Tindakan torakosentesis Indikasi torakosentesis adalah : (2)
1. efusi parapne parapneumon umonik ik yang yang mengalam mengalamii komplika komplikasi si atau empiema empiema 2. meng mengur uran angi gi rasa rasa ses sesak ak naf nafas as 3. evalua evaluasi si dasar dasar peny penyaki akitt paru paru kroni kronik k Pada tindakan torakosentesis perlu diperhatikan : -
cara aspirasi cairan dengan terarah arum yang miring.
-
dikeluarkan cairan !P sampai 1"""- 12"" ml sekali am#il
-
lakukan monitoring dengan o$ymeter agar saturasi %&"'. Pasca torakosenstesis dapat hipoksemia teradi aki#at reaksi paradoksal pada perluasan area dengan rasio * yang rendah+ dan edem paru unilateral aki#at reekpansi paru.
-
dapat dilakukan aspirasi ulangan #ila ada indikasi+ namun #ila selalu ter#entuk cairan kem#ali perlu dipertim#angkan tindakan pleurodesis.
Thoracentesis Overview
Background ,horacentesis (thoracocentesis) is a core procedural skill for hospitalists+ critical care physicians+ and emergency physicians. physicians. ith proper training in #oth thoracentesis itself and the use of #edside ultrasonography+ providers can perform this procedure safely and successfully.1+ 2/ 0efore the procedure+ #edside ultrasonography can #e used to determine the presence and sie of pleural effusions and to look for loculations. uring the procedure+ procedure+ it can #e used in real time to facilitate anesthesia and then guide needle placement.
Indications ,horacentesis is indicated for the symptomatic treatment of large pleural large pleural effusions (see effusions (see the images #elo) or for treatment of empyemas of empyemas.. It is also indicated for pleural effusions of any sie that re4uire diagnostic analysis. analysis.3/
Image of a 48-year-old woman with cancer and large left pleural effusion (2.5 liters were removed). The patient was tachypneic hypo!ic and reported
pleuritic chest pain. patient shown a#ove.
"hest radiograph after thoracentesis of the cancer
,ransudative effusions result from decreased plasma oncotic pressures and increased hydrostatic pressures. 5eart failure is #y far the most common cause+ folloed #y liver cirrhosis and nephrotic syndrome. !$udative effusions result from local destructive or surgical processes that cause increased capillary permea#ility and su#se4uent e$udation of intravascular components into potential spaces. 6auses are manifold and include pneumonia+ empyema+ cancer+ pulmonary em#olism+ and numerous infectious etiologies.
Contraindications ,here are no a#solute contraindications for thoracentesis. 7elative contraindications include the folloing: • •
$ncorrected #leeding diathesis "hest wall cellulitis at the site of puncture
Periprocedural Care
Patient Education/Informed Consent 0efore thoracentesis+ it is important to pay attention to the consent process and provide a focused set of risks and complications+ so that the patient is not surprised if he or she e$periences adverse effects.8/ 6onsent should #e o#tained from the patient or family mem#er. ,he reason the procedure is #eing performed (suspected diagnosis)9 the risk+ #enefits+ and alternatives of the procedure9 the risks and #enefits of the alternative procedure9 and the risk and #enefits of not undergoing the procedure. llo the patient the opportunity to ask any 4uestions and address any concerns they may have. ;ake sure that they have an understanding a#out the procedure so they can make an informed decision. ,he patient should #e counseled a#out the risks of pneumothora$+ hemothora$+ lung laceration+ infection+ empyema+ damage to the intercostals+ or internal mammary vessels+ diaphragmatic inury+ puncture of the liver or spleen+ damage to other a#dominal organs+ a#dominal hemorrhage+ ree$pansion pulmonary edema+ air em#olism+ cough+ pain+ and catheter fragment left in the pleural space. iscuss ho these risks can #e avoided or prevented (eg+ proper positioning+ ensuring that the patient remains as still as possi#le during the procedure+ ade4uate analgesia).
