trauma musculoskeletal - spine fkk umj1

7/26/2019 Trauma Musculoskeletal - Spine FKK UMJ1

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MUSCULOSKELETAL TRAUMA

Dr Moh Adib Khumaidi, SpOT


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Introduction

85 % of blunt trauma

Resuscitation priority is like another trauma

Reevaluation


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Introduction

Millions of cases annually.

Multiple MOI :

Falls, Automobile collisions, Crashes, Violence, etc Multi-system trauma

Rarely life threatening

Improperly treated can result permanent disability.


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Anatomy & Physiology of theMusculoskeletal System


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Structures

Skin

Bones

Joints

where bones interact

Muscles

Tendons - connect muscle to bone

Ligaments - connect bone to bone

Neurovascular


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The Skeleton


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Types of Muscles


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The Neurovascular


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FUNCTION

Protects organs

Allows for efficient movement

Stores salts and other materials needed for metabolism

Produces RBCis

Scaffolding / Support


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Pathophysiology of the MusculoskeletalSystem


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Injuries to the Musculoskeletal System

Four basic types of musculoskeletal injuries are:

Strain- An extreme stretching or tearing of MUSCLE & / ORTENDON.

Sprain- partial or complete tearing of LIGAMENTS and tissues atthe joint.

Dislocation- displacement or separation of a bone from itsnormal position at the joint.

Fracture- a break or disruption in bone closed - the broken bones do not penetrate the skin

open - the skin is pierced by broken bone fragments


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Accident Scene..


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Life before Limb !!


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PRIORITY ?

Life threatening

Limb threatening


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Primary Survey & Resuscitation

ABCDE

A irway with cervical spine control

B reathing

C irculation with control of hemorrage

D isability (neurological state) E xposure (take the patient clothes off)


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Primary Survey

Bleeding controldirect padding

Splinting bleeding

Fluid resuscitation


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Adjunction in Primary Survey

Tractionanatomical position Splint

Be careful in dislocation !

Fracture immobilization


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Adjuncts : X-Rays

Determinited by patients condition

Obtain AP pelvis early if hemodynamically abnormal and no

obvious source of bleeding

Primary Survey & Resuscitation


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Secondary Survey

Physical Examination

Undress the patient

Component have to be examined :

1. Skin

2. Neuromuscular function

3. Circulatory state

4. Bone & ligament integrity

Dont forget the back!


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Secondary Survey

Physical Examination

Look

Feel

Move


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Life Threatening Musculoskeletal

Trauma

Pelvic Trauma with Massive Bleeding

Main Arterial Rupture

Crush Syndrome


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Trauma


Examination

- hematoma : pelvic, skrotal,perianal

- high riding prostate

- meatal bleeding- leg length discrepancy


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Pelvic Trauma with

Massive Bleeding


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Trauma


Management

- Bleeding control & resuscitation

- PSAG

- Traction

- Pelvic sling

- Pelvic Open fracture padding with

tampon

- Pelvic wrapping


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Pelvic Wrapping


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Pelvic Wrapping

DISADVANTAGES

Non anatomical

Soft tissue pressure

Risk of visceralRisk of Sacral root inj.

ADVANTAGES

Easy to useRapid stabilization

Inexpensive


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PSAG


ADVANTAGES

Easy to useRapid

Reusable

DISADVANTAGES

Decrease vital capacityCompartmental synd.

Exacerbate CHF


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PELVIC C-CLAMP


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Trauma

Crush Syndrome

Mechanism

- Crush injury & long compression ;

thigh, leg

Examination

- Dark Urine

- Rhabdomiolisis hipovolemic,

metabolic acidosis, hipercalemia,

hipocalsemia & DIC

Management

- Fluid resuscitation & osmotic diuretic

- Alkalinization

m rea en ng


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m rea en ngMusculoskeletal Trauma

Open Fractures

Vascular Trauma & Traumatic Amputation

Compartement Syndrome

Dislocations


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Open Fracture grade 1


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Open Fracture grade 2


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Open Fracture grade 3A


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Open Fracture grade 3B


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Open Fracture

grade 3C

Life Threatening


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Life Threatening

Musculoskeletal Trauma

Open Fractures

Principles of treatment

4 essentilals are :

1. Wound debridement

2. Antibiotic prophylaxis

3. Stabilization of the fractures

4. Early wound cover

Limb Threatening


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Accident Site

Reduction

Sterile Dressing

Splinting

g


Open Fractures

Emergency RoomLimb Threatening


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Emergency Room

Resuscitation !

g


Open Fractures

E R


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Emergency Room...

