Thomas Erwin C J Huwae

SMF Orthopaedi dan Traumatologi

RSU Dr Saiful Anwar Malang
This presentation
1. General management for trauma
2. Fracture definition
3. Fracture management

Musculoskeletal module
General concept of musculoskeletal injury and
upper extremity injury
1. General management for trauma
2. Fracture definition
3. Fracture management
 Penyebab kematian terbanyak usia < 40 Th
 KLL
 Kecelakaan kerja
 Kecelakaan RT
 Kematian pertama: < 1 jam setelah trauma (sblm
tindakan RS)
 Penyebab:
 Trauma kepala berat
 Cardiovasculer injuri
 Sumbatan jalan nafas Dapat dicegah
 Perdarahan eksternal
 Kedua: 1-4 jam setelah trauma
 Penyebab:
 Hipoksia
 Uncompensated blood loss

 Ketiga: hari – minggu

 Penyebab:
 Komplikasi trauma
 MOF
 KASUS TRAUMA BERAT
 Tindakan dilakukan di:
 Tempat kejadian dan tranportasi  emergensi
resusitasi
 RS di IRD/UGD  internal bleeding, cardiorespiratori
komplikasi, fiksasi fraktur.
 Tindakan definitif
 Rehabilitasi.
7
 ATLS ADVANCED TRAUMA LIFE SUPPORT.
 Program standar emergensi
 Primary survey  simultaneous
resuscitation
 Secondary survey
 Re-evaluation
 Definitive care
Primary survey
Airway with control cervical
spine A
Breathing & Oxygenation
E B
Circulation & control of bleeding

Disability D C
Exposure & avoidance of
hypothermia
 Re-evaluation
 Menilai resusitasi
 Menemukan perubahan/kelainan sedini mungkin
 Catheter urethra
 Nasogastric tube
 ECG monitor
 Tanda vital
 Secondary
Survey
Allergie Medication

AMPLE Past Medical

History
Last Meal

Event at
injury

Head to Toe
 X-ray :
 Cervical AP
 Thorax AP
 Pelvis AP
 Pemeriksaan lain
 Penderita tetap di ruang resusitasi sp dinyatakan stabil

GOLDEN
HOUR
 Airway problem:
 Penurunan kesadaran
 Trauma maxillofacial
 Muntahan /benda asing
 Chest injury
 Breathing & circulation
 Tension pneumothorax
 Cardiac tamponade
 Flail chest
 Shock :
 Hypovolaemic
 Cardiogenic
 Neurogenic
 septic
 Hormonal & cellular mechanisms
 Kerusakan jaringan
 Shock
 Respon inflamasi
 Perubahan metabolisme:
1. Respon awal (ebb phase)
 Mekanisme pertahanan tubuh  humoral
 Renin, aldosteron, cortisol,PTH
 Respon inflamasi cytokines (IL1, TNF,PG,Vasoactive)
 Energi diperoleh dr beberapa sumber
 Perubahan hormon metabolisme
 Glikogenolisis
 Glukoneogenesis
 gula darah ↗ dalam 24 jam:
 metabolisme↑
 Oksigen ↑
 Suhu tubuh ↑
2. Flow phase
 Kerusakan jaringan  katabolisme
 Perbaikan/penyembuhan jaringan  anabolisme
 Tetanus
 ARDS
 Fat Embolism Syndrome
 DIC
 Crush syndrome
 MOF
 Trauma Score
 FISIOLOGI :
 GCS
 RTS : GCS + Sistolik BP + RR
 Kerusakan anatomi (regio):
 ISS
 RTS score of 12 is labeled DELAYED (walking
wounded)
 11 is URGENT(intervention is required but the
patient can wait a short time)
 10-3 is IMMEDIATE (immediate intervention is
necessary)
 MORGUE, which is given to seriously injured
people with a RTS score of 3 or lower

19
FRACTURE
Structural break in its
continuity, whether its a bone,
an epiphyseal plate or a
cartilaginous joint surface

Robert Bruce Salter

 RECOGNITION
History Phys. Exam. Lab/Radio.