Equipment
•
%rrow-"lar&e Thoracentesis 'evice (Telefle! edical esearch Triangle *ar& +") %rgyle Tur&el ,afety Thoracentesis ,ystem ("ovidien ansfield %)
•
"ritical "are Thoracentesis ,et ("oo& edical loomington I+)
•
If a commercial use-specific device is not availa#le+ all of the necessary e4uipment can #e o#tained from the supplies located in most inpatient settings+ critical care units (66=s)+ or emergency departments (!s). •
•
Thoracentesis device - This typically consists of an 8-rench catheter over an /8gauge 0.5-in. (/1-cm) needle with a -way stopcoc& and ideally a self-sealing valve ,elf-assem#led device if a thoracentesis device is unavaila#le - 3ptions include using an /8-gauge needle or a /2-gauge intravenous (I) catheter connected to a 6-m7 syringe and then to a stopcoc& after the needle is removed from the 6-m7 syringe
•
Inection needle 9 22 gauge /.5 in. (.8/ cm)
•
Inection needle 9 25 gauge / in. (2.54 cm)
•
7uer-7o& syringe - /6 m7
•
7uer-7o& syringe - 5 m7
•
7uer-7o& syringe - 6 m7
•
Tu#ing set with aspiration:discharge device
•
%ntiseptic - "hlorhe!idine solution ;
•
7idocaine - /> or 2> solution /6-m7 ampule
•
,pecimen cap for 6-m7 syringe
•
,pecimen vials or #lood tu#es
•
'rainage #ag or vacuum #ottle
•
'rape - 24 ? 6 in. with 4-in. fenestration with adhesive strip
•
,terile towels
•
,calpel - +o. // #lade
•
%dhesive dressing - 0. ? 2.5 cm
•
@auAe pad(s) - 4 ? 4 in.
Patient Preparation Patient preparation includes ade4uate anesthesia and proper positioning.
Anesthesia In addition to local anesthesia+ mild sedation may also #e considered. I midaolam or loraepam can attenuate the an$iety that may #e associated ith any invasive procedure. nalgesia is critically important+ in that pain is the most common complication of thoracentesis. >ocal anesthesia is achieved ith generous local infiltration of lidocaine. ,he skin+ su#cutaneous tissue+ ri# periosteum+ intercostal muscle+ and parietal pleura should all #e ell infiltrated ith local anesthetic. It is particularly important to anesthetie the deep part of the intercostal muscle and the parietal pleura #ecause puncture of these tissues generates the most pain. Pleural fluid is often o#tained via aspiration during anesthetic infiltration of these deeper structures9 this helps confirm proper needle location.
Positioning Patients ho are alert and cooperative are most comforta#le in a seated position (see the image #elo)+ leaning slightly forard and resting the head on the arms or hands or on a pillo+ hich is placed on an adusta#le #edside ta#le. ,his position facilitates access to the posterior a$illary space+ hich is the most dependent part of the thora$. =nsta#le patients and those ho are una#le to sit up may #e supine for the procedure.
3ne option for proper positioning of patient. Basy access to the 0-1 ri# space along the posterior a!illary line.
,he patient is moved to the e$treme side of the #ed+ the ipsilateral hand is placed #ehind the head+ and a toel roll is placed under the contralateral shoulder. ,his measure facilitates dependent drainage and provides good access to the posterior a$illary space.
Technique
Approach Considerations Proper personnel resources should #e ensured+ appropriate e4uipment collected+ and diagnostic la#oratory studies preordered+ as necessary. ,he clinician should #ecome comforta#le ith the e4uipment availa#le at the facility. If necessary+ an unused kit or one from an a#orted procedure may #e opened to permit evaluation of the components. ,he clinician should likeise #ecome comforta#le ith the ultrasound machine and learn ho to adust key functions such as depth and overall gain. n$iolysis should #e considered and good local analgesia provided. ,horacentesis can #e fraught ith patient an$iety+ and pain is the most common complication. If mild sedation is
#eing considered+ intravenous (I) medications should #e administered to the patient in advance. ,he patient should #e positioned appropriately. ,horacentesis can #e performed ith the patient sitting upright and leaning over a ;ayo stand or ith the patient supine (via an a$illary approach).
Thoracentesis (Thoracocentesis) ,horacentesis is performed as follos.?/
Bedside ultrasonography fter the patient has #een positioned+ ultrasonography is performed to confirm the pleural effusion+ assess its sie+ look for loculations+ and determine the optimal puncture site. !ither a curvilinear transducer (2-? ;5) or a high-fre4uency linear transducer (@.?-1 ;5) may #e used (see the image #elo). ,he diaphragm is #rightly echogenic and should #e clearly identified. Its e$act location throughout the respiratory cycle should #e determined. It is important to select a ri# interspace into hich the diaphragm does not rise up at ende$halation.
