30.trauma musculoskeletal blok 27.ppt

MUSCULOSKELETAL TRAUMA

Dr.dr. Nur Rachmat Lubis, SpOT.

FRACTURE & DISLOCATION

FRACTUREDefinition :A fracture, whether of a bone, an epiphyseal plate or a cartilaginous joint surface, is simply a structural break in its continuity.

must be consider : surrounding soft tissue around the fracture site

Physical factors in the Production of Fractures

1. Cortical Bone: can withstand compression and shearing forces better

that it can withstand tension forces

2. Cancellous Bone/ spongious:Can’t withstand compression.

Can produced: Crush # / compression # Impacted #

Descriptive Terms Pertaining to Fractures

1. Fracture site : Diaphyseal Metaphyseal Epiphyseal

2. Extent of Fracture:complete Incomplete

3. Configuration of #:1. Transverse2. Oblique3. Spiral4. Comminuted

1 2 3 4

4. Relationship of the Fracture Fragments to Each Other :UndisplacedDisplaced :

1. Overriding2. Angulated3. Rotated4. Distracted5. Impacted6. Shifted

sideways

Relationship of the fracture fragments to each other caused by :

• Effects of Gravity• Effects of muscle pull on the fragments

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 (from

without)

6. Complication : Uncomplicated Complicated:

Local : InfectionSystemic : Emboli, Sepsis

THE DIAGNOSIS OF FRACTURES

HISTORY :Fall, Direct Trauma.Mechanism of injury.Common symptom of # :

Localized pain.Decreased function of the involved part.


PHYSICAL EXAMINATION:INSPECTION ( LOOKING ):

Swelling ( edema )Deformity( angulations, rotation, shortening )Abnormal movementEchymosis( subcutaneous extravasations of blood )

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

RANGE OF MOVEMENT (ROM):Limitation.


!!!! CAREFULL ASSESSMENTPatient’s General ConditionSearch for associated injuries:

BrainSpinal CordPeripheral NervesMajor vesselsThoracesAbdominal viscera


RADIOGRAPHIC EXAMINATION:# : PHYSICAL EXAMINATIONConfirmation by X-Ray Accurate DiagnosisTo determine extent and configuration of the fracture.Include entire length of the bone and the joints at

each end.2 Projection : AP / Lat, particularly obliqueSpine and pelvis : (+) CT

THE NORMAL HEALING OF FRACTURES1. Cortical bone (diaphyseal bone/ tubular

bone)# 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

From endosteum Internal callusCartilage callus change in to bone by

Endochondral Ossification2 Clinical Union ( fracture line still

apparent)3 Consolidation ( Radiographic Union )4 Remodeling

THE NORMAL HEALING OF FRACTURES

2. CANCELLOUS BONEInternal Fracture Hematoma

osteogenic cells from trabeculae▼

Internal callus▼

Clinical Union▼

Consolidation

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

HEALING TIME UNCOMPLICATED #

2. # Site and Configuration # through bones that are surrounded by

muscle >union faster cancellous bone # > union faster than

cortical bone long oblique / spiral # > union faster than

transverse #

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 good blood supply healing faster

ABNORMAL HEALING OF FRACTURES

MALUNION Heal normally expected time but in unsatisfactory

position with residual bone deformity DELAYED UNION

union time longer than normal NON UNION

fractures fail to heal by bone : Fibrous Union False joint (Pseudoarthrosis)

PRELIMINARY CARE FOR PATIENTS WITH #

PRIORITY1. Airway2. Breathing3. Shock4. # and dislocation

Complete PE Splinting Extr # :

To minimize pain Prevent further injury to the soft tissue

INITIAL

CLASSIFICATION OF OPEN #

TYPE IWound Ø < 1 cmClean woundBone penetrated skin with minimal injury

to the muscle (usually from within)Simple #, transverse, short oblique


TYPE II:Wound Ø > 1 cmWithout extensive soft tissue damage,

skin flaps or avulsionsimple # transverse, short oblique,mild

comminuted


TYPE III:Extensive soft tissue damage ; skin,

muscle, nerve injuries and major arterial injury

Often caused by high speed injuryExample :Traffic accident, farm accidentsGunshot wound> 8 hours


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

woundSegmental # or severe cominuttedTYPE III B :High speed injury> soft tissue lossAvulsion of periosteumWound with severe contaminationTYPE III C :Major arterial injury need to repair

SPECIAL TYPES OF # Stress # (fatigue #) :

March # metatarsal II-III #Prox. Tibia # jumpers and ballet

dancersPathological # :

