GANGGUAN MUSKULOSKELETAL SEHUBUNGAN DENGAN

PENYAKIT KEGANASAN TULANG, TEKNIK AMPUTASI DAN

PEMASANGAN TRAKSI

RAMSES INDRIAWAN

DEPARTMENT OF SURGERY NTB PROVINCE HOSPITAL MATARAM

TUMOR TULANG

Klasifikasi Tumor tulang

� Tumor Jinak

1. Osteokondroma

2. Endokondroma

3. Kondroblastoma3. Kondroblastoma

4. Kondromiksoid Fibroma

� Tumor Ganas

1. Kondrosarkoma

2. Multiple Mieloma

3. Ewing Sarkoma

Tumor Jinak

1. OSTEOKONDROMA

� Definisi

merupakan tumor jinak tulang yang terjadi padadaerah metafisis

� Lokasi� Lokasi

ditemukan pada bagian metafisis tulang panjang(ujung distal femur, ujung proksimal tibia dan ujungproksimal humerus)

� Klasifikasi

- tipe bertangkai (pedunculated)

- tipe sesil

� Klinis

- mengenai dewasa muda

- terdapat benjolan

- pada umumnya tidak nyeri

- penekanan tendon dan saraf menimbulkannyerinyeri

� Terapi

Eksisi

� Prognosis

- baik

- dapat menjadi ganas dengan persentase 1%

2. ENDOKONDROMA� Definisi

merupakan tumor jinak yang berasal dari dalamrongga sumsum tulang

� Lokasi

sering mengenai tulang-tulang tubuler kecil padatangan dan kakitangan dan kaki

� Klinis

- dewasa muda

- benjolan

- tidak nyeri

� Gambaran Radiologi

gambaran lesi radiolusen dengan bercak-bercakklasifikasi tulang

� Terapi

- kuretase

- bone graft

� Prognosis� Prognosis

- menjadi ganas sekitar 20-25%

- presentase keganasan meningkat jika mengenaitulang panjang besar atau pelvis

3. KONDROBLASTOMA� Lokasi

- humerus

- femur

- tibia

� Klinis

- umur <20 tahun- umur <20 tahun

- benjolan

- tidak nyeri

� Gambaran radiologi

- tampak gambaran lesi osteolitik yang terletakeksentrik pada epifisi tulang panjang

- bercak-bercak klasifikasi

� Terapi

- kuretase

- bone graft

� Prognosis

- baik

4. KONDROMIKSOID FIBROMA� Definisi

merupakan tumor jinak tulang yang paling jarangditemukan.

� Lokasi

pada tulang-tulang ekstremitas bawah di daerahmetafisis.metafisis.

� Klinis

- umur 20-30 tahun

- benjolan

- tidak nyeri

� Gambaran Radiologi

- gambaran daerah osteolitik dengan tepi sklerotik

- terletak eksentrik di metafisis

- gambaran korteks yang mengalami erosi

- reaksi periosteal

� Terapi

- eksisi- eksisi

� Prognosis

dapat mengalami rekuren sampai 25%.

Tumor Ganas

1. KONDROSARKOMA

� Definisi

merupakan tumor ganas tulang rawan yang berasal daridegenerasi maligna lesi jinak

� Lokasi� Lokasi

- tulang pelvis

- scapula

- femur

- humerus

� Klinis

- benjolan yang disertai nyeri

� Gambaran Radiologi

- gambaran lesi osteolitik dengan bercak-bercakklasifikasi

- proses dekstruksi korteks

� Patologi

- sel-sel ganas yang membentuk tulang rawan

- sel-sel mengalami mitosis- sel-sel mengalami mitosis

� Terapi

operatif���� reseksi luas

ajuvans���� radioterapi dan kemoterapi tidak begitubermanfaat

2. MULTIPEL MIOLOMA

� Definisi

merupakan tumor ganas primer tulang yang seringmengenai laki-laki usia >40 tahun

� Lokasi

- tulang vertebra

- tulang pelvis- tulang pelvis

- tulang kranium

� Klinis

- benjolan

- nyeri hebat

- anemia

- malaise

- demam

- berat badan menurun- berat badan menurun

� Pemeriksaan menunjang

- Bone Scan

- BMP (Bone Marrow Puncture

- UL terdapat protein bence jone

- radiologi���� gambaran lesi osteolitik bulat (punched out)