$ltrasound image using curvilinear pro#e. Image shows chest wall and large volume of pleural fluid.
;otion-mode (;-mode) ultrasonography can also #e used to determine the depth of the lung and the amount of fluid #eteen the chest all and the visceral pleura (see the image #elo). Areely floating lung can #e seen as avelike undulations on the ;-mode tracing.
$ltrasound image in -mode showing sinusoidal wave pattern. This is created #y the lung moving within the large pleural effusion during respiration. The depth of the lung and the amount of fluid #etween the parietal pleura (adherent to the chest wall) and visceral pleura (adherent to lung tissue) are easily measured with ultrasonograp hy.
0edside ultrasonography is a useful guide for thoracentesis: It can determine the optimal puncture site+ improve the administration of local anesthetics+ and+ most important+ minimie the complications of the procedure.2/ ,he optimal puncture site may #e determined #y searching for the largest pocket of fluid superficial to the lung and #y identifying the respiratory path of the diaphragm (see the video #elo). ,raditionally+ this is #eteen the @th and &th ri# spaces and #eteen the posterior a$illary line and the midline. 0edside ultrasonography can confirm the optimal puncture site+ hich is then marked. ideo clip of ultrasound using the linear pro#e. Image demonstrates 2 ri#s with their associated acoustic shadows ri# interspace pleural fluid and the presence of the diaphragm rising up into this ri# interspace.
Preparation of puncture site
%pplication of chlorhe!idine solution.
sterile drape is placed over the puncture site (see the first image #elo)+ and sterile toels are used to esta#lish a large sterile field ithin hich to ork (see the second image #elo).
,terile drape with fenestration and adhesive strip placed over
puncture site with sterile towels draping a large wor& area. towels on the #ed creating a large sterile wor& space.
,terile
If the patient has loose skin or significant su#cutaneous tissue+ the puncture site can #e optimied #y using 3-in. tape to pull the skin or su#cutaneous tissue out of the ay #efore marking the spot and cleaning the puncture site. ,he skin+ su#cutaneous tissue+ ri# periosteum+ intercostal muscles+ and parietal pleura should #e ell infiltrated ith anesthetic (lidocaine 1-2') (see the image #elo). Infiltration can also #e guided #y real-time ultrasonography using a high-fre4uency linear transducer (@.?-1" ;5).
%dministering anesthesia to the s&in su#cutaneous tissue ri# periosteum intercostal muscle and parietal pleura.
Insertion of deice or catheter and drainage of effusion If a commercially availa#le device or a large intravenous catheter is #eing used+ the skin should #e nicked ith a Co. 11 scalpel #lade to reduce drag as the catheter is advanced through the skin (see the image #elo).
+ic&ing the s&in with scalpel to reduce s&in drag as the catheter is advanced through the s&in.
ith aspiration initiated+ the device is advanced over the superior aspect of the ri# until pleural fluid is o#tained (see the image #elo). ,he neurovascular #undle is located at the inferior #order of the ri# and should #e avoided.
%dvancing the device over the superior aspect of the ri#.
;ost commercial devices have a marker at ? cm (see the image #elo). t this depth+ the hemithora$ is usually entered+ and the needle need not need #e advanced any further.
The 5-cm mar& is at the level of the s&in.
,he catheter is then fed over the needle introducer (see the first image #elo). In most cases+ it can #e fed all the ay to the hu# (see the second image #elo).
eeding the catheter over the needle introducer.
The catheter is fed all the way to the hu#.
ith either a syringe pump or a vacuum #ottle+ the pleural effusion is drained until the desired volume has #een removed for symptomatic relief or diagnostic analysis (see the image #elo).
$se the manual syringe pump method or a vacuum #ottle. The syringe pump method (shown here) is more la#or intensive and can cause thum# neurapra!ia in the operator.
Completion of procedure ,he catheter or needle is carefully removed+ and the ound is dressed. If there is any dou#t+ pleural fluid should #e sent for diagnostic analysis (see #elo)9 in practice+ diagnostic analysis is almost alays necessary. ,he patient is repositioned as appropriate for his or her comfort and respiratory status. Ainally+ a procedure note is ritten+ commenting specifically on the descriptive characteristics of the pleural fluid.