Occur in abnormal boneWithout major trauma

DISLOCATIONStructural loss of its stability3 structure that prevent normal ROM & also

prevent joint stability

Joint shape ( joint surface )

Capsule and ligament

Muscle that prevent joint stability

DISLOCATION

3 DEGREES OF JOINT INSTABILITY :1st Degree : Occult Joint instability

( apparent only when joint is stressed)2nd Degree : Subluxation ( less than luxation) 3rd Degree : Dislocation (Luxation)

( joint surfaces have completely lost contact)

DISLOCATION

Joint most susceptible to traumatic dislocation:

ShoulderElbowHipInter phalangealAnkle

DIAGNOSIS

Physical Examination :Swelling (edema)Deformity ( angulation, rotation, loss of normal

contour, shortening)Abnormal movementLocal tenderness

Radiographic Examination :Typical features of a subluxationAP / LAT projection

SPECIFIC TYPES OF JOINT INJURIES CONTUSION:

Hemarthrosis (rupture of synovial vessels) Normal X-rayLIGAMENTOUS SPRAIN: Acute sprain, strain sudden stretching of the

ligament withincomplete tears local hemorrhage local swelling tenderness, pain aggravated by movement

Radiographic examination : normal Treatment : strapping / splinting

DISLOCATION : Anatomical reduction immobilization

SPECIFIC FRACTURES AND JOINT INJURIES IN ADULTS

Fracture less common, but more seriousWeaker and less active Periosteum Less rapid fracture healingFewer problems of DiagnosisNo spontaneous correction of residual fracture

deformitiesDifferences in complication:

Open fracture > common in adultMajor arterial trauma Fat embolism

SPECIFIC FRACTURES AND JOINT INJURIES IN ADULTS

Torn ligaments and Dislocations more commonBecause > rigid, child > elasticIf in children make separation in adult dislocation

/ # dislocation

Better tolerance of major blood lossDifferent emphasis on methods of treatment

> frequently require ORIFIf undisplaced # , adult tend to be more cooperative

during treatment, # can be treated by protection alone

SPECIFIC FRACTURES AND DISLOCATIONSTHE HAND

General features: Common Treatment should always deference prevent

disability Edema >> disturbance function elevation

to▼ # digits immobilized as short as possible

never more than 3 weeksfinger Immobilized in the flexed position

SPECIFIC FRACTURES AND DISLOCATIONSTHE HAND

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

Passive flexion distal of the interphalangeal joint with the extensor tendon under tension may avulse a fragment of bone from the base of the distal phalanx into which the tendon is inserted.

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

PIP joint flexed 3 weeks. ORIF with wire fixation.

SPESIFIC FRACTURES AND DISLOCATIONSTHE HAND

. METACARPAL S:1.Boxer Fracture ( Street

Fighter # ):# neck metacarpal VStreet fighter’s #

Treatment :Reduction Immobilized in cast not more

than 2 weeksORIF with K-wire fixation if #

unstable


2. Bennet’s Fracture :# dislocation of the 1st carpo metacarpal joint

Longitudinal force along the axis of the 1st metacarpal with the thumb in flexed

Serious intraarticular fracture dislocation of the CMC joint

Treatment: Closed reduction ORIF K-wire


3. Rolando # :# base 1st metacarpal with intrarticular T or Y #

SPESIFIC FRACTURES AND DISLOCATIONSTHE WRIST AND FOREARM

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

# radius, 2,5 cm / 1 inch from wrist jointCommonest # in adults, > 50 th ♀ > ♂Fracture occur through bone that has became markedly

weakened by combination senile & post menopausal osteoporosis

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

Dinner fork deformity : posterior displacement or posterior tilt of the distal radial fragment

COLLE’S FRACTURE

CLINICAL FEATURES : DINNER’S FORK DEFORMITY

COLLE’S FRACTURE

Radiographic features :Stable type :

There is 1 main transverse # line with little cortical comminution

Unstable type :Gross comminution, particularly of the dorsal cortex,

and also marked crushing of the cancellous bone

COLLE’S FRACTURE TREATMENT :

Undisplaced # : immobilization with Below Elbow Cast for 4 weeksDisplaced # : Closed Reduction + BE cast Closed Reduction+ External Fixation

COMPLICATION :Usually Colles # had clinical union in acceptable position

within 6 weeksPreventable complication:

Finger Stiffness, Shoulder stiffness, malunionRare complication: Sudeck’s Reflex Symphatetic DystrophyLate rupture EPL

2. Reverse Colles # / Smith’s #

Predominantly in young menOccurs ♂ young adults Fall on the back of the flexed

wrist and hence is a pronation injury

Distal fragment dislocated to the anterior side


SMITH’S #

Treatment : Closed reduction requires strong

supination of the wristAbove Elbow Cast, for 6 weeks, maintain

the position in supination

3.Barton’s #Other form of smith #

Intra articular #


FRACTURE OF THE SHAFT OF THE RADIUS AND ULNA

RADIUS – ULNA :

1. GALEAZZI # : # of the shaft of the radius and

dislocation of the distal radio-ulnar joint. displaced # of distal third of the radial

shaft associated with complete disruption & dislokation of the distal radioulnar joint.