ExaminationClinical examination

Vascular status

Neurolgic status

X-ray diagnostics

Limb Threatening


Open Fractures


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Limb Threatening Musculoskeletal TraumaVascular Trauma & Traumatic Amputation

History & Examination ?

Time & Initial Management ?

Crush Or Sharp Wound ?

ascu ar rauma


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ascu ar raumaTraumatic Amputation

Can We Replanted ?

Proper amputee management!

Immediate orthopaedic consult

Li b Th t i


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Limb Threatening

Musculoskeletal Trauma Compartement

Syndrome

Threaten the Circulation To The Enclosed (Intracompartmental)

Muscle, Nerve, And Vascular

Increased Pressure Within

Rigid Osteofascial Compartement

Limb Threatening


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Limb Threatening


Syndrome

Clinical features

Five Ps

Also Check for :

- Out of proportion Pain !

- Pain on Passive Stretching

PainPallorParaestesiaPulselessParalysis

Limb Threatening


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Limb Threatening


Syndrome

Treatment

Decompression by

Open fasciotomy


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Joint islocations

Displacement of bone from normal joint

Location : hip, shoulder, elbow, finger, patella,

knee, ankle, acromioclavicular

Sign :

loss of normal shape & movement

Always Check For

Neurovascular Injury !


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ELBOW DISLOCATION


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SHOULDER DISLOCATION


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HIP DISLOCATION


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Penyembuhan fraktur tergantung pada :

Integritas Jaringan lunak sekitar fraktur

Suplai darah ke tulang

Derajat kontaminasi bakteri

Konfigurasi fraktur

Usia

STABILITAS ujung-ujung fraktur

PRINSIP


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RECOGNIZE

REDUCE

RETAINREHABILI

TATION

PENANGANAN

FRAKTUR


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RECOGNIZE

Tegakkan Diagnosa !

History : Riwayat Trauma ( trivial fall ?? )

Pemeriksaan fisik : tanda fraktur

- Look : bengkak, luka, deformitas

- Feel : Nyeri , NVD

- Move : pastikan gerakan2 pada bagian distal

X Ray : AP, Lat ( 2D)


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RECOGNIZE

Gejala yang menyertai :

- Numbness/ weakness

- Skin pallor/ cyanosis

- Blood in urine

- Abdomen pain

- Transient loss of consciousness


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REDUCE

Pergeseran fragmen +

Reduce = reposisi

Reposisi tertutup : manipulasi w/o bedah

Reposisi terbuka : manipulasi w/ bedah


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RETENTION

Stabilisasi / immobilisasi / fiksasi daerah fraktur

External : bidai , gips, Orthosis , external fixator

Internal : Implant Orthopaedi ;

- extra medular

- intra medular


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PRIMARY CARE PHYSICIAN MUST KNOW

Treat common fractures

Refer fracture to specialist / hospital (

ER )


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Emergency

Open Fractures

Dislocation/ Subluxation

Closed Fractures w/ NV problems

Spine fractures


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Summary

Primary Survey :Identifylife-threatening

Injuries

Secondary Survey :Identifylimb-threatening injuries

Proper immobilization

Early Orthopaedic consultation


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CEDERA SPINAL


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Trauma Tulang Belakang

Trauma multipel Cederavertebra & medula spinalis

15% cedera diatas klavikula :cedera servikal

5% cedera kepala : cederavertebra

Cedera vertebra : 55% cedera servikal

15% cedera torakal

15% cedera torakolumbal 15% cedera lumbosakral


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Pendahuluan

Cedera disingkirkan dengan : Sadar : neurologis normal & sakit / nyeri tekan (-)

Tidak sadar : pem. radiologis

Kesalahan penanganan dapat memperburukkerusakan neurologis dan prognosa.