!iagnostic Analysis of Pleural "luid Pleural fluid is la#eled and sent for diagnostic analysis. If the effusion is small and contains a large amount of #lood+ the fluid should #e placed in a #lood tu#e ith anticoagulant so that it does not clot. ,he folloing la#oratory tests should #e re4uested:
•
p< level @ram stain culture
•
"ell count and differential
•
@lucose level protein levels and lactic acid dehydrogenase (7'<) level
•
"ytology
•
•
•
•
"reatinine level if urinothora! is suspected (eg after an a#dominal or pelvic procedure) %mylase level if esophageal perforation or pancreatitis is suspected Triglyceride levels if chylothora! is suspected (eg after coronary artery #ypass graft ;"%@= especially if the inferior mesenteric artery ;I%= was usedC mil&y appearance is not sensitive)
!$udative pleural fluid can #e distinguished from transudative pleural fluid #y looking for the folloing characteristics (e$udates have 1 or more of these characteristics+ hereas transudates have none):
•
luid:serum 7'< ratio D 6. luid:serum protein ratio D 6.5
•
luid 7'< level within the upper two thirds of the normal serum 7'< level
•
Complications of Procedure 6omplication rates for thoracentesis performed #y e$perienced clinicians are not availa#le. 5oever+ data on complications that develop after thoracentesis performed #y residents learning the procedure are availa#le.@+ 1/ ;aor complications include the folloing:
•
*neumothora! (//>;8= ) )
•
7aceration of the liver or spleen (6.8>)
•
'iaphragmatic inury
•
Bmpyema
•
Tumor seeding
•
;inor complications include the folloing:
•
*ain (22>) 'ry tap (/>)
•
"ough (//>)
•
,u#cutaneous hematoma (2>)
•
,u#cutaneous seroma (6.8>)
•
asovagal syncope
•
o
*eru#ahan *atologi atau *atofisiologi Tulang #ersifat terlalu rapuh namun cu&up mempunyai &e&uatan dan daya
tahan pegas untu& menahan te&anan tulang yang mengalami fra&tur #iasanya dii&uti &erusa&an aringan se&itarnya. ra&tur ini suatu permasalahan yang &omple&s &arena pada fra&tur terse#ut tida& dilu&ai lu&a ter#u&a sehingga dalam mereposisi fra&tur terse#ut perlu pertim#angan dengan fi&sasi yang #ai& agar tida& tim#ul &ompli&asi selama reposisi. *enggunaan fi&sasi yang tepat yaitu dengan internal fi&sasi enis plate and screw . 'ila&u&an operasi terhadap tulang ini #ertuuan mengem#ali&an posisi tulang yang patah &e normal atau posisi tulang sudah dalam &eadaan seaar sehingga a&an teradi proses penyam#ungan tulang yang menurut (%ppley onald /115). ,tadium penyem#uhan fra&tur melalui #e#erapa tahap antara lain dapat dilihat pada ta#elE Ta#el 2.5 Tahap-tahap atau proses penyem#uhan tulang
,ulang
5ematoma ,ulang patah
Proliferasi
Dalsifikasi Earingan
Donsolidasi 6allus yang
7emodeling ,ulang
mengenai
periosteum dan
seluler yang
#elum masak
menyam#ung
pem#uluh
endosteum paling
keluar dari
akan
atau
darah
menonol pada
masing-masing
mem#entuk
mem#entuk
tahap proliferasi
fragmen yang
callus
#aik dari luar
,er#entuk
sudah matang
hematoma di
Proliferasi dari
sekitar
sel-sel dalam
pepatahan
maupun dari 0erlangsung
dalam canalis
#ertahap dan
medularis.
periosteum yang
mem#eri
#eru#ah-u#ah
menutupi fraktur+
perlengkapan
5ematoma
sel-sel ini
untuk
danya
menga#sor#si
di#entuk
merupakan
osteo#last.
aktivitas
pem#entukan
aringan lunak
tum#uhnya
osteo#last
tulang yang
di sekitarnya
osteo#last
6ondo#last
menadi tulang
le#ih.
mem#entuk
le#ih kuat dan
Fsteo#last
Permukaan
kan melepaskan
callus yang
masa
0erlangsung
tulang yang
unsur-unsur
#elum masak
strukturnya
selama 28
patah tidak
intraseluler dan
dan
#erlapis-lapis
minggu
mendapatkan
kemudian
mem#entuk
supplay
menadi fragmen
endolan.
lain
sampai 1 0erlangsung
tahun
setelah 12-18
0erlangsung
0erlangsung
danya
selama28 am
selama 3-8 hari
rigiditas pada
setelah teradi
minggu
fraktur
perpatahan 0erlangsung selama B-12 minggu
Ta#el 2. Tahap-tahap atau proses penyem#uhan otot
Ftot
Peradangan 7adang adalah
Proliferasi ,eradinya per#aikan aringan
#emodeling ,eradi
mekanisme
epitelium dan aringan penghu#ung
pem#entukan matrik
pertahanan diri pada
(connectifity).
aringan connective
otot yang terluka.
