trauma musculoskeletal blok 27.ppt

8/11/2019 Trauma musculoskeletal blok 27.ppt

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MUSCULOSKELETAL

TRAUMA

Dr.dr. Nur Rachmat Lubis, SpOT.


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FRACTURE & DISLOCATION

FRACTURE

Definition :

A fracture, whether of a bone, an epiphysealplate or a cartilaginous joint surface, is simply a

structural break in its continuity.

must be consider :

surrounding soft tissue around the fracture

site


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Physical factors in the Production of Fractures

1. Cortical Bone:

can withstand compression and shearing forces better

that it can withstand tension forces


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2. Cancellous Bone/ spongious:

Cant withstand compression.

Can produced:

Crush # / compression #

Impacted #


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Descriptive Terms Pertaining to

Fractures

1. Fracture site :

Diaphyseal

Metaphyseal

Epiphyseal


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2. Extent of Fracture:

complete

Incomplete


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3. Configuration of #:

1. Transverse

2. Oblique

3. Spiral4. Comminuted

1 2 34


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4. Relationship of the Fracture

Fragments to Each Other :

UndisplacedDisplaced :

1. Overriding

2. Angulated

3. Rotated4. Distracted

5. Impacted

6. Shifted

sideways

Relationship of the fracture fragments to each other

caused by :Effects of Gravity

Effects of muscle pull on the fragments


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5. Relationship of the Fracture to the External

Environment:

Closed #

Open #:

Fracture fragment has penetrated the skin ( from within)

Sharp object has penetrated the skin to # the bone (fromwithout)

6. Complication :

Uncomplicated

Complicated:

Local : Infection

Systemic : Emboli, Sepsis


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THE DIAGNOSIS OF FRACTURES

HISTORY :

Fall, Direct Trauma.

Mechanism of injury.

Common symptom of # :

Localized pain.

Decreased function of the involved

part.


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PHYSICAL EXAMINATION:INSPECTION ( LOOKING ):Swelling ( edema )

Deformity( angulations, rotation, shortening )Abnormal movement

Echymosis( subcutaneous extravasations of blood )

PALPATION ( FEELING ) :

Localized tenderness at the # site.Crepitus (not necessary)

RANGE OF MOVEMENT (ROM):Limitation.


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!!!! CAREFULL ASSESSMENT

Patients General Condition

Search for associated injuries:Brain

Spinal Cord

Peripheral Nerves

Major vesselsThoraces

Abdominal viscera


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RADIOGRAPHIC EXAMINATION:

# : PHYSICAL EXAMINATION

Confirmation by X-Ray

Accurate Diagnosis To determine extent and configuration of the

fracture.

Include entire length of the bone and the joints at

each end.

2 Projection : AP / Lat, particularly oblique

Spine and pelvis : (+) CT


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THE NORMAL HEALING OF FRACTURES

1. Cortical bone (diaphyseal bone/ tubularbone)# torn of blood vessels, canaliculi, Haversian canal

on the # site Osteocyte in the lacunae

A vascular

Bleeding from periosteum

1.Fracture Hematoma

Localized on the end of fragment #

Osteogenic cells from periosteum formed

External callus


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From endosteumInternal callus

Cartilage callus change in to bone by

Endochondral Ossification

2 Clinical Union ( fracture line stillapparent)

3 Consolidation ( Radiographic Union )

4 Remodeling


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THE NORMAL HEALING OF FRACTURES

2. CANCELLOUS BONEInternal Fracture Hematoma

osteogenic cells from trabeculae

Internal callus

Clinical Union

Consolidation


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THE TIME REQUIRED FOR UNCOMPLICATED # HEALING

FACTOR INFLUENCE:1. Age of the patient

Younger age, the healing rate faster.

Example :femur # after birth union 3 weeks

femur # on the age 8 year union 8 weeks

femur # on the age 12 year union 12 weeks

femur # on the age 20 th/>union 20 weeks


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HEALING TIME UNCOMPLICATED #

2. # Site and Configuration

# through bones that are surrounded by

muscle

>union fastercancellous bone #> union faster than

cortical bone

long oblique / spiral #> union faster thantransverse #


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WAKTU PENYEMBUHAN # UNCOMPLICATED

3. Initial Displacement of the Fracture :

undisplaced #, intact periosteum heal

twice as rapidly as displaced #

4. Blood supply to the Fragments :

If both fracture fragments have a goodblood supplyhealing faster


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PRELIMINARY CARE FOR PATIENTS WITH #