Usually sustained by young adults Distal fragment tilted posteriorly


Treatment :Open Reduction &

Internal fixation of the radius, the dislocatiwill be on reduced.


4. MONTEGGIA # :

# of the Prox half of the ulna accompanied by anterior dislocation of the prox radioulnar joint

Dislocation post / antCommon type, hyperextension & pronation

injury. Can also produced by direct trauma over the

ulnar border of the forearm.


Treatment :Adult ORIF

ELBOW AND ARM

1. # OLECRANON Commonest type is

due to a fall with passive flexion of the elbow combined with powerful contraction of the triceps muscle.

Treatment : ORIF using TBW

(Tension Band Wire)

POSTERIOR DISLOCATION OF THE ELBOW

MECHANISM OF INJURY : Fall on the hand with the

elbow slightly flexed Severe Hyperextension

injury of the elbowCLINICAL FINDING :

Swollen elbow is held in a position of semi flexion

Olecranon is readily palpable posteriorly

RADIOGRAHIC EXAMINATION : Dislocation.

POSTERIOR DISLOCATION OF THE ELBOW

TREATMENT: Closed Reduction Immobilization by cast for at least 3 weeks

COMPLICATION :Elbow stiffnessMedian nerve injury

FRACTURE DISLOCATION OF THE ELBOW

Side swipe injury :Occurs when a driver has his elbow out the

open window of a car at the moment the car is struck from the side by another vehicle.

Usually :Elbow dislocationMultiple comminuted # of the humerus, radius &

ulnaTreatment :

Wait until soft tissue healedORIF

FRACTURES OF THE SHAFT OF THE HUMERUS

> adults Direct trauma # transverse / comminuted Indirect trauma fall on the hand # spiral Clinical Examination :

Flail armPatient tries to support with the opposite hand, Radial Nerve

lesion should always be sought and its presence or absence recorded at the time of the initial examination


Treatment :Closed treatmentIndication for ORIF if injury of Brachial artery

which necessitates arterial repairTRANSVERSE # OF THE HUMERAL SHAFT:

Anaesthesia reduction U Slab (Sugar Tong Splint) / Hanging Cast

Clinical union achieved within 6 weeks


# 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 InjuryDelayed UnionNon Union

FRACTURES OF THE NECK OF THE HUMERUS

In elderly persons, especially ♀Impacted # relatively commonTreatment :

only protection from further injury by a sling during 6 weeks required for union

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 HipocratesAfter reduce must immobilized by Velpeau Bandage

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 may recur more and more frequently with less and less violence.

Treatment :Surgical repair with Putti Platt operation capsule as well as

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

SHOULDER JOINT3. Posterior Dislocation of the ShoulderLess common than anterior dislocationPosterior dislocation can occur :

Fall on the front of the shoulder, with shoulder adducted and internally rotated

Clinical Finding :The patient’s arm seems locked in a position of adduction and

internal rotattedRadiographic 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 lying posteriorly

Treatment : Closed reduction

SHOULDER JOINT

4. Acromioclavicular Joint Dislocation (AC Joint)

Complains of severe pain over the shoulder

Local tenderness (+) overthe AC joint

Radiolographic examination: Patient standing and holding a

weight in each hand.

SHOULDER JOINT

Treatment :Non operatif : Kenny-Howard Sling, depress the

clavicle and elevate the acromionIf failed ORIF, capsult repair, insertion of a

K-wireK-wire removed after 6 weeks

SHOULDER JOINT5. FRACTURE OF CLAVICLECommon site is the middle third of the clavicleLateral fragment pulled inferiorly and medially by

the weight of the shoulder and upper limbTreatment :

Figure of 8 padded bandageClinical united in 3 weeks

ComplicationMalunionDelayed unionNonunion relative rare

FOOT

2.CALCANEAL #Fall from a considerable height onto one or both heels.High incidence of associated compression # of the spineTreatment

