kuliah fracture coass emergensi

7/26/2019 Kuliah Fracture Coass emergensi

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Approach to Musculoskeletal

Injuries

Department of Orthopaedic SurgeryDepartment of Orthopaedic SurgeryFatmawati General HospitalFatmawati General Hospital

LUTHFI GATAMORTHOPAEDIC PI!E CO!ULTA!T


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O"ER"IE#

$ i%ni&icant percenta%e o& all

e'er%enc( roo' care ren)ere)*

$ In FGH+ o,er - 'onth perio)+ sur,e(

sho.e) chie& co'plaint o&

'usculoskeletal pro/le' co'prise)appro0* 112 o& all patients 31 in 45*


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Musculoskeletal Injuries

$ ED ph(sician nee)s a coherent+s(ste'atic approach to orthopae)ic

co'plaints*$ e,erit( ran%es &ro' tri,ial sprains toli&e6 or li'/6threatenin% trau'a*

$ O&ten acute trau'a is the cause o& the

presentation*$ Pain an) )ecrease) ROM are the 'ain

s('pto's*


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#hat #e Co''onl( ee

$ Musculoskeletal )isor)ers co''onl(seen in the ED inclu)e78o&t Tissue Injuries 3strains an)

sprains5998Fractures 3open+ close)+ lon% /one+ pel,ic5

8Dislocations

8 In&ections 3so&t6tissue+ /ite .oun)s599

8E&&usions 998Deep ,enous thro'/osis


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Less Co''on :ut;

$ Musculoskeletal )isor)ers less co''onl(

seen in the ED+ /ut un'istaka/l( i'portant7

8pinal Injuries

8Crush Injuries

8Co'part'ent s(n)ro'e


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FRACTURE


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Fractures

$ A partial or co'plete /reak in a /one*

8:one is the tissue in the hu'an /o)( that heals

/( re%eneration .ithout scarrin%*

8For re%eneration to occur the /one 'ust /e

i''o/ili


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Fractures

$ !e. :one For'ation7$ A he'ato'a &or's /et.een reali%ne) F0 &ra%'ents*

$ He'atopoietic cells in the he'ato'a secrete %ro.th

&actors 3GF=s5*$ GF=s sti'ulate &or'ation o& %ranulation tissue at the

F0 en)s+ slo.l( resor/in% the he'ato'a*

$ A pri'ar( callus &or's+ pro%ressin% &ro' a so&t

callus to har) callus*$ Final phase o& healin%7 )urin% re'o)elin% the /one

reassu'es its ori%inal architecture*


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Fractures

$ !o'enclature o& &ractures is essential tosuccess&ul F0 'ana%e'ent in the ED

$ A)e>uate )escription7

8Open or close)?

8#hich /one in,ol,e)?

8Location .ithin the /one?

8Direction o& the 'ain &racture line?8!u'/er o& &ra%'ents?

8Ali%n'ent an) )isplace'ent o& the &ra%'ents?

8Co'plications?


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Close) Fracture


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Open El/o. Fracture


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Open Fractures

$ ORTHOPEDIC EMERGE!C@$ I''e)iate control o& he'orrha%e*

$ plintin% B6 re)uction*$ Copious irri%ation*

$ Earl( a)'inistration o& su&&icient anal%esia+appropriate anti/iotics+ an) tetanus

proph(la0is*

$ E'er%ent consultation .B orthopae)ics &or allT(pe II an) T(pe III open F0=s 3an) so'e T(peI=s5*


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Fractures6Open Classi&ication

I 1c' lon%+ 'ini'al conta'ination+ lo. ener%( &orceA:7 1stBn)Ceph &or )

II 1c' lon%+ 'o)erate conta'ination an) &orce A:71stBn)Ceph plus a'ino%l(c &or )

III Hi%h ener%(+ co''inute) &0+ e0tensi,e tissue )a'a%e+enou%h tissue to co,er .oun)+ e0tensi,e conta'ination+arterial injur(

A:7 1stBn)Ceph plus a'ino%l(c &or )


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PEL"IC FRACTURE


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Pel,ic Fractures

$ Least co''on &racture 325

$ Most are result o& auto6collisions

$ Co''onl( associate) .ith other injuries

$ Pel,is contains 'an( i'portant structures78Iliac ,essels+ uro%enital or%ans+ ner,e ple0i;**

$ Patients can sustain lar%e ,olu'e /loo) loss


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Clinical E,aluation$ An( patient assess'ent /e%ins .ith the A:C=s

3Air.a(+ :reathin%+ Circulation5

$ Co'plete neurolo%ic an) ,ascular e0a'