PRIORITY

1. Airway

2. Breathing

3. Shock

4. # and dislocation Complete PE

Splinting Extr # : To minimize pain

Prevent further injury to the soft tissue

INITIAL


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CLASSIFICATION OF OPEN #

TYPE I

Wound < 1 cm

Clean wound

Bone penetrated skin with minimal injury

to the muscle (usually from within)

Simple #, transverse, short oblique


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CLASSIFICATION OF OPEN #

TYPE III A :High speed injury, soft tissue can coverage the

wound

Segmental # or severe cominutted

TYPE III B :High speed injury

> soft tissue loss

Avulsion of periosteum

Wound with severe contamination

TYPE III C :

Major arterial injury need to repair


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SPECIAL TYPES OF #Stress # (fatigue #) :

March #metatarsal II-III #

Prox. Tibia # jumpers and balletdancers

Pathological # :

Occur in abnormal bone

Without major trauma


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DISLOCATION

Joint most susceptible to traumatic

dislocation:

Shoulder

Elbow

Hip

Inter phalangeal

Ankle


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SPECIFIC TYPES OF JOINT INJURIES

CONTUSION:

Hemarthrosis (rupture of synovial vessels)

Normal X-ray

LIGAMENTOUS SPRAIN:

Acute sprain, strain

sudden stretching of theligament withincomplete tears local hemorrhage

local swellingtenderness, pain aggravated bymovement

Radiographic examination : normal

Treatment : strapping / splinting

DISLOCATION :

Anatomical reduction

immobilization


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SPECIFIC FRACTURES AND JOINT

INJURIES IN ADULTS

Fracture less common, but more serious

Weaker and less active Periosteum

Less rapid fracture healing

Fewer problems of Diagnosis

No spontaneous correction of residual fracture

deformities

Differences in complication:Open fracture > common in adult

Major arterial trauma

Fat embolism


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SPECIFIC FRACTURES AND JOINT

INJURIES IN ADULTS

Torn ligaments and Dislocations more commonBecause > rigid, child > elastic

If in children make separationin adultdislocation

/ # dislocation

Better tolerance of major blood loss

Different emphasis on methods of treatment> frequently require ORIF

If undisplaced # , adult tend to be more cooperativeduring treatment, # can be treated by protection alone


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SPECIFIC FRACTURES AND DISLOCATIONS

THE HAND

General features:

Common

Treatment should always deference prevent

disability

Edema >>disturbance function elevation

to

# digits immobilized as short as possiblenever more than 3 weeks

finger Immobilized in the flexed position



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THE HAND

. DISTAL PHALANX :Mallet Finger ( baseball finger, cricket finger )

Caused by:Passive flexion distal of the interphalangeal joint with

the extensor tendon under tensionmay avulse a

fragment of bone from the base of the distal phalanx intowhich the tendon is inserted.

Treatment:Acute : Splinting the finger with DIP joint extended & the

PIP joint flexed3 weeks.

ORIF with wire fixation.


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SPESIFIC FRACTURES AND DISLOCATIONS

THE HAND

. METACARPAL S:

1.Boxer Fracture( StreetFighter # ):

# neck metacarpal VStreet fighters #

Treatment :

Reduction

Immobilized in cast not morethan 2 weeks

ORIF with K-wire fixation if #

unstable


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THE HAND

2. Bennet

s Fracture:

# dislocation of the 1stcarpo

metacarpal joint

Longitudinal force along the axisof the 1stmetacarpal with the

thumb in flexed

Serious intraarticular fracture

dislocation of the CMC joint

Treatment:

Closed reduction

ORIF K-wire


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THE HAND

3. Rolando # :

# base 1st metacarpal

with intrarticular T or Y #


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THE WRIST AND FOREARM

1. Distal end of the Radius ( Colles# )Colles

# :# radius, 2,5 cm / 1 inch from wrist joint

Commonest # in adults, > 50 th

>

Fracture occur through bone that has becamemarkedly weakened by combination senile & postmenopausal osteoporosis

Mechanism of injury :fall with lands on outstretched hand positionClinical features:

Dinner fork deformity : posterior displacement or posterior tilt ofthe distal radial fragment


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COLLES FRACTURE

CLINICAL FEATURES : DINNERS FORK DEFORMITY


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COLLES FRACTURE

Radiographic features :

Stable type :

There is 1 main transverse # line with little cortical

comminutionUnstable type :

Gross comminution, particularly of the dorsal cortex,

and also marked crushing of the cancellous bone


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COLLES FRACTURE

TREATMENT :Undisplaced # : immobilization with Below Elbow

Cast for 4 weeks

Displaced # : Closed Reduction + BE cast

Closed Reduction+ External Fixation

COMPLICATION :

