review sistem gerak
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REVIEW SISTEMREVIEW SISTEMGERAKGERAK
CompartmentCompartmentSyndromeSyndrome
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Review
Definisi Pening tekanan di dalam ruang kompartemenfascial
Pathophysiology
y Intracellular swelling/Hematomay Pressure rises and capillary perfusion drops
y Tissues vary in susceptibility to damage
Nerve < 4 hours
Muscle < 8 hours
y After 8 hours irreversible damagey Experimentally
Within 10mmHg of diastolic pressure
Injured tissue 20 mmHg
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Review
Etiologyy Temporary vascular occlusion
Trauma, thrombus
Clinical Presentationy History of injury / energy absorbedy Swelling, Pain
y Passive stretch
y Pallor, paresthesia, pulselessness, paralysis
Investigationy Compartmental pressure measurements
y Dont delay getting measurements if diagnosis is obvious (20mmHG less than diastolic)
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Review
Treatmenty Remove dressings
y Do not excessively elevate the foot
Level of the heart
y Analgesia
y Have low threshold to proceed surgically
y Emergency fascial release
y 3 incisions
1 medial 2 Dorsal
yDivide fascia
y Delayed closure
+/- skin grafting
y Prophylactic releases
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komplikasi
Early
y Myonecrosis
y Renal concerns
Late
y Deformities from contracture of necrotic
muscle
y Nerve Injury Ulcerations
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osteomyelitisosteomyelitis
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Definisi INFLAMMATORY PROCESS IN BONE & BONEMARROW ACUTE & CHRONIC
Pathophysiology Hematogenous Osteomyelitis
Contiguous-Focus Osteomyelitis
Peripheral Vascular Disease-associated
Bacteria escape host defenses by: Adhering tightly to damage bonePersisting in osteoblastsProtective polysaccharide-rich biofilm
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PATHOPHYSIOLOGYPATHOPHYSIOLOGYMicroorganisms enter bone (Phagocytosis).
Phagocyte contains the infection
Release enzymes
Lyse bone
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PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Pus spreads into vascular channels
Raising intraosseous pressure
Impairing blood flow
Chronic ischemic necrosis
Separation of large devascularized fragment
New bone formation
(involucrum)
(Sequestra)(Sequestra)
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PATHOLOGYPATHOLOGY
Acute Infiltration of PMNsCongested or thrombosed vessels
Chronic Necrotic bone Absence of living osteocyteMononuclear cells predominateGranulation & fibrous tissue
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HEMATOGENOUS OSTEPMYELITISHEMATOGENOUS OSTEPMYELITIS
Rapidly growing boneRapidly growing boneChildren:Children:
Long bone, Femur, Tibia,Long bone, Femur, Tibia, HumerusHumerus
Older patients: Vertebral boneOlder patients: Vertebral bone
Neonate & infant < 1 year oldNeonate & infant < 1 year old
Septic arthritis is common.Septic arthritis is common.Growth deformities is common.Growth deformities is common.Soft tissue involvement is common.Soft tissue involvement is common.
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HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
Clinical manifestationClinical manifestationClassic presentation: Sudden onsetClassic presentation: Sudden onsetUsually presentation: Slow, insidiousUsually presentation: Slow, insidious
High fever, Night sweatsHigh fever, Night sweatsFatigue, Anorexia, Weight lossFatigue, Anorexia, Weight loss
Restriction of movementRestriction of movementLocal edema, Erythema, &Local edema, Erythema, & TenderrnessTenderrness
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HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
DifferentialsDifferentialsCellulitisCellulitis
Gas gangreneGas gangreneNeoplasmNeoplasm Aseptic bone infection Aseptic bone infection
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Clenched fistClenched fist
osteomyelitisosteomyelitis
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HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
Diagnosis & workDiagnosis & work--upupLab study:Lab study:WBCWBC May be elevated, Usually normalMay be elevated, Usually normal
CC--Reactive Protein (CRP)Reactive Protein (CRP)
Erythrocyte Sedimentation RateErythrocyte Sedimentation Rate(Usually is elevated at presentation(Usually is elevated at presentationFalls with successful therapy)Falls with successful therapy)
Blood cultureBlood culture( Acute osteomyelitis + ve > 50% )( Acute osteomyelitis + ve > 50% )
{{
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HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
Diagnosis & workDiagnosis & work--upupImagingImaging
Radiology:Radiology:NormalNormalSoft tissue swellingSoft tissue swellingPeriosteal elevationPeriosteal elevationLytic changeLytic changeSclerotic changewSclerotic changew
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HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
Diagnosis & workDiagnosis & work--upupUltrasonographyUltrasonography
Simple & inexpensiveSimple & inexpensive
Demonstration anomaly 1Demonstration anomaly 1 2 days after onset2 days after onset
Soft tissue abscess, Fluid collection, &Soft tissue abscess, Fluid collection, &Periosteal elevationPeriosteal elevation
It allows for aspirationIt allows for aspiration
It doesnt allow for evaluation of bone cortex.It doesnt allow for evaluation of bone cortex.