!pitelium adalah lapisan yang
dan se#agai fase
7eaksi radang
mem#entuk epidemis kulit dan
penguatan aringan
menye#a#kan
lapisan permukan mukosa.
parut+ aringan
musnahnya agen yang
Earingan penghu#ung adalah
kolagen dilepaskan
mem#ahayakan dan
aringan yang terdapat pada aringan
oleh fi#riosis serta
mencegah penye#aran
ekstra selular.
aringan connective
yang luas.
Ai#rio#rasi akan #erguna pada
masih #ersifat
7adang uga
daerah yang mengalami peradangan
lunak.
menye#a#kan aringan
dengan mem#entuk fi#rin+ lalu akan
Frganisasi seaar
yang cidera diper#aiki
mem#entuk aringan parut yang
masih ter#entuk
atau diganti yang
akan menyokong tensil strength
pada permukaan
#aru.
untuk per#aikan.
luka sehingga akan
,anda-tanda radang:
isaat yang #ersamaan sel endotel
memelihara tensil
0engkak (tumor)+
#aru #erkem#ang.
strength.
#erarna kemerahan
Camun kekuatan
(ru#on)+ panas (kalor)+
degenerasi protein miofi#ril akan
ma$imum dari
gangguan gerak
#erlangsung secara perlahan-lahan
aringan parut hanya
(fungsiolesi)
yang diikuti dengan serangan
@"' dari aringan
phagocytic.
normal.
Ta#el 2.0 Tahap-tahap atau proses penyem#uhan &ulit
Dulit
#adang Pada 28 am pertama akan
Poliferasi
Cicatrik ;erupakan fase
mengalami reaksi radang
menutup kem#ali keratin dan
pem#entukan
yang mendadak.
meluasnya permukaan luka
aringan parut
5al-hal di #aah merupakan
yang #erkem#ang.
permanen
keadian hislogik yang teradi
!pidermis yang #erhu#ungan aringan parut
8G am pertama
dengan selokan #erkurang
terse#ut akan
penyem#uhan luka.
karena mutasi atau
#erkonstruksi dan
G am+ meluasnya area
perpindahan+ dari fi#ro#ast
pem#uluh darah
aringan yang mengalami
dan terisi oleh aringan
yang terdapat
nekrosis pada kedua sisi
granulasi+ aringan granulasi
didalamnya akan
sayatan.
tersusun dari epitelialossel.
dilenyapkan+
1B am epitelium yang
Ai#ro#last yang melepaskan
sehingga aringan
terletak antara aringan yang
collagen yang digunakan
parut #eru#ah
masih hidup dengan aringan
untuk pem#entukan #ekas
putih+ colagen
nekrotik mengalami
luka dan kapiler mem#antu
menadi kuat+
pene#alan 28 am ke 2+ epitel
ter#entuknya aringan parut
#ekas luka tidak
yang #erasal dari aringan
yang kemerahan.
#isa dihilangkan.
epitel yang masih hidup dan
Earinan garnulasi akan
0erlangsung
#erinvasi mendekatkan ke 2
ter#entuk #erdasarkan
#e#erapa minggu
uungnya.
teradinya luka.
sampai #e#erapa
8" sampai 8G am kedua+
#ulan
epitel terse#ut akan #ertemu
terse#ut ter#entuk+ aringan
dan mem#uang nekrotik dari
granulasi yang #aru
lapisan aringan yang
#erga#ung dengan fi#ro#last
keraktiosa+ lalu keduanya
dan kapiler akan #erangsur
#erga#ung dan menyatu di
pulih.
#aah luka dengan
>alu secara #erangsur-angsur
memutuskan hu#ungan pada
akan teradi konstruksi pada
luka yang #ertuuan
luka dipermukaan epitelium.
mengeluarkan perompeng.
