STEP 3

1. What is the anatomy from os. Coxae?

Parts of os. Coxae=buka sobotta

The predilection of fracture in os. Coxae = pelvis major and pelvis minor

2. What is the etiology of the diagnostic from the scenario?

ETIOLOGY OF FRACTURES
EXTRINSIC CAUSES
DIRECT VIOLENCE
Trauma is the most common cause of fractures in small animals and is usually due to
automobile injury or falling from a height. Since direct trauma is rarely delivered in a
calibrated amount to a specific place, the resultant fracture is rarely predictable. The amount
and direction of force will vary from accident to accident. Most fractures resulting from
violent direct trauma are either comminuted or multiple.

INDIRECT VIOLENCE
Fractures due to indirect trauma are more predictable than those due to direct trauma.
Generally a force is transmitted to a bone in a specific fashion and at a "weak link"
within the bone, causing a fracture to occur.

BENDING FORCES
Bending fractures occur when force is applied to a specific focal point on a bone to
the extent that the traumatic force overcomes the elastic limit of the bone diaphysis.
The initial effect of a bending force is a cortical break opposite the site of the trauma.
The periosteum will remain intact on the side of the force while tearing over the
fracture on the opposite side. With additional force the entire bone snaps, with
attendant tearing of vascular and soft tissue structures within or on the diaphysis.
Bending fractures are generally oblique or transverse, or they may have a butterfly
fragment. (Example: A dog running across a field steps into a gopher hole with the
hind limb; the edge of the hole is a fulcrum producing a bending fracture of the
midshaft tibia.)

TORSIONAL FORCES
Torsional fractures occur when a twisting force is applied to the long axis of a bone.
Usually this is a result of one end of a bone being placed in a fixed position while the
other end of the bone is forced to rotate. The resulting fracture will be a very long
spiral with sharp points and often sharp edges. It is possible for the sharp points or
edges to compromise soft tissues or to cut through the skin and result in an open
fracture. Torsional forces generally result in short or long spiral fractures. (Example:
A cat jumping from a garage roof to a fence misjudges the distance and catches its
hock in the fence. The resulting force of its body twisting against the fixed lower
extremity results in a spiral fracture of the tibial diaphysis.)

COMPRESSION FORCES
Compressive forces along the long axis of a bone may force the smaller diaphyseal or
metaphyseal portion of a bone to impact into the larger epiphysis: bony substance is
thereby crushed. Similarly a compressive force directed along the axis of the spine
may result in collapse of a vertebral body. For compressive force to result in fracture,
one end of a bone must be in a fixed position while the other end is forced toward the
fixed end. Compressive forces result in impacted fractures or compression fractures.
(Example: A large breed puppy jumps for a frisbee and in landing forces the hock
plantigrade into the ground. The full weight of the dog then crushes the proximal
tibial epiphysis over the proximal tibial metaphysis.)

SHEARING FORCES
A shearing fracture is caused by a force transmitted along the axis of a bone, which is
then transferred to a portion of the same bone that lies peripheral to the axis or across
a joint to other bones that are not protected by the axis of the bone. The force shears
off that bony portion unable to continue transmission of the force along the axis. The
fracture line in a shear fracture will be parallel to the direction of the applied force.
Shearing forces result in the fracture of bony prominences not placed along the direct
axis of a diaphysis. (Example: An immature miniature breed dog is dropped from its
owner's arms to a hard surface. The force transmitted up the radius and ulna, across
the elbow joint and into the distal humerus will shear off the lateral humeral condyle.)

INTRINSIC CAUSES
FRACTURES DUE TO MUSCULAR ACTION
Fractures caused by violent contraction of a muscle are called avulsion fractures. They may
occur because of violent isometric contraction but are associated more commonly with
trauma that results in forceful muscular shortening. These fractures frequently occur in
immature animals while the physeal plate remains open. Such muscular forces are more
likely to separate a cartilaginous union than the eventual bony union of mature animals.

Avulsion fractures affecting bony prominences that serve as the major origin or
insertion of a muscle are seen routinely. The processes commonly avulsed include the
acromion, scapular tuberosity, greater humeral tubercle, olecranon, ischial tuberosity,
greater trochanter, tibial tuberosity, and the calcaneus of the fibular tarsal bone.

