pada lokasi lokasi teka tekanan nan
Plas Pl aste terr Slab Slab Cas Cast t – –
lemp lempen eng gan gips gips untu untuk k imob imobil ilis isas asii Sebagian besar fraktur dislab untuk 24-48 pertama untu untuk k meng mengak akom omod odas asii pem pembeng bengk kakan, sebe sebelu lum m dipasang gips sirkuler sirkuler
Cast Cast Splin plinta tage ge
U Slab Slab
Back Bac k Slab Slab