� Komplikasi

fraktur patologis

� Terapi

- radioterapi dan kemoterapi

- fiksasi internal jika ada komplikasi

� Prognosis

buruk. Penderita umumnya meninggal dalam 2 tahunburuk. Penderita umumnya meninggal dalam 2 tahun

3. EWING SARKOMA� Definisi

merupakan tumor ganas yang jarang, biasanyamengenai usia ,20 tahun

� Lokasi

diafisis tulang-tulang panjang (femur, tibia dan fibula)

� Klinis� Klinis

- benjolan

- nyeri hebat

- leukositisis

- LED meningkat

� Gambaran Radiologi

gambaran dektruksi tulang dengan batas yang tidakjelas

gambaran union skin

gambaran sunburst

� Terapi

reseksi luasreseksi luas

radioterapi dan kemoterapi

� Prognosis

buruk

AMPUTASI.

Overall Aims

� Gain an understanding of pathophysiology of amputation

� Differentiate between the different types of amputation

� Understanding of the nursing challenges of patients undergoing amputation

The role of the multidisciplinary team� The role of the multidisciplinary team

� Understanding the psychological response to limb loss

How will we achieve this?� Theory 1 hour: main components

� Group work 1/2 hour : Care Plan

� Practical Session: bandaging, pressure reduction, wound care.

� Discussion� Discussion

ContentContentContentContent� Pathophysiology of vascular disease

� When is amputation necessary ?

� Care of the patient before and after surgery

� The role of the multidisciplinary team in rehabilitation of patientspatients

� Psychological and psychosocial issues

Conditions which may lead to

amputation of a limb

� Peripheral Arterial occlusive disease

� Acute occlusion due to embolism

� Aneurysm

� Diabetic limb disease

Necrotising fasciitis� Necrotising fasciitis

Peripheral Vascular Disease (PVD)

Peripheral vascular disease

Atherosclerotic plaque build up

Vascular network compromisedbody attempts to compensate by collateral circulation

Lactic acid build up(calf pain)

Intermittent claudicationRest pain

Eventual ischaemiaLimb damage ensues

Signs and Symptoms� Pain due to reduced perfusion often relieved by lowering the limb

� Absence of pulses popliteal, dorsalis pedis

� Skin changes: temperature, hairless, flaky, ulcerated, shiny,

� Blue/ black discolouration, necrosis of toes/foot� Blue/ black discolouration, necrosis of toes/foot

� Anaerobic infection Aeromonas hydrophylia -’gas gangrene’

Treatment options� Angiogram-angioplasty

� Sypathectomy

� Insertion of bypass graft

� Removal of affected toes or partial foot amputation

Below through or above knee amputation� Below through or above knee amputation

Acute embolism� Most often a saddle embolis which straddles the aorto-femoral junction causing vascular occlusion

� Can be treated with surgery to remove, may occasionally have caused enough damage to require amputation

� Patient will require treatment for probable cardiac valve � Patient will require treatment for probable cardiac valve disease

Aortic Aneurysm� Wall of the aorta swells progressively over time, eventually rupturing

� Sudden pronounced cardiovascular shock often fatal

� graft can be inserted (ABG)

� Depending on size can affect peripheral circulation� Depending on size can affect peripheral circulation

Diabetes� Damage to micro-vessels

� Peripheral neuropathy, no sensation

� Ulcers develop due to trauma, infection often ensues

� Arterial blood supply is reduced

Ulcer becomes chronic with bouts of acute infection leading � Ulcer becomes chronic with bouts of acute infection leading to loss of digits/foot/limb

Other Factors� Malignancy: squamous cell carcinoma

� Cardiac disease: AF, CCF, MI,

� Trauma: RTA, crushing injury, gunshot, bomb blast, industrial machinery and burns.

Types of Amputation: Toe � Minimal interruption to blood supply

� Foot should be well perfused

� Toe should be easily isolated

� No evidence of infection

Bone is ‘nibbled’ until skin flap can cover defect� Bone is ‘nibbled’ until skin flap can cover defect

� Care of wound is critical !!