$ Ha,e hi%h suspicion o& intra6a/)o'inal injuries$ Ph(sical e0a'7

8Ecch('osis or contusion aroun) hips+ perineu'

8Pel,ic insta/ilit( .ith stressin%

8uspect i& si%ns o& urolo%icB%(n &in)in%s7 /loo) aturethral 'eatus+ hi%h6ri)in% prostate

8Hi%h &orce 'echanis's also associate) 3',c+ &e'ur&05


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Pel,ic Fracture6Mana%e'ent

$ 166Control o& /lee)in% ,essels

$ In he'o)(na'icall( unsta/le pts+ consi)er

an%io%raph(

$ 66ur%ical 'ana%e'ent o& the /roken

/one can procee) LATER a&ter li&e6

threatenin% con)itions are controlle)*


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LO!G :O!E FRACTURE


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Lon% :one Fractures

$ Fractures o& the &e'ur+ hu'erus+ ti/iaB&i/ula

$ :lunt an) penetratin% trau'a

$ Re>uires hi%h ener%( to /reak /one+there&ore look &or other injuries*

$ :one has a %enerous /loo) suppl(*$ Does patient ha,e associate) /lee)in%

)isor)er?


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Lon% :one Fractures

$ F0=s cause locali


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Lon% :one Fracture


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Mana%e'ent

$ A:C=s

$ !euro,ascular e0a' 3,ascular B6 ner,e injur(5

$ plint in,ol,e) e0tre'it(

8Re)uction )ecreases pain+ /lee)in%

$ Orthope)ic consultation &or )e&initi,e 'ana%e'ent

$ Co'plications7

8Fat6e'/oli s(n)ro'e8:loo) loss


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Fracture Co'plications

$ Vascular Injuries8Most co''onl( occur in open F0=s+ F06)islocations+ or

.i)el( )isplace) F0=s andat sites .here the ,essels lie in

close pro0i'it( to the /one or sites .here the ,esselsare hel) in a relati,el( &i0e) position*

$ Classic si%ns7 The P=s7 Pain, Pallor,Pulselessness (or diminished pulse), Paresthesia,

and Paralysis*8Location o& F0 an) MOI )ictate nee) to assess &or

potential ,ascular injur( in as('pto'atic patient*


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$ Nerve Injuries8Occur 'ore &re>uentl( than ,ascular injuries in

assoc* .B F0*8Can occur B /lunt trau'a+ alon% path o&

penetratin% trau'a+ or /e cause) /( the F0&ra%'ents the'sel,es*

8!er,es are increase) risk o& injur( .hen the(are super&icial to the skin+ lie close to the /one+ orspan a joint+ 'akin% the' suscepti/le to stretchinjur(*


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$ at !m"oli Syndrome (!S)8Most co''on &or' o& non6thro'/otic

e'/olis'*

8in%le or 'ultiple lon% /one &ractures in (oun%or pel,icBhip &ractures in el)erl( pre)ispose toFE*

8J2 o& patients .B pel,ic or lon% /one&ractures ha,e )etecta/le &at )roplets in their

/loo)*


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$ Fat E'/oli (n)ro'e 3FE58"ast 'ajorit( re'ain as('pto'atic

8Has characteristic clinical course71* Fracture sustaine)*

* Other than &racture6associate) pain+ patient isas('pto'atic &or 16- hours*

* u))en onset o& li&e6threatenin% s(n)ro'e characteri


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Deep "enous Thro'/osis


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Deep "enous Thro'/osis

$ Clot &or'in% in one o& the )eep ,eins o& ane0tre'it(7 Le%s Ar's*

$ I& clot propa%ates a/o,e the popliteal &ossa+su/stantial risk o& piece o& clot /reakin% &ree+e'/oli


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CRUH I!UR@


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Crush Injuries

$ First )escriptions &ro' 'ilitar( recor)s+

/o'/in%s in En%lan) an) Europe )urin% .orl)

.ars$ !o. 'ore co''onl( seen in natural )isasters+

/uil)in% collapse+ acts o& terroris'+ a&ter

poisionin%+ a&ter )ru% o,er)oses

$ Injur( results &ro' prolon%e) continuous

pressure on a /o)( part+ t(picall( an e0tre'it(


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Crush Injuries

$ Un)er )irect pressure+ cellular ische'ia incurre)causin% loss cellular inte%rit(

