Dr. Luthfi Hidayat, Sp.

OT
• Common injury
• Vast array (simple to complicated)
• Lots of Structure
• Bone
• Tendon
• Muscle
• Nerve
• Vascular
• Each has its own protocols
• break in the structural
continuity of bone
• What cause fracture
• (1) injury
• (2) repetitive stress
• or (3) abnormal weakening
of the bone (a
‘pathological’ fracture).
• direct force the bone breaks
at the point of impact; the soft
tissues also are damaged.

• indirect force the bone

breaks at a distance from where
the force is applied; soft-tissue
damage at the fracture site is not
inevitable
 spiral pattern
(twisting)

Short oblique pattern

(compression)
triangular ‘butterfly’
fragment
(bending)
transverse
pattern
(tension)
• occur in normal bone which is subject to
repeated heavy loading
• athletes, dancers or military personnel

high loads  minute deformations 

remodelling repeated and prolonged 
resorption occurs faster than replacement
 liable to fracture
• occur even with normal stresses if the bone has
been weakened
• change in its structure (e.g. in osteoporosis,
osteogenesis imperfecta or Paget’s disease)
• through a lytic lesion (e.g. a bone cyst or a metastasis)
INCOMPLETE FRACTURES COMPLETE FRACTURES
incompletely divided and the The bone is split into two or
periosteum remains in continuity more fragments
• Translation (shift)
• Angulation (tilt)
• •Rotation (twist)
• •Length
1. Tissue destruction and haematoma formation
2. Inflammation and cellular proliferation
3. Callus formation
4. Consolidation
5. Remodelling
• HISTORY
- Injury  inability to use the injured limb
- Pain, bruising, Swelling. Deformity  more
sugesstive
- Assosiated injury ?
• GENERAL SIGN
- ABC  ATLS
- Alert to predisposing cause (Paget disease,
metastase)
• LOCAL SIGN
Systematically Approach :
1. Examine most obviously injured part
2. Test for artery & nerve damage
3. Look for assosiated injuries in the region
4. Look for assosiated injuries in distant part
 Skin
Shape
Activeand posture
movement
LOOK warm/cold, moist/dry,
ROM, painful? overall
Thin or obese,
sensibility
posture, curved spine,
muscle
Soft tissue power
shoulder level
Passive
lump, movement
characteristic
Swelling, wasting, lump
Feel
Bone for crepitus
and
Deformity joint
FEEL Unstable
outline,
Skin movement
effusion,
crepitation,
Color Tenderness
Provocative movement
Neurovascular
Brusing, wound
impingement, Distal
Sensoric
ulceration  dermatome
apprehension test
Motoric
Scar  specific
MOVE nerve, myotome
Vascular  Color,
temperature, pulse, CRT
• LOCAL SIGN
Look :
Any swelling, bruising, or deformity?
Is skin intact ?
How about posture of distal extremity ?
How about colour of skin ?
• LOCAL SIGN
Feel :
Palpate local tenderness ?
Any Assosiated injury ?
Any Vascular/Nerve abnormality ?
(before & after treatment)
 X ray

Remember the RULE of TWO :

1. Two Views
2. Two Joints
3. Two Limbs
4. Two Injuries
5. Two Occasions
• CT SCAN
- To visualizing the difficult sites
• MRI
• Evaluation of Soft Tissue Injury
• Radioisotop scanning :
- Diagnosing a suspected stress
fracture
- Diagnosing undysplaced #
1. Open or Closed ?
2. Which bone is broken, where?
3. Its involved the joint ?
4. What is the shape of the break ?
5. Stable or Not ?
6. High or Low Energy ?
7. Who is the person ?
Treat the patient, not only the fracture

Treatment Consist Of :
1. Manipulation, improve the fragment position
2. Splintage, Hold until unite
3. Movement, must be preserved
4. Weight-Bearing, promote # healing by
physiological loading
CLASSIFICATION (Gustillo, 1990)
Wound Debridement
Sterility & Antibiotic
Wound Closure
Stabilization Of the Fracture
Aftercare
 Wound Debridement
- Remove all of foreign material
- Excision wound margins. Leave the healthy skin edges
- Wound extension, provide adequate exposure to remove
debris
- Wound cleansing, with copius amount of saline (6-12 L)
- Removed devitalized tissue, recognized by its purplish
colour, mushy consistency, failure to contracted when stimulated,
and failure to bleed when cut
- Leave cut nerves & tendon
 Sterility & Antibiotic
- Antibiotic given ASAP, no matter how small the laceration
- Most Cases : combination of benzylpenicillin & flucloxacillin, or
2nd Cephalosporin, given 6-hourly for 48 hours
- If heavily contaminated  add Gentamycin or metronidazol,
continued for 4-5 days
 Wound Closure
- Small, uncontaminated wound may be sutured
- Other wounds, must be left open until danger of
tension & infection passed. Reinspected 2 days later, If
clean  Delayed primary closure
- Type III wounds, may have debrided >1 times
 Stabilization Of the Fracture
- Method of treatment vary depend on degree of
contamination
- Open # Up to grade IIIA  Can be treated as closed #
if : - No Obvious contamination
- Less than 8 hours
Aftercare
- Elevate Limb, and watch the circulation carefully
- Continued antibiotic cover
- Delayed primary suture on 2-3 days
- STSG or Skin Flaps if there much of skin loss
 Aftercare
- Elevate Limb, and watch the circulation carefully
- Continued antibiotic cover
- Delayed primary suture on 2-3 days
- STSG or Skin Flaps if there much of skin loss
Soft
Tissue
Injury
• Sprain: joint injury involving partial or complete temporary
dislocation of bone ends and partial or complete tearing of
supporting ligaments

• Strain (Muscle pull): stretching or tearing of muscle fibers

without actual joint or ligament damage (less serious)
• to reduce local tissue temperature
• to reduce pain
• to limit and reduce inflammatory exudate
• to reduce metabolic demands of the tissues
• to protect the damaged tissue from further injury
• to protect the newly-formed fibrin bonds from
disruption
• to promote collagen fibre growth and realignment
• to maintain general levels of cardio-respiratory
and musculoskeletal fitness / activity.
PRICE
• Protect
• Rest or relative rest
• Ice
• Compression
•Elevation.
• Early mobilization needs to occur but very carefully to avoid
triggering further tissue damage
Protection
• Protection should be applied during the early stages of the
healing process
• The duration dictated by the severity of pain and the extent of
injury.
• The mode of application of protection will depend on the site
and nature of injury.
• Avoid complete immobilisation of the part whenever possible
Rest
• immediately following injury.
• Stress on the injured tissue should be avoided during inflammatory
phase, as the tensile strength of the injured tissue is greatly reduced
at this time
• one to five days, depending on the severity of injury.
• Early mobilisation should initially avoid undue stress on the healing
tissue
• Isometric work may be performed
• Overall general activity should be reduced to avoid increasing
metabolic rate and producing a generalised increase in blood flow
Ice
• Considerations in the application of ice:
• duration of application (ranges from five minutes to 40 minutes)
• frequency of application - consider duration of effects
• the area to be covered
• nature of underlying structures
• the most effective means of application
• Compress
• Elevate
• Elevation of the injured part
• lowers the pressure in local blood vessels
• helps to limit the bleeding
• increase drainage of the inflammatory exudate through
the lymph vessels
• reducing/limiting oedema
• Extremity Trauma is a common injury
• Can Involve Hard and soft tissue
• Need proper identification for proper
treatment
• Always follow rules of ATLS
terimakasih