fracture and dislocation.ppt
TRANSCRIPT
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FRACTURE AND DISLOCATION
Nucki N Hidajat, dr, MS, SpBO (K), FICSDepartment Orthopaedi & Traumatology
Faculty of Medicine, Padjadjaran UniversityDr Hasan Sadikin Hospital - Bandung
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Orthopaedic tree
orthospaedos
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introduction 1741, Nicolas Andry
“Orthopaedia, the Art of Preventing and Correcting Deformities in Children”
The present scope of orthopaedics: Include all ages Consist of art and science of prevention, investigation,
diagnosis, and treatment of disorders and injuries of the musculoskeletal system by medical, surgical, and physical means
Orthopedist Surveys in North America – at least 15% of the total
patients 80% of the blunt trauma in ER.
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introduction The musculoskeletal system
Organ system include bones, cartilage, muscles, tendons, ligaments, neurovascular in upper and lower extremities, joints, and vertebrae
Congenital deformities, infections and inflammation, Neoplasms, fracture and associated trauma, degenerative.
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fracture
DefinitionA fracture is a break in the
structural continuity of bone, or cartilage, or epiphyseal plate
Must constantly think soft tissue surrounding the bone Physical factors in the
production of fracture
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How fractures happen?
Fracture due to a traumatic incident Caused by sudden and
excessive force Direct or Indirect
Pathologic fracture Bone weakened (abnormal) Change in structure :
osteoporosis, tumor Can occur even normal stresses
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How fracture happen?
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Descriptive terms pertaining of Fractures
1. Site.
2. Extent
3. Configuration
4. Relationship of the fragments
5. Relation to external environment
6. complications
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1.Anatomical site Diaphyseal Metaphyseal Epiphyseal Intra-articular Fracture dislocation
2. Extent•Complete•Incomplete•Hard tissue •Soft tissue
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extent
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3. configuration Transverse Oblique Spiral Comminuted segmented
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4. Relation of fragments
UndisplacedDisplaced
Translated Angulated Rotated Distracted Overriding impacted
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5. Relationship to external environment
Close fracture• There no contact the external environment• Severity and configuration depend on
energy
Open fracture• Direct contact with external non steril
environment
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Classification of Close fracturewith soft tissue damage (tscherne,1982)
Type 0 : minimal ST damage, indirect violence, simple # patterns
Type I : superficial abrasion caused by pressure from within, moderately severe fracture
Type II : deep, contaminated abrasion, skin or muscle contusion, impending compartment syndrome
Type III : extensive skin contusion or crush, underlying muscle damage, subcutaneous avulsion, comminuted fracture
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Open fracture
Fracture Soft tissue injuries Contaminant from
external environment High risk :
1. Infection, tetanus, gas gangrene, sepsis
2. Nonunion
3. Limb threathening
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Classification open factureGustilo-Anderson (1984)
Type I wound 1 cm or less, quite clean, inside to outside, minimal muscle contusion, simple # patterns
Type II laceration more than 1 cm long, with extensive soft tissue damage, flaps or avulsions, minimal
comminution.
Type III extensive soft tissue damage including muscles, neurovascular structures, often ahigh velocity
injury
IIIA adequate bone coverage, segmental #IIIB periosteal stripping and bone exposure, with
massive contaminationIIIC vascular injury requiring repair
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Open Fracture grade I
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Open Fracture grade II
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Open Fracture grade III
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6. complication
Uncomplicated Complicated
Neurovascular Compartment syndrome infection
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Diagnosis of fracture1. History
• Mechanism of injury, environment, pre-injury status, finding at the incident site, pre-hospital care
2. Physical examination1. Look2. Feel3. Move/ask
3. Investigation1. Lab.2. X-ray3. Scanning
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Mechanism of injury
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Physical examination General conditions
Air way Breathing Circulation
Local conditions Look Feel move
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Physical examinationsLook
Evidence of painSwellingDeformityWounds
FeelSharply locallized painAggravation of painTest artery & nerve
MovecrepitusAbnormal movement
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Diagnostic imaging
X-ray (rule of Two) Two joints Two views Two limbs Two injuries Two occasions
CT Scan MRI
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How fractures heal
Similar with wound healing
Two types of healing process Primary (bridging osteon) Secondary (callus
formations)1. Inflammation
2. Callus formation
3. consolidation
4. remodeling
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Pre-hospital management
According ATLS procedure.
1. Primary survey
2. Secondary survey
A-B-C-D-E Reduction Immobilization Cover the wounds transportation
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immobilization
Two joints minimal include immobilized
Splintage Prevent further injury Re-evaluation
neurovascular distal fracture
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Goals treatment fracture
1. Relieve pain
2. To obtain and maintain satisfactory position of the fracture fragments
3. To allow bony union
4. Restore optimum function
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Specific Methods of treatment for close fracture
1. Protection alone2. Immobilization with or
without reduction3. Closed reduction
followed by traction4. CR followed by
external fixation5. ORIF6. Excision of fragment
fracture
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Immobilization by traction
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Open Reduction and Internal Fixation (ORIF)
Indications1. Intra-articular fracture
2. Avulsion fracture
3. Soft tissue interposition
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4. Grossly unstable fracture
5. Coexistent with vascular injury
6. Pathologic fracture
7. # in children cross epiphyseal plate
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External Fixation
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Excision fragment fracture
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Treatment for Open Fractures:
1. Cleansing of the wound2. Excision of devitalized
tissue (debridement)3. Treatment of the fracture4. Closure of the wound5. Antibacterial drugs6. Prevention of tetanus
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complications Immediately
Bleeding Injury to the nerve Soft tissue
Early Infections Delayed Union Joints stiffness
Late Malunion Osteoarthritis AVN
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Risk AVN in head femur fracture
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Fracture specific
Fracture in children Fracture incomplete most common Conservative treatment Heal faster than adult
Pathologic fracture In porotic bone Abnormal bone structure Abnormal metabolic process in bone
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Joints
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Anatomy Diarthodial Joint
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dislocations
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DISLOKASI
Keluarnya bagian tulang di persendian dari posisi yang normal
Lokasi : hip, shoulder, elbow, finger, patella, knee, ankle, acromioclavicular
Gejala : hilangnya bentuk normal disertai hambatan gerak
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dislokasi Anterior Sendi Bahu
•Sering terjadi (95%)•Sering terjadi pada usia muda•Lengan atas pada posisi abduksi, ekstensi dan rotasi eksternal•Harus segera direduksi
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Dislokasi sendi panggul
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DISLOKASI Dislokasi Posterior Sendi Panggul
• Akut Traumatik• Harus segera reduksi• Dalam anestesi umum• Teknik ; Allis, Bigelow, Hipocrates• Re-evaluasi neurovasluler problem• Imobilisasi sampai soft tissue healing• Bila disertai fraktur ----reduksi terbuka
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Dislokasi elbow
•Reduksi tertutup mudah dilakukan•Imobilisasi 3 minggu•Re-evaluasi neurovaskuler
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Bahan bacaan
Robert B. Salter(1999); Textbook of disorders and Injuries of the musculoskeletal System, 3rd ed.Williams & Wilkins, Baltimore. p: 1-3; 417-511.
Louis Solomon et.al (2001) ; Apley’s System of Orthopaedics and Fractures. 8th ed.Arnold, London. p: 521-583.