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

manually compressed from side to side walking cast for 6 weeks

intra-artikular # :ORIF

FOOT

3. FRACTURES OF THE NECK OF THE TALUS No muscle attached to talus> covered by articular cartilageBlood supply not to good# neck talus correlate with ▲ incidence of

avascular necrosis (the body) and non union

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 diseaseNonunion

THE ANKLE

# & # DISLOCATIONS OF THE ANKLE1. Isolated # of the Medial Maleolus Abduction injury avulse medial

maleolus below the joint line

Adduction injury shear off the medial maleolus above the joint line

Treatment : Undisplaced : BK cast for 8 weeks Displaced : ORIF

ANKLE

2. Isolated # of the Lateral MaleolusAbduction / external rotation injuryMost common injury of the ankleTreatment :

Closed reduction stable immobilized in BK Cast for 6 weeks

NWB 3 weeks

ANKLE3. Bimalleolar # (# of both medial & lateral

malleolus)Severe injuries of the

abduction or external rotation

Treatment : closed reduction

unstable ORIF

4. Trimalleolar #Treatment :

ORIF

ANKLE

Complication :Joint stiffnessnon-union rare>> malunion sbg hsl dari loss of correction

dari fragmen #Degenerative joint disease

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 trauma bumper, Traffic accident Clinical features :

Swelling, deformity, Tenderness Radiographic : AP / Lateral

LOWER EXTREMITYTreatment

Reduction of the tibiaOblique & transverse # closed reductionClinical Union after 3-4 weeksUnstable oblique # & spiral # ORIF

ComplicationAnkle stiffnessNerve injuryDelayed unionNon-unionmalunion

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 the

lateral aspect of the limb with the foot fixed on the ground. Treatment:

Closed reduction for elderly If the patient young ORIF

KNEE JOINT

2. Traumatic Dislocation of the knee jointTorn of 4 major ligaments :

CMLCLLACLPCL

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

3. FRACTURES OF THE PATELLAIndirect :

Tears of the Quadriceps expansion at the level of the patella produce transverse avulsion fracture of the patella

Direct :Direct trauma comminutted

Clinical finding :Patient can’t extent the lower extremity

Treatment :TBW

KNEE JOINT

4.INTERCONDYLAR FEMUR #Patient fall (knee in flexion position) from

height.Clinical finding : swelling >>Radiolographic :Treatment :

ORIF

FEMUR

FRACTURES OF THE FEMORAL SHAFT

Clinical features: swelling >> deformity

Radiographic examination : Done after ABC stabile

FEMURTreatment:1. Nonoperative treatment :

Longer period in the hospitalLonger period of weight bearingContinuous traction (12 weeks )▼Clinical union▼ active exercise, non weight bearingRadiological union▼Weight bearing

2. Operative treatment : ORIF with intramedullary nail

FRACTURES OF THE FEMORAL SHAFT Indication for intramedullary nail # of the femur :

1. Fail in Closed reduction2. Multiple trauma (head trauma)3. Femoral Artery injury need to repair.4. Elderly, prolonged bed rest is deleterious5. Pathological #

Complication : Shock Fat embolism Knee stiffness Non-union

PELVIS

1. TROCHANTERIC # OF THE FEMUR Include:

Intertrochanter # ( # between the lesser and greater trochanters)

# through the trochanter pertrochanteric # > common in adults over the age of 60 years ♀ > ♂ Clinical features

Lower limb complete external rotation Extremity appears short Upper part of thigh is swollen

PELVIS

Radiolographic examination: extent of the #

Treatment :ORIF Nonoperatif

Complication:Malunion nonoperatif

NECK FEMORAL FRACTURE

1. Subcapital2. Transcervical3. BasilarGarden classification :4 type (intracapsular)Type 1 : incompleteType 2 : complete,

undisplacedType 3 : partially displacedType 4 : complete displaced

NECK FEMORAL FRACTURE

Treatment :Operative : Hemiarthroplasty for the elderly

patientComplication:

Avascular necrosis femoral headNon-union > 30%

TRAUMATIC DISLOCATION &# DISLOCATION OF THE HIP

1. POSTERIOR DISLOCATION Position:

Flexion & adduction, internal rotation

Usually caused by dashboard injury

Extremity became shortens


Treatment:Closed ReductionMethods

Complication :Avascular necrosis

femoral headSciatic nerve lesionPost traumatic

degenerative joint disease


2. ANTERIOR DISLOCATIONLess commonCaused by a violent injury

which forces the hip into extension, abduction and external rotation.

Radiographical finding: head femur below the

acetabulum


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)


1. Full flexion2. Adduction of the hip3. Internal rotation4. Extension5. Neutral position

30.trauma musculoskeletal blok 27.ppt

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