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TREATMENTTREATMENT
Initial treatmentInitial treatment shoudshoud be aggressive.be aggressive.Inadequate therapyInadequate therapy Chronic diseaseChronic disease Antibiotic use: Antibiotic use:
ParenteralParenteralHigh dosesHigh doses
Good penetration in boneGood penetration in boneFull courseFull courseEmpiric therapyEmpiric therapy
SurgerySurgeryDiagnosticDiagnosticHip joint involvementHip joint involvementNeurologic complicationNeurologic complicationPoor or no response to IV therapyPoor or no response to IV therapy
SequestrationSequestration
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ContiguousContiguous--focus Osteomyelitisfocus Osteomyelitis
Clinical setting:Clinical setting:Postoperative infectionPostoperative infectionContamination of boneContamination of boneContiguous soft tissue infectionContiguous soft tissue infection
Puncture woundsPuncture wounds
Microbiologic featuresMicrobiologic features
StaphylococciStaphylococci AureusAureus,, EpidermidisEpidermidis
GramGram--negative bacterianegative bacteria Anaerobic infection Anaerobic infectionUnusual organismsUnusual organisms Clostridia,Clostridia, NocardiaNocardia
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ContiguousContiguous--focus Osteomyelitisfocus Osteomyelitis
DiagnosisDiagnosisLeukocyte countLeukocyte countBlood culture (infrequently positive)Blood culture (infrequently positive)ESR & CRPESR & CRP
Radiologic evaluationRadiologic evaluationTechnetium bone scanTechnetium bone scanOpen bone biopsyOpen bone biopsyCulture of wound & draining sinuses??Culture of wound & draining sinuses??
TreatmentTreatmentSurgery is essential.Surgery is essential.
AntibioticsAntibiotics SpecificSpecific
DurationDuration
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ArthritisArthritis
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review
l Types ofarthritis
l Symptoms ofarthritis
l Signs ofarthritis
l Treatment ofarthritis
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Types of Arthritis
l Rheumatoid arthritis (RA)
l Osteoarthritis (OA)
l Sero-negative arthritis
l Ankylosing spondylitis
l
Reiters diseasel Crystal arthropathies
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Rheumatoid Arthritis
Pathology
l Synovitis
chronic infl, synovial hypertrophy,effusion
l Destruction
proteolytic enzymes, pannus
l Deformity
articular destruction, capsular stretching,tendon rupture
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Rheumatoid Arthritis
extra-articular
l nodules
l tendon sheathl vasculitis
l myopathy and neuropathy
l
reticulo-endothelial systeml visceral - lungs, heart, kidneys, brain, GI
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Rheumatoid Arthritis
early symptoms
myopathy, tiredness, weight loss, malaise proximal finger joints wrists, feet, knees, shoulders
start up pain tendon crepitus
late symptoms
joint destruction pain
deformity
instability
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Rheumatoid Arthritis
advanced joint changes
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Rheumatoid Arthritis
X-ray findings
joint space narrowing
peri-articular osteopenia
erosions
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Rheumatoid Arthritis
treatment stop synovitis prevent deformity
reconstruct
Rehabilitate
Prognosis
10% improve
60% intermittent, slowly worsening
20% severe joint erosion, multiple surgery
10% completely disabled
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Osteoarthritis
A chronic joint disorder in which there is
progressive softening and disintegration
of articular cartilage accompanied by
new growth of cartilage and bone at the
joint margins (osteophytes) and capsular
fibrosis
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Osteoarthritis
classification
Primary or idiopathic
Secondary - infection
- dysplasia
- Perthes
- SUFE
- trauma
- AVN
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Osteoarthritis
aetiology
Genetic
metabolic hormonal
mechanical
ageing
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Osteoarthritis
mechanism 1
Disparity between:-
stress applied to articular cartilage
and
strength of articular cartilage
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Osteoarthritis
mechanism 2
Increased stress (F/A)
increased load eg BW or activity decreased area eg varus knee or
dysplastic hip
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Osteoarthritis
mechanism 3
Weak cartilage
age
stiff eg ochronosis
soft eg inflammation
abnormal bony support eg AVN
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Osteoarthritis
X-ray changes
joint space narrowing
subchondral sclerosis osteophytes
cysts
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Osteoarthritis