Ta#el 2.8 Tahap-tahap atau proses penyem#uhan aringan luna&
Peradangan
$aringan lunak
merusak sel karena trauma+ infeksi+ ischemia+ sekunder atau agen fisik.
7eaksi radang untuk memulai proses healing+ tetapi proses healing tidak teradi sampai reaksi peradangan reda.
engan dimulainya respon peradangan maka siklus perlukaan telah terlihat
alam persendian dan struktur peri artikuler reaksi aringan mengarah kepada reaksi yang #erle#ihan+ synovial menadi hipertensi+ kadang hematrosis dan akhirnya proses ini tidak terleati akan teradi degenerasi.
Earingan lunak lainnya reaksi salah satunya adalah oedem dan kadang disertai hemorage.
Peru#ahan ini mem#uat peradangan mengarah pada nyeri dan protektif spastik Pem#ekuan
engan adanya luka yang diikuti pendarahan dan vasokontriksi pada pem#uluh darah. ;ekanisme pem#ekuan+ #iasanya selesai selama ? menit tetapi dapat memakan 28 sampai 3G am
,rom#oplastin+ trom#oplastin (plasma protein) menadi trom#in di#antu enim trom#o plastin dan lonca trom#in serta fi#rinogen #erga#ung mem#entuk fi#rin yang akhirnya fi#rin #ersama platelest menadi #ekuan darah.
7econstitution
engan istirahat dan terapi yang adekuat akan mempercepat penanganan
of communty
sehingga respon penyem#uhan dapat teradi.
0erpengaruh terhadap per#aikan+ regenerasi+ hypertrophy+ pengurangan nyeri+ pengem#alian 7F;+ menadikan aringan normal+ per#aikan kekuatan+ per#aikan pola gerakan normal
Ta#el 2.1 Tahap-tahap atau proses penyem#uhan syaraf %yaraf
$aringan lunak Proses penyem#uhan neufi#ril #agian proksimal cidera menuu distal.
Pem#entukan selu#ung myelin dari selu#ung chutan terus #erkem#ang+ neurofi#ril tum#uh di sekeliling protoplasma. Pertum#uhan ini teradi 1 mmhari. 0ila selu#ung myelin sem#uh sempurna maka fungsi syaraf akan pulih. ,anda aalnya #ila disentuh akan terasa nyeri pada syaraf. Proses per#aikan syaraf tergantung dari: Panang luas yang mengalami cidera+ teknik pem#edahan+ lama aktu penyem#uhan
Bagaimana fraktur terjadi? Tulang #ersifat relatif rapuh namun cu&up mempunyai &e&uatan dan gaya pegas untu& menahan te&anan. ra&tur dapat teradi a&i#atE /) peristiwa trauma tunggal 2) Te&anan yang #erulang-ulang atau ) &elemahan a#normal pada tulang (fra&tur patologi&).
Fraktur akibat peristiwa trauma ,e#agian #esar fra&tur dise#a#&an oleh &e&uatan yang ti#a-ti#a dan #erle#ihan yang dapat #erupa pemu&ulan pemuntiran atau penari&an. ila ter&ena &e&uatan langsung tulang dapat patah pada tempat yang ter&ena aringan luna& uga pasti rusa&. *emu&uan (pu&uran sementara) #iasanya menye#a#&an fra&tur melintang dan &erusa&an pada &ulit diatasnyaC penghancuran &emung&inan a&an menye#a#&an fra&tur &ominutif disertai &erusa&an aringan luna& yang luas (%ppley /115). ila ter&ena &e&uatan yang tida& langsung tulang dapat mengalami fra&tur pada tempat tang auh dari tempat yang ter&ena &e&uatan ituC &erusa&an aringan luna& di tempat fra&tur mung&in tida& ada (%ppley /115).
Fe&uatan dapat #erupE /) pemuntiran yang menye#a#&an fra&tur spinalC 2) pene&u&an yang
menye#a#&an
fra&tur
melintangC
)
pene&u&an
dan
pene&anan
yang
menga&i#at&an fra&tur yang se#agian melintang tetapi disertai fragmen &upu-&upu #er#entu& segitiga yang terpisahC (4) &om#inasi dari pemuntiran pene&u&an dan pene&anan yang menye#a#&an fra&tur o#li& pende& atau 5) penari&an dimana tendon atau ligament #enar-#enar menari& tulang sampai terpisah (%ppley /115).