PATHOLOGIC FRACTURES
Pathologic fractures occur because of underlying bony or systemic disease that causes
one, many, or all bones of an animal's skeletal system to be abnormal and thus more
susceptible to fracture. Pathologic fractures may occur from any type of trauma:
bending force, torsional force, compressive force, or shearing force. Often the only
force necessary to cause fracture is the animal's weight; thus, spontaneous fracture
occurs without overt trauma.

Pathologic fracture may occur through any of the following types of bony pathology:
neoplasia, bone cysts, osteoporotic bone caused by secondary NHPO, nutritional
hyperparathyroidism, localized bone infection (osteomyelitis), osteoporotic bone
caused by disuse following prolonged external fixation or removal of a rigid
internaldevice

A pathologic fracture can occur in any bone, in any location within a bone, and take
any shape. The diagnosis of underlying pathology is usually of more importance than
 immediate bone fixation. Once the pathologic basis for the fracture has been
diagnosed and specific corrective measures initiated, the fracture or fractures can be
treated. Treatment of all pathologic fractures, including those due to neoplasms, can
be successful.

http://cal.vet.upenn.edu/projects/saortho/chapter_11/11mast.htm

3. What is the risk factor of fracture?

 Age. The rate of hip fractures increases substantially with age. As you age, your bone
density and muscle mass both decrease. Older age may also bring vision and balance
problems, along with slower reaction time to avoid falling when you feel unsteady. If
you're inactive, your muscles tend to weaken even more as you age. All of these
factors combined can increase your risk of a hip fracture.

 Your sex. Women lose bone density at a faster rate than men do. The drop in estrogen
levels that occurs with menopause accelerates bone loss, increasing the risk of hip
fractures. However, men also can develop dangerously low levels of bone density.

 Chronic medical conditions. Osteoporosis is the most powerful risk factor for hip
fracture, but other medical conditions may lead to fragile bones. These include
endocrine disorders, such as an overactive thyroid, and intestinal disorders, which
may reduce your absorption of vitamin D and calcium.

 Certain medications. Cortisone medications, such as prednisone, can weaken bone if

you take them long term. In some cases, certain drugs or the combination of
medications can make you dizzy and more prone to falling.

 Nutritional problems. Lack of calcium and vitamin D in your diet when you're
young lowers your peak bone mass and increases your risk of fracture later in life.
Serious eating disorders, such as anorexia nervosa and bulimia, can damage your
skeleton by depriving your body of essential nutrients needed for bone building.

 Physical inactivity. Weight-bearing exercises, such as walking, help strengthen bones

and muscles, making falls and fractures less likely. If you don't regularly participate in
weight-bearing exercise, you may have lower bone density and weaker bones.

 Tobacco and alcohol use. Smoking and drinking alcohol can interfere with the
normal processes of bone building and remodeling, resulting in bone loss.

Determinan Fraktur

a) Faktor Manusia

Beberapa faktor yang berhubungan dengan orang yang mengalami fraktur atau
patah tulang antara lain dipengaruhi oleh usia, jenis kelamin, aktivitas olah raga dan

massa tulang.

a.1. Umur

Pada kelompok umur muda lebih banyak melakukan aktivitas yang berat

daripada kelompok umur tua. Aktivitas yang banyak akan cenderung

mengalami kelelahan tulang dan jika ada trauma benturan atau kekerasan

tulang bisa saja patah. Aktivitas masyarakat umur muda di luar rumah cukup tinggi dengan
pergerakan yang cepat pula dapat meningkatkan risiko

terjadinya benturan atau kecelakaan yang menyebabkan fraktur. Insidens

kecelakaan yang menyebabkan fraktur lebih banyak pada kelompok umur

muda pada waktu berolahraga, kecelakaan lalu lintas, atau jatuh dari

ketinggian. Berdasarkan penelitian Nazar Moesbar tahun 2007 di Rumah

Sakit Haji Adam Malik Medan terdapat sebanyak 864 kasus patah tulang, di

antaranya banyak penderita kelompok umur muda. Penderita patah tulang

pada kelompok umur 11 – 20 tahun sebanyak 14% dan pada kelompok umur

21 – 30 tahun sebanyak 38% orang. 13

a.2. Jenis Kelamin

Laki – laki pada umumnya lebih banyak mengalami kecelakaan yang

menyebabkan fraktur yakni 3 kali lebih besar daripada perempuan.18 Pada

umumnya Laki – laki lebih aktif dan lebih banyak melakukan aktivitas

daripada perempuan. Misalnya aktivitas di luar rumah untuk bekerja sehingga

mempunyai risiko lebih tinggi mengalami cedera. Cedera patah tulang

umumnya lebih banyak terjadi karena kecelakaan lalu lintas. Tingginya kasus

patah tulang akibat kecelakaan lalulintas pada laki – laki dikarenakan laki –

laki mempunyai perilaku mengemudi dengan kecepatan yang tinggi sehingga

menyebabkan kecelakaan yang lebih fatal dibandingkan perempuan.