Usually Colles # had clinical union in acceptable positionwithin 6 weeks

Preventable complication:

Finger Stiffness, Shoulder stiffness, malunion

Rare complication: Sudecks Reflex Symphatetic Dystrophy

Late rupture EPL



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2. Reverse Colles # /Smith

s #

Predominantly in young men

Occursyoung adultsFall on the back of the flexed

wrist and hence is a pronation

injury

Distal fragment dislocated to

the anterior side




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SMITHS #

Treatment :

Closed reduction requires strong

supination of the wrist

Above Elbow Cast, for 6 weeks, maintainthe position in supination


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3.Barton

s #

Other form of smith #

Intra articular #




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FRACTURE OF THE SHAFT OF THE

RADIUS AND ULNA

RADIUS ULNA :

1. GALEAZZI #:

# of the shaft of the radius anddislocation of the distal radio-ulnar joint.

displaced # of distal third of the radialshaft associated with completedisruption & dislokation of the distalradioulnar joint.

Usually sustained by young adults

Distal fragment tilted posteriorly


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RADIUS AND ULNA

Treatment:Open Reduction &

Internal fixation of the

radius, the dislocatiwill beon reduced.


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RADIUS AND ULNA

4. MONTEGGIA # :

# of the Prox half of the ulna accompanied by

anterior dislocation of the prox radioulnar joint

Dislocation post / ant

Common type, hyperextension & pronation

injury.

Can also produced by direct trauma over the

ulnar border of the forearm.


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ELBOW AND ARM

1. # OLECRANON Commonest type is

due to a fall with

passive flexion of

the elbowcombined with

powerful

contraction of the

triceps muscle. Treatment:

ORIF using TBW

(Tension Band

Wire)


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POSTERIOR DISLOCATION OF THE ELBOW

MECHANISM OF INJURY : Fall on the hand with the

elbow slightly flexed

Severe Hyperextensioninjury of the elbow

CLINICAL FINDING : Swollen elbow is held in

a position of semi flexion

Olecranon is readily palpableposteriorly

RADIOGRAHIC EXAMINATION: Dislocation.


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POSTERIOR DISLOCATION OF THE ELBOW

TREATMENT:

Closed Reduction

Immobilization by cast for at least 3 weeks

COMPLICATION :

Elbow stiffness

Median nerve injury


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FRACTURES OF THE SHAFT OF


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FRACTURES OF THE SHAFT OF

THE HUMERUS

# SPIRAL & COMMINUTED FRACTURES:Do not require reduction / anaesthesiaGravity alone is adequate to provide alignment of

the fracture fragment

immobilized in U shaped plaster slab

COMPLICATION :Radial Nerve Injury

Delayed UnionNon Union

FRACTURES OF THE NECK OF


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FRACTURES OF THE NECK OF

THE HUMERUS

In elderly persons, especially

Impacted # relatively common

Treatment :

only protection from further injury by

a sling during 6 weeks required for union


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SHOULDER JOINT

1. Shoulder Joint Dislocation Anterior Dislocation of the Shoulder Predominantly of young adults

Caused by forced external rotation and extension of the

shoulder Radiographic examination : confirm the diagnosis

Treatment : Reduce as soon as possible, methods :

Kocher Method Gravitation

Hipocrates

After reduce must immobilized by Velpeau Bandage


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SHOULDER JOINT

2.Recurrent Anterior Dislocation of The Shoulder :

The stability of the shoulder depend on the integrity of

the joint capsule capsule, capsule & anterior labrum

are nearly always avulsed caused the dislocation mayrecur more and more frequently with less and less

violence.

Treatment :

Surgical repair with Putti Platt operationcapsule as well as

the Subscapularis muscle are divided and then refeed(overlapped) limiting external rotation.

SHOULDER JOINT


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SHOULDER JOINT3. Posterior Dislocation of the Shoulder

Less common than anterior dislocation Posterior dislocation can occur :Fall on the front of the shoulder, with shoulder adducted and

internally rotated

Clinical Finding :

The patients arm seems locked in a position of adduction andinternal rotatted

Radiographic finding:Not readily detected in an AP projection, need special

examination :Superoinferior (axillary) projection with the shoulder abducted, is

necessary to confirm that the humeral head is in fact lyingposteriorly

Treatment : Closed reduction


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SHOULDER JOINT

4. Acromioclavicular JointDislocation (AC Joint)

Complains of severe pain overthe shoulder

Local tenderness (+) overthe ACjoint

Radiolographic examination:

Patient standing and holding

a weight in each hand.