Transmetatarsal� Long flap from sole of foot is brought round to meet upper flap to create weight bearing substance

� Most often used on diabetic patients

� High failure rate, Why?

Below Knee Amputation� Long posterior flap, Burgess op.

� 8cm down tibia, below knee joint

� Best chance of rehab due too presence of knee joint

� Only carried out if tissue is adequately perfused.

Above knee Amputation (AKA, AKA)� Normally carried out to allow maximum length of femur to help balance

� Dependent on perfusion

� Equal anterior and posterior flaps

� Bone is divided and smoothed� Bone is divided and smoothed

� Less easy for rehabilitation

Sites for amputation

� Aim: to provide a useful, functional, well moulded, healthy stump to allow prosthetic attachment

� Total excision of diseased tissue

� Maintenance of sufficient blood supply to allow healing

� Stump of sufficient length to allow prosthetic attachment � Stump of sufficient length to allow prosthetic attachment

Caring for amputation patients Pre-op

phase

� Counselling and Support, regardless of the reason for the surgery

� Helping patient to cope with the loss, stages of bereavement

� Looking after relatives, involve when appropriate

� Prepare by introducing other members of the team, possibly � Prepare by introducing other members of the team, possibly an amputee who has coped well with the surgery

Pre op care� Chest X ray, ECG, FBC U and E, glucose, blood grouped and saved

� Lower foot of the bed, pain control (opiates, NSAID, epidural)

� Odour absorbent dressings on necrotic areas � Odour absorbent dressings on necrotic areas

Specific Care� Information esp. r/e mobility, pain control

� Building strength in other limbs which will be dependent in the post op phase

� Advice regarding pressure ulcers

� Limb should be marked pre-op� Limb should be marked pre-op

� Nutrition and hydration needs should be met

Post Op Care� Standard post op care

� Specific:

� Insert a bed cage to minimise pressure, with stump in neutral position

� Pain: 3 sources, wound pain, back pain and phantom pain. � Pain: 3 sources, wound pain, back pain and phantom pain. Wound pain can be controlled with opiates in the immediate phase and, if needed, NSAID’s used.

Post op care (contd)� Haemodynamic stability monitored through BP, pulse, urine output

� Respirations to check for signs of atelectasis, opiate narcosis.

� Blood glucose monitoring

Phantom Pain

� A phenomenon which sees the patient experiencing pain in the missing limb, which can last for months post op.

� TENS machine has been shown to aid this pain

� Local nerve blocksLocal nerve blocks

� Longer term use of Carbimazapine

� Relaxation /complimentary therapy

Preventing Contracture� Patient should be prone with the stump flat at first, BKA patients will often have a brace in situ to prevent post popliteal tendon contracture.

� Physio involvement is tentative at this stage to avoid wound problemsproblems

Mobilising� Sitting out of bed within 48 hrs

� Wheelchair used to assist mobility

� Practice in transferring, standing and early walking with crutches supervised with physio.

� Use of the PPAM aid, inflatable tube in metal frame with � Use of the PPAM aid, inflatable tube in metal frame with rocker foot, used on parallel bars for support

Clothing� Patients need to come to terms with clothing issues, i.e. tucking in sleeves to pockets, pinning of trouser legs

� Can be psychologically traumatic, we should be aware of the effect this may have

Wound Care� Initial contact layer should be absorbent non-adherent and occlusive to avoid infection

� Vacuum drains may be in place until drainage subsides sufficiently (48 hrs)

� Padding should be applied for comfort and protection and � Padding should be applied for comfort and protection and bandaging should be firm but not restrictive

Wound care� Wound Checks should note the following: Colour, temperature (systemic also), odour, presence of erythema, bleeding and/or exudate, discolouration of wound edges, pain levels (should be decreasing),

Potential Wound Care Problems� Ischaemia: poor perfusion, infection, wound breakdown, pain.