X-ray changes
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Arthritis
symptoms
pain
swelling stiffness
deformity
instability
loss of function
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Arthritis
non-surgical treatment
analgesia
disease modifying drugs (RA) altered activity
walking aids
physiotherapy
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Arthritis
surgical treatment
arthroscopy osteotomy
arthrodesis
excision arthroplasty
replacement arthroplasty
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Arthritis
knee arthroplasty
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Joint Replacement
indications
Disabling pain
Functional limitations
History
pain
function medical
expectations
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Joint Replacement
investigation
X-ray - alignment
- deformity
- previous fractures and implants- AVN
- osteophytes
- bone loss CT, MRI, bone scan - rarely
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Ankylosing Spondylitis
0.2% of population
mainly affects spine and SI joints male > female
HLA B27 in 90%
synovitis
enthesopathy
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Ankylosing Spondylitis
hips and knees
flexion deformities
arthritis with large osteophytes ankylosis
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Ankylosing Spondylitis
X-ray changes
joint space narrowing
large osteophytes heterotopic bone
ankylosis
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Tumor MusculoskeletalTumor Musculoskeletal
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Introduction
PrimaryMusculoskeletal tumorsarise from tissue ofmesenchymal origin (ie.bone, muscle,
connective tissue,adipose.)
These primary tumorsmay spread to othersites, usually other
bones or lung. Secondary bone tumors
arise from a host ofother tissues and in theappropriate age
category must be
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Introduction
The work-up of any tumor must be
thought of in terms ofLocal disease
and Systemic disease.
By doing so you will have a sensible
approach to determining the ultimate
pathologic diagnosis and the extent of
the disease in the body.
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Local Investigations
X-ray.the mosthelpful in focusing ourdifferential and furtherinvestigations.
Cat scan.. Bonearchitecture,neocorticalization,?fracture.
MRI.marrow extent,soft tissue extent,neurovascularinvolvement, skip
lesions.
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Radiographic Features of the
Various Tumors Benign: well circumscribed, narrow transition,
no reaction, sclerotic border, does onething.
Benign Aggressive: neocorticalization,expansion, thinning of cortex, usually lytic,+/-reaction, +/- narrow zone of transition.
Malignant: ++++reaction, large, permeative,moth eaten, does more than one thing.
Conditions/Mets: more than one bone,symmetry.
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Invasive Investigation
Biopsy..the goal is to obtain a piece of
tissue adequate to make a pathologic
diagnosis.
Should be done after all other
investigations are complete
Needle, Tru-cut, incisional.
CT/US guided.
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Primary Bone Tumors
Osteogenic
Fibrous
Chondroid Lipomatous
Other
*****These are thebroadcategories******
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Osteogenic
Benign: Osteoma,Osteoid Osteoma,Bone Islands
Benign Aggressive:Osteoblastoma
Malignant:OsteogenicSarcoma
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Fibrous Tumours
Benign: Fibrous Cortical
Defect, Non-Ossifying
Fibroma, Fibroma of
Bone. Benign Aggressive:
Fibromatosis(desmoid),
Ossifying Fibroma of
bone, Fibrous Dysplasia.
Malignant: Malignant
Fibrous Histiocytoma of
bone, Fibrosarcoma.
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Chondroid
Benign:Enchondroma, Peri-
osteal Chondroma,
Osteochondroma.
Benign Aggressive:
Chondromyxoid
Fibroma,
Chondroblastoma.
Malignant:
Chondrosarcoma.
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Other Bone Tumors
Benign: Bone Cyst,Ganglion,Hemangioma.
Benign Aggressive:
Giant Cell Tumor,Aneurysmal BoneCyst, EOG.
Malignant:
Adamantinoma,Chordoma, Ewings.
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Sites of Tumors
Diaphyseal: Ewings, Osteoid Osteoma,
Mets, Adamantinoma, Fibrous
Dysplasia
Epiphyseal: Chondroblastoma, Clear
Cell Chondrosarcoma, GCT, Ganglion of
Bone.
Metaphyseal: Everything!!!!!!
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Age of Tumors
20>..Osteogenic Sarcoma, Ewings.
40GCT, Chondrosarcoma, MFH,
Lymphoma, Mets.
60Mets, Myeloma,
Chondrosarcoma, late Osteogenic,MFH, Fibrosarcoma.
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