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SHOULDER JOINT

5. FRACTURE OF CLAVICLECommon site is the middle third of the clavicle

Lateral fragment pulled inferiorly and medially by

the weight of the shoulder and upper limb

Treatment :

Figure of 8 padded bandage

Clinical united in 3 weeks

ComplicationMalunion

Delayed union

Nonunionrelative rare


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FOOT

2.CALCANEAL #

Fall from a considerable height onto one or both heels.

High incidence of associated compression # of the spine

Treatmentextra-artikular # :Under anaesthesia the two major fragments should

manually compressed from side to side

walkingcast for 6 weeks

intra-artikular # :ORIF


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FOOT

3. FRACTURES OF THE NECK OF THE TALUS

No muscle attached to talus

> covered by articular cartilage

Blood supply not to good

# neck talus correlate with incidence of

avascular necrosis (the body) and non union


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FOOT

Mechanism of trauma

Severe dorsoflexion injury as may be incurred when the

driver has his foot hard on the brake pedal at the

moment of a head-on collision

Treatment :

Closed reduction BK cast for at least 8 weeks

Complication:

Avascular necrosisDegenerative joint disease

Nonunion


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THE ANKLE

# & # DISLOCATIONS OF THE ANKLE1. Isolated # of the Medial Maleolus

Abduction injuryavulse medialmaleolus below the joint line

Adduction injuryshear off themedial maleolus above the joint line

Treatment :

Undisplaced : BK cast for 8 weeks Displaced : ORIF


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ANKLE

2. Isolated # of the Lateral Maleolus

Abduction / external rotation injury

Most common injury of the ankle

Treatment :Closed reductionstableimmobilized

in BK Cast for 6 weeks

NWB 3 weeks


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ANKLE

Complication :

Joint stiffness

non-union rare

>> malunionsbg hsl dari loss of correctiondari fragmen #

Degenerative joint disease


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LOWER EXTREMITY

# OF THE SHAFTS TIBIA & FIBULA > fractured more frequently

Periosteum is thin in adult

Frequency open #

Rate of union slow

Mechanism of injury : Direct traumabumper, Traffic accident

Clinical features : Swelling, deformity, Tenderness

Radiographic : AP / Lateral


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KNEE JOINT

1. # of the proximal end of theTibia ( Bumper #) Mechanism of injury : Usually in elderly

A severe abduction injury, usually a direct blow on thelateral aspect of the limb with the foot fixed on the ground.

Treatment: Closed reduction for elderly

If the patient young ORIF


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KNEE JOINT

2. Traumatic Dislocation of the knee joint Torn of 4 major ligaments :CML

CLL

ACLPCL

Complication:Trauma of the Popliteal Artery

risk of gangren in the distal part

Treatment:Reduced as soon as possible

Complete Dislocation of the

knee joint

KNEE JOINT


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KNEE JOINT

3. FRACTURES OF THE PATELLA

Indirect :

Tears of the Quadriceps expansion at the level of the

patella produce transverse avulsion fracture of the

patella

Direct :

Direct traumacomminutted

Clinical finding :

Patient cant extent the lower extremity

Treatment :

TBW


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FEMUR

FRACTURES OF THE FEMORALSHAFT

Clinical features:

swelling >> deformity

Radiographic examination :

Done after ABC stabile


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PELVIS


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PELVIS

Radiolographic examination:extent of the #

Treatment :

ORIF

Nonoperatif

Complication:

Malunionnonoperatif

NECK FEMORAL FRACTURE


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NECK FEMORAL FRACTURE

1. Subcapital 2. Transcervical

3. Basilar

Garden classification :4 type (intracapsular)

Type 1 : incomplete

Type 2 : complete, undisplaced

Type 3 : partially displaced

Type 4 : complete displaced


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TRAUMATIC DISLOCATION &


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# DISLOCATION OF THE HIP

1. POSTERIOR DISLOCATION

Position:

Flexion & adduction, internal

rotation

Usually caused by dashboard injury

Extremity became shortens


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2. ANTERIOR DISLOCATION

Less common

Caused by a violent injury

which forces the hip intoextension, abduction and

external rotation.

Radiographical finding:

head femur below the

acetabulum



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Treatment :

Closed reduction as soon as possible

Applying traction on the flexed thigh and then

internally rotating and adducting the hip.After reduction, the patient hip should be

immobilized in a Hip Spica Cast in its most

stable position ( flexion, adduktion, internal

rotation)



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1. Full flexion

2. Adduction of the hip

3. Internal rotation

4. Extension5. Neutral position


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trauma musculoskeletal blok 27.ppt

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