$ Cells leak Q an) '(o%lo/in$ In&lu0 o& ions into the cells causin% irre,ersi/le

cell )eath

$ Can ha,e lar%e &lui) ,olu'e shi&ts

$ Electrol(te a/nor'alities78 H(perkale'ia+ h(perphosphate'ia+ '(o%lo/ine'ia+

h(pocalce'ia+ 'eta/olic aci)osis


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Crush Injuries

$ M(o%lo/in concentrates in

the renal tu/ules

o/structi,e nephropath(

acute renal &ailure

$ #hen ARF occurs+

'ortalit( J6KJ2

$ Arr(th'ias

$ Concern &or sepsis .ith

)e,itali


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Crush Injuries6Treat'ent

$ Earl( consi)eration Breco%nition

$ Flui) resuscitation

8ARF approaches 1JJ2 i& h()ration)ela(e) 1 hours

$ Alkalini


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COMPARTME!T@!DROME


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Co'part'ent (n)ro'e

$ Occurs .hen pressure .Bi so&t tissues in a&i0e) /o)( co'part'ent increases to le,elthat e0cee)s venouspressure+co'pro'isin% ,enous /loo) &lo.+ an)li'itin% capillar( per&usion*

$ Lea)s to 'uscle ische'ia an) necrosis*

$ #$%! O$#&OP!DI' !!$!N'*


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Co'part'ent (n)ro'e

$ Contri/utin% Factors

$ E0ternal7

8Con)itions that re)uce) si


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Han) an) Foot

Co'part'ents


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C6Reco%nition

$ uspect .ith lon% /one &0+ crush injuries

$ Presents as pain out o& proportion to

ph(sical &in)in%s+ B6 h(poesthesia+

pulselessness 3late5*

M i t t t l


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Measure intra6co'part'ental pressure

.hen consi)erin% co'part'ent

s(n)ro'e

Pressures +-mm&g considered dangerous


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Co'part'ent (n)ro'e

Co'part'ent s(n)ro'e

shoul) /e suspecte) in

lon% /one F0=s an) F0=s

associate) .B si%ni&icant

,ascular injuries or

pronounce) s.ellin%*

Intra6co'part'ent pressures

'ust /e 'easure) once the

issue o& co'part'ent

s(n)ro'e is raise)*


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PI!AL I!UR@


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pinal Injuries

$ De,astatin% injuries

$ J2 occur in (oun% 'ales

$ Motor ,ehicle acci)ents+ &alls &ro' hei%ht+%unshot .oun)

$ #orriso'e presentations78pain o,er spine in settin% o& trau'a

8 loss o& 'otor &unction8 incontinence

8priapis'


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pinal Injuries

$ A))itional risk &actors &or spinal PAI!7

8Metastatic cancer

8Osteoporosis+ rheu'atic )


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pinal Injur(

$ Assess'ent

8A:Cs

8I''o/ili


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Classi&ication o& !eurolo%ic Injur(

$ Frankel core

$ A Co'plete loss o& 'otor an)

sensor( &unction

$ : Onl( sensor( &unction re'ains

$ C Motor &unction is present /ut o&no practical use 3i*e*+ can 'o,e le%s

/ut not .alk5

$ D Motor &unction i'paire)

3i*e*can .alk /ut not .ith nor'al

%ait5

$ E !o neuro i'pair'ent note)


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$ I)enti&ia/le spine

&ractures re>uireOrthope)ic OROrthopae)ic spineconsultation


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Case Study: T12 burst fracture; treated with T12corpectomy and autograft; posterior fusion and

instrumentation


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u/lu0ation an) Dislocation


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u/lu0ation an) Dislocation

$ Acute or chronic li%a'entous la0it(Btearin%

can result in su/lu0ation or )islocation o& a

joint*

$ Classic e0a'ple7 %lenohu'eral joint7

8u/lu0ation7 1 /one /eco'es partiall(

)isarticulate) &ro' the otherN articular sur&aces

re'ain partiall( intact*

8Dislocation7 /ones co'pletel( )isarticulate)N

no parts o& articular sur&aces are in contact*


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Dislocations

$ !o'enclature is strai%ht&or.ar)7

8Most occur a joint &or'e) /( /ones an)

the )islocation is na'e) a&ter the a&&ecte) joint*

8Direction o& )islocation re&ers to the position o&

the )istal /one in relation to the pro0i'al*


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$ Clinicall(7

8Pain+ )e&or'it(+ )ecrease) ROM*

8Certain )islocations are associate) .B speci&ic

co'plications+ .hich 'ust /e rule) out in theroutine e,aluation o& the injur(;e*%*+ the a0illar(

ner,e 3125 an) the 'usculocutaneous ner,e

325 are risk in anterior )islocations o& the

%lenohu'eral joint*

8'ooth+ ti'el( re)uction is 'an)ator(*


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:ilateral Hip Dislocations


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More )islocations


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kuliah fracture coass emergensi

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