Berdasarkan penelitian Juita, pada tahun 2002 di Rumah Sakit St. Elisabeth

Medan terdapat kasus fraktur sebanyak 169 kasus dimana jumlah penderita

laki –laki sebanyak 68% dan perempuan sebanyak 32%.

a.3. Aktivitas Olahraga

Aktivitas yang berat dengan gerakan yang cepat pula dapat menjadi risiko

penyebab cedera pada otot dan tulang. Daya tekan pada saat berolah raga

seperti hentakan, loncatan atau benturan dapat menyebabkan cedera dan jika

hentakan atau benturan yang timbul cukup besar maka dapat mengarah pada

fraktur. Setiap tulang yang mendapat tekanan terus menerus di luar

kapasitasnya dapat mengalami keretakan tulang. Kebanyakan terjadi pada

kaki, misalnya pada pemain sepak bola yang sering mengalami benturan kaki

antar pemain. Kelemahan struktur tulang juga sering terjadi pada atlet ski,

jogging, pelari, pendaki gunung ataupun olahraga lain yang dilakukan dengan

kecepatan yang berisiko terjadinya benturan yang dapat menyebabkan patah

tulang.

a.4. Massa Tulang

Massa tulang yang rendah akan cenderung mengalami fraktur daripada tulang

yang padat. Dengan sedikit benturan dapat langsung menyebabkan patah

tulang karena massa tulang yeng rendah tidak mampu menahan daya dari

benturan tersebut. Massa tulang berhubungan dengan gizi tubuh seseorang.

Dalam hal ini peran kalsium penting bagi penguatan jaringan tulang. Massa

tulang yang maksimal dapat dicapai apabila konsumsi gizi dan vitamin D

tercukupi pada masa kanak – kanak dan remaja. Pada masa dewasa

kemampuan mempertahankan massa tulang menjadi berkurang seiring

menurunnya fungsi organ tubuh. Pengurangan massa tulang terlihat jelas pada wanita yang
menopause. Hal ini terjadi karena pengaruh hormon yang
berkurang sehingga tidak mampu dengan baik mengontrol proses penguatan

tulang misalnya hormon estrogen.

b) Faktor Perantara

Agent yang menyebabkan fraktur sebenarnya tidak ada karena merupakan

peristiwa penyakit tidak menular dan langsung terjadi. Namun bisa dikatakan sebagai

suatu perantara utama terjadinya fraktur adalah trauma benturan. Benturan yang keras

sudah pasti menyebabkan fraktur karena tulang tidak mampu menahan daya atau

tekanan yang ditimbulkan sehingga tulang retak atau langsung patah. Kekuatan dan

arah benturan akan mempengaruhi tingkat keparahan tulang yang mengalami fraktur.

Meski jarang terjadi, benturan yang kecil juga dapat menyebabkan fraktur bila terjadi

pada tulang yang sama pada saat berolahraga atau aktivitas rutin yang menggunakan

kekuatan tulang di tempat yang sama atau disebut juga stress fraktur karena

kelelahan.

c) Faktor lingkungan

Faktor lingkungan yang mempengaruhi terjadinya fraktur dapat berupa

kondisi jalan raya, permukaan jalan yang tidak rata atau berlubang, lantai yang licin

dapat menyebabkan kecelakaan fraktur akibat terjatuh. Aktivitas pengendara yang

dilakukan dengan cepat di jalan raya yang padat, bila tidak hati – hati dan tidak

mematuhi rambu lalu lintas maka akan terjadi kecelakaan. Kecelakaan lalu lintas

yang terjadi banyak menimbulkan fraktur. Berdasarkan data dari Unit Pelaksana Teknis
Makmal Terpadu Imunoendokrinologi FKUI di Indonesia pada tahun 2006

dari 1690 kasus kecelakaan lalu lintas proporsi yang mengalami fraktur adalah sekitar

20%.

