Transcript FRAKTUR UMUM - Dokter bedah tulang

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FRAKTUR UMUM
DR. WAHYU EKO W, SPOT
ORTHOPAEDI DAN TULANG BELAKANG
RS BINA HUSADA
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SMF Bedah FK UKI
FRAKTUR
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Putusnya hubungan kesinambungan/ diskontinuitas
tulang dan atau tulang rawan
Fraktur tertutup :Bila kulit sekitar intak
Fraktur terbuka :Bila ada luka, sehingga
kemungkinan terjadi kontaminasi atau infeksi
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KLASIFIKASI
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I.
Berdasarkan hub dengan dunia luar :
1.Fraktur
tertutup
2. Fraktur
terbuka
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KLASIFIKASI
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Gustillo – Anderson :
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I.
II.
III.
Luka < 1 cm
Luka 1 – 10 cm
Luka > 10 cm
A. Soft tissue coverage
B. Bone exposed
C. Neurovascular injury
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KLASIFIKASI
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
Gustillo – Anderson :
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Fractures due to a traumatic incident
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Caused by sudden and exessive force, which may
be tapping, crushing, bending, twisting or pulling.
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Direct violence : blow on the arm which shatters
the ulna at the point of impact
Indirect violence: forcible traction by a tendon or
ligament which literally pulls the bone apart
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Fatigue or stress fractures
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Due to repetitive stress
Most often seen in the tibia or fibula or
metatarsals, especially in atheletes, dancers and
army recruits.
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Pathological fractures
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Fractures may occur even with normal stresses
if the bone has been weakened (by a tumor)
or if it is excessivelly brittle (paget’s disease)
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How fractures are disposed
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Complete fractures
The bone is compeletely broken into 2 or more
fragments.
Transverse
oblique or spiral,
Impacted fracture
Comminuted fracture
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•Incomplete fracture
The bone is incompeletely divided and
the periosteum remains in continuity.
•Greenstick fracture
•Compression fracture
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KLASIFIKASI
II.
Berdasarkan garis
patah
1.Komplet
2.Inkomplet
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KLASIFIKASI
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III.
Jumlah garis patah
1. Simple
2. Komunitif
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3. Segmental
KLASIFIKASI
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IV.
Arah garis patah
1. Transversal 2. Oblique 3. Spiral
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4. Kompresi
KLASIFIKASI
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V.
Lokasi
1.
Tulang Panjang
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1/3 proksimal
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1/3 tengah
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1/3 distal
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Tulang Melintang
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1/4 medial
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1/4 lateral
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KLASIFIKASI
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Dislokasi Fragmen
VI.
Undisplaced
Displaced
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Fragmen tlg searah (ad latus)
Fragmen tlg membentuk sudut (ad axim)
Fragmen distal memutar (ad periferum)
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How fractures heal
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Tissue destruction and haematoma formation
Inflamation and cellular proliferation
Callus formation
Consolidation
Remodelling
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Stadium Penyembuhan
Fraktur
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Healing by direct repair
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Fractures of cancellous bone
Fractures treated by rigid internal fixation
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The time factor
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Rate of repair depends upon :
 the type of bone (cancellous bone heals faster
than cortical bone.
 type of fracture (transverse fracture takes longer
than spiral fracture)
 Blood supply (poor circulation means slow
healing)
 General constitution (healthy bone heals faster
 Age (healing is almost twice as fast in children
as in adults)
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Time table
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Callus visible
on x-ray
Upper limb
Lower limb
2-3 weeks
2 - 3 weeks
Union (fracture 4-6 weeks
firm)
8 - 12 weeks
Consolidation
(bone secure)
12 - 16 weeks
6-8 weeks
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Fractures that fail to unite
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Causes of non union
 Distraction and separation of the fragments
 Interposition of soft tissue between the
fragments
 Excessive movement at fracture line
 Poor blood supply
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Most fracture will unite provide the
bone fragments are
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Placed in contact with each other and
Held more or less immobile until new bone
formation is apparent
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Anamnesa
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
The fracture is not always at the site of the
injury
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ANAMNESIS
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Umur, jenis kelamin
Pendidikan
Riwayat trauma:
•
•
- Pekerjaan
- Lingkungan rumah
Arah
Jenis
- Lokalisasi nyeri
- Gangguan fungsi
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Examination
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General signs
A broken bone is part of a patient. It is
important to look for evidence of : (1) shock or
haemorrhage; (2) associted damage to brain,
spinal cord or viscera; and (3) a prediposing cause
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Look
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Swelling,
bruising,
Deformity
Skin intact ?
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Feel
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Local tenderness
Examine distal to the fracture in order to feel
the pulse and test the sensation
Compartement syndrome ?