TREATMENT
Close Open

MANTAINANCE OF REDUCTION
Instrumentation w/o instrument

Rehabilitation
 Anatomic location

Fracture pattern
history Phys.exam Lab/radiology
Fracture displacement

Associated soft tissue injury

 WHICH
BONE ?

Anatomic location
Fracture pattern
 Fracture displacement

Angulation Rotation Shortening

• Tibial fracture
• Diaphyseal fracture
• Short oblique / transverse
• Anteroposterior displacement
• Radial fracture
• Metpahyseal fracture
• Compound / comminutive fracture
• Intraarticular fracture
 CLINICAL SIGN OF
FRACTURE

FALSE
DEFORMITY CREPITATION
MOVEMENT
DEFORMITY OF THE
BONE
1. Discontinuity ;
angulation, rotation
2.Bony outgrowth
3.Abnormal length
Associated soft tissue injury

Nerve Vasccular Ligament,

injury injury tendon
RADIOLOGY

Fullfill the rule of 2’s

• 2 views (tangential to each other)
• 2 joints (above and below the fracture)
• 2 bones (for comparison with other
side)
• 2 occasions (for comparison, to assess
progress)
STAGE OF FRACTURE HEALING

inflammation Soft callus Hard callus Remodelling

• hematoma • callus formation • woven bone • lamellar bone
• activated bone • start bridging • restoration of • medula
cell callus strength reconstituted
• angiogenesis • mineralization
THE FAMOUS 3R OF FRACTURE
& DISLOCATION TREATMENT

REDUCTION OF
DEFORMITY
RETAIN OF REDUCTION
REHABILITATION
 Restoration
of
Function and
rehabilitation
Anatomicaly
retain

reduction
Reduction
• Realiagnment
• Effort to anatomical restoration
• Displaced fracture

1.Closed reduction
2.Open reduction
Retain

1. Protection
2. Casting
3. Traction
4. Internal fixation
5. External fixation
DISLOCATION

SEPARATION
OF THE
JOINT
WHAT HAPPENED IF DISLOCATION
OCCURED ?

VASCULAR
NERVE INJURY
INJURY

LIGAMENT ASSOCIATED
WITH
INJURY FRACTURE

SOFT TISSUE
ENTRAPMENT
DISLOCATION
IS EMERGENCY
SITUATION !!
Rehabilitation

Range of motion

Strengthening

Endurance
OPEN FRACTURE

BONE EXPOSED
TO OUTER
ENVIRONMENT
GUSTILLO & ANDERSON ( 1985 )

GRADE 1

1. Wound < 1 cm
2. Usually in-out wound
3. Simple fracture
4. Mild-modreate contamination
GRADE 2

1. Wound > 1 cm
2. Periosteal sleeve exposed
3. No soft tissue avulsion
4. Short oblique fracture
5. Moderate contamination
GRADE 3 A

1. Periosteal stripped
2. Soft tissue avulsion but still
adequate coverage
3. Communitive fracture
4. Moderate – high contaminated
GRADE 3 B

1. Periosteal stripped and no

adequate soft tissue coverage
that need surgical coverage
2. Comminutive fracture
3. High contaminated
GRADE 3 C

Open fracture with major artery disruption

HOW TO TREAT ??

1.Clean the wound

2.Antibiotic based on culture
3.Fixed the fracture
4.Adequate fracture coverage
COMPARTMENT SYNDROME

Disruption of
distal extremity
perfussion cause
by increasing
intracompatme
nt pressure
Pain ( passive strech )
Parestesia
Pallor
Puffiness
Plegi
Pulseless
 Intra
compartment
Pressure

Tissue
edema
Perfusion

Venous
stasis
 TREATMENT

CUT THE VISCIOUS CYCLE

1. Release all cast or devices
tightened the extremity
2. Elevation the extremity
3. Release the pressure by fasciotomy
If you do not know what you do not know,
its the end of learning

THANK YOU