� Flap tension: tightness of skin over bone causing tension in the wound

� Oedema: Due to tissue damage, dependence and poor � Oedema: Due to tissue damage, dependence and poor venous drainage

� Infection:high risk due to ischaemia, particularly diabetic patients, poor healing,

Dealing with wound care issues� Regular reassessment of the wound and surrounding skin is necessary

� Accurate documentation is essential to ensure monitoring of the wound progress, improvement or detereoration

� Knowledge of appropriate dressing regimes� Knowledge of appropriate dressing regimes

� Use of prophylactic antibiotics

Prognosis� Dependent on: indication for surgery, level of amputation, cardiac status, infection, pain, length of time to surgery, anxiety and ability to cope with the situation.

Body Image� Body reality- body ideal and body presentation

� Potential sexual problems

� Socialisation issues, feeling of inadequacy

� Nurses must strengthen perceptions of self worth and improve confidence improve confidence

Promoting Independence� Encourage the patient to take care of the skin on the stump, checking for pressure points, using moisturiser.

� Carer or relative taught to apply stump bandage correctly to ensure good fit for prosthesis

� Encourage social interaction and meeting of friends � Encourage social interaction and meeting of friends

Rehabilitation and Discharge

� Involvement of the multidisciplinary team is essential: physio for mobility, provision of stump board for wheelchair OT for home assessment and safety issues, social work, benefits, motability car, district nurse for wound checks and/or control of diabetes. control of diabetes.

� Involvement in local amputee groups

� Medical follow up at o/p clinic

Adaptations to Home� External ramps required

� Stair lift, railings.

� Doors widened

� Kitchen worktops and sinks adjusted

Shower on level, with chair access� Shower on level, with chair access

� Possible hoist for bath

� Adapted furniture

Traumatic Amputation: Special

considerations

� Potentially greater psychological impact

� Patient more likely to have been younger and fitter.

� Wound may be left open until signs of oedema and signs of infection reduce

� Psychosocial issues are often far reaching Discuss these: � Psychosocial issues are often far reaching Discuss these:

Ongoing Care� Continued visit to the limb fitting centre

� Outpatient follow up

� Risk factor modification : Smoking cessation clinic, hyperlipidaemia, cardiology

� Care of the other limb� Care of the other limb

� Support groups

CARA PERAWATAN PENDERITA CARA PERAWATAN PENDERITA CARA PERAWATAN PENDERITA CARA PERAWATAN PENDERITA

DENGAN TRAKSIDENGAN TRAKSIDENGAN TRAKSIDENGAN TRAKSI

Keuntungan Tindakan Traksi� Menghindari tindakan bedah pada keadaan tertentu

� Memudahkan tindakan bedah selanjutnya

� Mencegah kerusakan jaringan lunak pada fraktur

� Memungkinkan pergerakan sendi sehingga menghindarkan � Memungkinkan pergerakan sendi sehingga menghindarkan

kekakuan

Kerugian Tindakan Traksi

� Tidak dapat digunakan untuk semua jenis fraktur

� Tirah baring yang lama

� Tirah baring yang lama juga meningkatkan risiko terjadinya

komplikasi di tr. respiratorius (pneumonia orthostatik), system

kardiovaskular (penyakit tomboemboli), tr. digestivus (obstipasi), kardiovaskular (penyakit tomboemboli), tr. digestivus (obstipasi),

dll.

Jenis Traksi

Menurut cara pemasangannya:

� Skin Traction (Traksi kulit)

� Skeletal Traction (Traksi skeletal)� Skeletal Traction (Traksi skeletal)

Traksi Kulit (Skin Traction)

� Bryant’s traction

� Buck’s Extension

� Dunlop’s traction

� dll

Bryant’s traction

� Traksi untuk fraktur femur

� pada anak usia kurang dari 1 tahun (sebelum bisa berjalan)

� Keuntungannya: memudahkan perawatan pada saat BAB dan BAK� Keuntungannya: memudahkan perawatan pada saat BAB dan BAK

� lama traksi: 10 hari - 2 minggu

Bryant’s traction

Buck’s extensionpada anak

� Tindakan definitif untuk fraktur femur pada usia lebih dari 1 tahun

(sudah bisa berjalan)

� Pemasangan traksi setinggi tempat fraktur� Pemasangan traksi setinggi tempat fraktur

� Sesudah terbentuk callus atau sticky dapat dilanjutkan dengan

pemasangan gips

� Lama traksi: 3 minggu

Buck’s extensionpada dewasa

� Tujuan:

� imobilisasi sementara fraktur femur sebelum operasi

� imobilisasi pasca reduksi dislokasi hipimobilisasi pasca reduksi dislokasi hip

� Pemasangan traksi di bawah lutut

� Beban kurang dari 5 kg

� Lama traksi: tidak lebih dari 15 hari

Buck’s extensionCara Pemasangan

• Bersihkan ekstremitas, cukur bila rambut lebat

• pemasangan pada kulit di bawah lutut

• Beri padding pada tulang yang menonjol (maleolus dan head • Beri padding pada tulang yang menonjol (maleolus dan head

fibula)

• Counter traction

Buck’s extension (1)

Buck’s extension (2)

Buck’s Extension:Cara Perawatan

� Selalu perhatikan posisi kelurusan (alignment)

ekstremitas

� Pada Buck Extension, cegah rotasi dengan diganjal� Pada Buck Extension, cegah rotasi dengan diganjal

� Jaga kebersihan: BAK dan BAB

Bryant’s traction dan Buck’s extension

Komplikasi (1)

� Lokal (pada tempat traksi):

� edema distal

� obstruksi pembuluh darah

� lesi nervus peroneus� lesi nervus peroneus

� nekrosis kulit di atas tulang yang menonjol

� bula/ blister bila beban terlalu besar

� elastis dibuka dan dikendorkan

Bryant’s traction dan Buck’s extension

Komplikasi (2)

� General:

� Hipotermi, terutama pada bayi dan anak kecil

� Traktus respiratorius� Traktus respiratorius

� Traktus urogenital

� Trakstus digestifus

� kekakuan sendi (stiffness)

Dunlop’s traction

� untuk fraktur supra dan intercondylar pada anak

� yang sulit dilakukan closed reduction karena edema, atau

� closed reduction dengan fleksi elbow berisiko mencederai

vaskularisasivaskularisasi

� Dilakukan selama 7-10 hari sampai edema berkurang dan dapat

dipasang gips

Dunlop’s tractionKomplikasi

� Volkman’s ischemic contracture

� Pada 2 hari pertama harus dilakukan evaluasi terhadap:

pain, pallor, pulseless, parestesia, paralisis

SETIAP JAM!!!SETIAP JAM!!!

Dunlop’s tractionDunlop’s tractionDunlop’s tractionDunlop’s traction

Traksi Skeletal (Skeletal Traction)

� Traksi skeletal femoral distal

� Traksi skeletal tibial proksimal

� dll� dll

Traksi skeletal femoral distalTraksi skeletal femoral distalTraksi skeletal femoral distalTraksi skeletal femoral distal

Traksi skeletal femoral distal

� Bila diperlukan beban yang lebih besar pada fraktur femur

proksimal

� Berat beban 7,5 – 12,5 kg

� Arah tarikan berorientasi sesuai aksis panjang femur

lama traksi: � lama traksi:

� traksi sementara: maksimal 3 minggu

� traksi definitif: 1,5 bulan dilanjutkan pemasangan

gips

Traksi skeletal tibial proksimal

� Bila diperlukan beban yang tidak terlalu besar pada fraktur femur 2/3 distal

� Berat beban 5 - 7,5 kg

� Kontraindikasi pada penderita dengan cedera ligamen lutut� Kontraindikasi pada penderita dengan cedera ligamen lutut

� Arah tarikan berorientasi sesuai aksis panjang femur

� lama traksi: idem sebelumnya

Cara

pemasangan:

Komplikasi lokal

� pin tract infection

� bila beban terlalu besar, nekrosis skletal dan kulit

� pressure sore pada bagian tulang yang menonjol

� kekakuan sendi

� malplacement pin

� lesi nervus peroneus

� Komplikasi general: idem traksi kulit (karena imobilisasi lama)

Perawatan

� ganti balut pada tempat masuknya pin secara steril dan bekala,

misalnya 2 hari sekali.

� pemberian talk pada lipatan kulit dan lipatan sendi

� padding pada bagian tulang yang menonjol� padding pada bagian tulang yang menonjol

� bed exercise untuk mencegah komplikasi general, misalnya

pneumonia, tromboemboli, obstipasi, dll.

Terima Kasih