Curiga cedera :

Imobilisasi adekuat Long spine board : transportasi, dilepas secepatnya

Log rolling / 2 jam : mencegah dekubitus.


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Anatomi Vertebra

Kolumna Vertebralis :

7 vertebra servikal,

12 torakal,

5 lumbal, sakrum &

koksigeus.


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AnatomiVertebra

Bagian :

Anterior: korpus, diskusintervertebralis,ligamentum longitudinal

anterior dan posterior.

Posterior: pedikel,lamina, sendi faset,ligamentum

interspinosus danmuskulus paraspinalis.

Pemeriksaan


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Pemeriksaan

Sensibilitas

C5 : area diatas deltoid

C6 : jempol

C7 : jari tengah

C8 : jari kelingking

T4 : papila mamae

T8 : xifosternum

T10 : umbilikus

T12 : simfisis

L4 : medial betis

L5 : web jari kaki I - II

S1 : lateral pedis

S3 : tuberositas iskhii

S4 & S5 : perianal

Pemeriksaan


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Pemeriksaan

Motoris

C5 : Abduksi bahu

C6 : Ekstensi wrist

C7 : Ekstensi siku

C8 : Fleksi jari tangan

T1 : Abduksi kelingking

L2 : Fleksi panggul

L3 : Ekstensi lutut

L4 : Dorsifleksi ankle

L5 : Ekstensi jari kaki I

S1 : Fleksi ankle

(+) Otot sfinger ani eksterna (colokdubur)


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Gradasi kekuatan Otot

0 : Kelumpuhan total

1 : Teraba kontraksi

2 : Gerakan tanpa menahan gaya berat 3 : Gerakan melawan gaya berat

4 : Gerakan melawan gaya berat dengan

tahanan kurang dari normal

5 : Kekuatan normal


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Syok Neurogenik dan Syok Spinal Syok neurogenik Akibat kerusakan jalur simpatis

Vasodilatasi viseral danekstermitas bawah : hipotensi

Atoni simpatis jantung :

bradikardia Responsif thd resusitasi cairan

(-)

Vasopresor : mempertahankanperfusi jaringan

Atropin : mengatasi bradikardia

Syok spinal

Terjadi setelah cedera medula

spinalis

flasid dan arefleksia

Lama berlangsungnyabervariasi

Efek terhadap organ lain :

Hipoventilasi ; paralisis ototinterkostal

Paralisis otot diafragma (cederaC3-C5)

Anestesia ; dapat menutupicedera lain


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Pengelolaan Umum

Imobilisasi

Sejak fase pra rumah sakit.

Meliputi bagian atas & bawah dari lokasi cedera

Dipertahankan s/d cedera disingkirkan.

Posisi netral : terlentang tanpa rotasi / fleksi-ekstensi

Bila tdp deformitas, jangan direduksi.

Kolar semirigid tidak menjamin stabilisasi, perlu penyanggatambahan pada long spine board.

Bila dilakukan intubasi : pada posisi netral. Gelisah / agitasi : sedativa / pelumpuh otot.


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Pengelolaan Umum

Cairan intravena

Dibatasi untuk maintenance, kecuali pada syok.

Syok neurogenik : vasopresor

Kateter schwann ganz : monitor cairan. Kateter urine : monitor urin.

Pipa nasogastrik

Mengosongkan lambung & mencegah aspirasi.


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Pengelolaan Umum

Obat-obatan

Metilprednisolon, pd 8 jam pertama, dosis :

30 mg/kgBB dalam 15 menit pertama.

5,4 mg/kgBB/jam untuk 23 jam berikutnya.

Transfer

Dilakukan setelah KU stabil

Telah difiksasi : bidai / backboard / kolar

Bila pernafasan tidak adekuat : intubasi


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Thoracolumbosacral orthosis (TLSO) fabricated from abody cast mold:

Anterior (A), lateral (B), and posterior (C) views of a patientfit with a custom. Note the contouring over the iliac crests.

PEDICLE SCREW SUBLAMINARY


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WIRING


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PEDICLE SCREW PLATING


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SYNTHES SYSTEM


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trauma musculoskeletal - spine fkk umj1

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