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Move
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Crepitus and abnormal movement may be
present, but it is more important to ask if the patient
can move the joint distal to injury
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Pemeriksaan Fisik
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Move :
 Nyeri
gerak
 Sensorik
 Motorik
aktif
pasif
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Bekas dukun
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Bekas dukun
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Xray
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Special imaging
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Tomography
CT- scan
MRI
Radioisotope scanning
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RADIOLOGI
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Rule of 2 :
 2 proyeksi
 2 sendi
 2 ekstremitas
 2 waktu
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PRINCIPLES OF FRACTURE
TREATMENT
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First aid
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Make sure that the airway is clear
If there is a wound, cover it with clean material
Stop bleeding by local compression
Give something for pain
If the neck or the bak is injured, prevent flexion
which may damage the spinal cord
If there is fracture,prevent movement
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Assesment in hospital
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Examine the airway and treat asphyxia
Make sure the patient can breathe
Note the obvious haemorrhage and stop it
Assess the degree of blood loss and shock
Check for spinal cord injury
Look for injuries of abdominal or pelvic viscera
Examine for the presence of fractures or dislocation
Look for soft tissue complications, especially nerve and
vascular injury
Arrange for an x-ray
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Definitive treatment of closed fracture
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Manipulation to improve the position of the
fragments, followed by splintage to hold them
together until they unite; meanwhile joint
movement and function must be preserved
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Reposisi
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Mengembalikan kedudukan tulang
Cara :
• Manual
• Traksi
• Operatif
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Fracture involving an articular
surface; this should be reduced
as near to perfection as
possible because any
irregularity will
predispose to degenerative
arthritis
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Closed reduction
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The distal part of limb is pulled in the line of the
bone
As the fragment disengage, they are repositioned
Alignment is adjusted in each plane
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Reposisi
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Reposisi
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Keberhasilan dinilai dari :
 Alignment
 Contact > 50 %
 Rotation (-)
 Discrepancy (-)
 Sudut < 15 °
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Indikasi konservatif
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Anak dalam masa pertumbuhan
Impending infeksi
Jenis fraktur tidak cocok untuk ORIF
Toleransi operasi tidak baik
Pasien menolak operasi
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Indikasi Operasi
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Sukar reposisi tertutup
Fraktur multipel
Fraktur patologis
Fraktur intra artikular
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HOLD REDUCTION
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In order to unite, a fracture must be imobilized
We splint most fractures, not to ensure union but
(1) to alliviate pain and (2) to ensure that union
takes place in good position
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Immobilisasi
(mempertahankan reposisi)
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Fiksasi eksterna
 Gips
 Roger

Anderson
Fiksasi interna
 Plate
+ Screw
 K-nail
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ORIF ; indications
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# that cannot be reduced except by operation
# that inherently unstable and prone to
redisplacemaent after reduction (#mid shaft
forearm)
# that unite poorly and take long time (# femoral
neck)
Pathological #
Multiple #
# in patients who prsent nursing difficulties
(paraplegics, multiple injuries and very elderly
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ORIF; complications
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INFECTION
NON – UNION
IMPLANT FAILURE
REFRACTURE
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OREF (open reduction external fixation)
; indications
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# associated wih severe soft tissue damage
# associated with nerve or vessel damage
Severely comminuted and unstable #
# pelvis
Infected #
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Fr Collim Femur
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OREF ; Complication
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Overdistraction
Reduced load transmission trough bone, which
delays fracture healing causes osteoporosis (EF
shoul be removed after 6-8 wo,and replace)
Pin tract infection
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OPEN FRACTURE
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EMERGENCY
GOLDEN PERIOD 6 – 8 HO
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OPEN FRACTURE; assesment
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Is circulation intact ?
Peripheral nerve intact ?
State of skin arround the wound
Does the wound communicate with # ?
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Fraktur Terbuka
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Perbaiki KU
Debridement, kultur/resistensi
ATS-Toxoid, Antibiotik
Tutup luka dengan kasa bersih
Reposisi
Imobilisasi
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ANTIBACTERIAL
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Antibiotics : asap, combination ampicilline and
cloxacillin, given 6ho; if wound heavily
contaminated, give gentamycin or metronidazole
for 4-5 do
Tetanus prophylaxis
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TREATMENT OF WOUND
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
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
To cleanse the wound of foreign material
Remove devitalized tissue (debridement)
4C:
Colour
Consistency
Contractility
Capacity of bleeding
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Complications of fracture
General complication
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Shock
Crush syndrome
Venous thrombosis and pulmonary embolism
Tetanus
Gas gangrene
Fat embolism
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Complication involving # bone
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Infection
Delayed union and non union
Malunion
Growth disturbance
Avascular necrosis
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Complication involving soft tissue
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Vascular injury
Compartement syndrome (Volkmann”s ischaemia)
Nerve injury
Visceral injury
Myositis osificans
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Compartement syndrome
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Arterial
ischaemia
Damage
reduced
painful
blood flow
pale
pulseless
paresthetic
paralysed
Direct
Injury
oedema
fasciotomy
incr comp pressure
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Complication involving joints
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Joint stiffness
Osteoarthritis
Sudeck’s atrophy
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TERIMA KASIH
Created by : “ Tepeng “
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