Pada lingkungan rumah tangga, kondisi lantai yang licin dapat mengakibatkan

peristiwa terjatuh terutama pada lanjut usia yang cenderung akan mengalami fraktur

bila terjatuh. Data dari RSUD Dr. Soetomo Surabaya pada tahun 2005 terdapat 83
kasus fraktur panggul, 36 kasus fraktur tulang belakang dan 173 kasus pergelangan

tangan, dimana sebagian besar penderita wanita >60 tahun dan penyebabnya adalah

kecelakaan rumah tangga.

http://repository.usu.ac.id/bitstream/123456789/22361/4/Chapter%20II.pdf

4. What are the types of fractures?

A fracture is a partial or complete break in the bone. When a fracture occurs, it

is classified as either open or closed:

 open fracture (Also called compound fracture.) - the bone exits and is
visible through the skin, or a deep wound that exposes the bone
through the skin.

 closed fracture (Also called simple fracture.) - the bone is broken, but
the skin is intact.

Fractures have a variety of names. Below is a listing of the common types that
may occur in children:
 greenstick - incomplete fracture. The broken bone is not completely
separated.

Illustration of greenstick fracture

 transverse - the break is in a straight line across the bone.

Illustration of transverse fracture

 spiral - the break spirals around the bone; common in a twisting injury.

Illustration of spiral fracture

 oblique - diagonal break across the bone.

Illustration of oblique fracture

 compression - the bone is crushed, causing the broken bone to be wider

or flatter in appearance.

Illustration of a compression fracture

 comminuted - the break is in three or more pieces.

 http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/orthopaedics/fr
acture.html

Some different types of fracture:

 Avulsion fracture - a muscle or ligament pulls on the bone, fracturing it.

 Comminuted fracture - the bone is shattered into many pieces.

 Compression (crush) fracture - generally occurs in the spongy bone in the spine. For
example, the front portion of a vertebra in the spine may collapse due to osteoporosis.

 Fracture dislocation - a joint becomes dislocated, and one of the bones of the joint
has a fracture.

 Greenstick fracture - the bone partly fractures on one side, but does not break
completely because the rest of the bone can bend. More common among children,
whose bones are softer and more elastic.

 Hairline fracture - a partial fracture of the bone. Often this type of fracture is
harder to detect.

 Impacted fracture - when the bone is fractured, one fragment of bone goes into
another.

 Longitudinal fracture - the break is along the length of the bone.

 Oblique fracture - A fracture that is diagonal to a bone's long axis.

 Pathological fracture - when an underlying disease or condition has already
weakened the bone, resulting in a fracture (bone fracture caused by an underlying
disease/condition that weakened the bone).

 Spiral fracture - A fracture where at least one part of the bone has been twisted.

 Stress fracture - more common among athletes. A bone breaks because of repeated
stresses and strains.

 Torus (buckle) fracture - bone deforms but does not crack. More common in
children. It is painful but stable.

 Transverse fracture - a straight break right across a bone.

http://www.medicalnewstoday.com/articles/173312.php

http://www.brennerchildrens.org/KidsHealth/Parents/General-Health/Aches-Pains-and-
Injuries/Broken-Bones.htm

Klasifikasi Fraktur

Fraktur dapat dibedakan jenisnya berdasarkan hubungan tulang dengan

jaringan disekitar, bentuk patahan tulang, dan lokasi pada tulang fisis.

Berdasarkan hubungan tulang dengan jaringan disekitar

Fraktur dapat dibagi menjadi :

a) Fraktur tertutup (closed),bila tidak terdapat hubungan antara fragmen tulang

dengan dunia luar.

b) Fraktur terbuka (open/compound), bila terdapat hubungan antara fragmen

tulang dengan dunia luar karena adanya perlukaan di kulit. Fraktur terbuka

terbagi atas tiga derajat (menurut R. Gustillo), yaitu:

b.1. Derajat I :

i. Luka <1 cm

ii. Kerusakan jaringan lunak sedikit, tak ada tanda luka remuk

iii. Fraktur sederhana, transversal, oblik, atau kominutif ringan

iv. Kontaminasi minimal

b.2. Derajat II :

i. Laserasi >1 cm

ii. Kerusakan jaringan lunak, tidak luas, flap/ avulsi

iii. Fraktur kominutif sedang

iv. Kontaminasi sedang

b.3. Derajat III :

Terjadi kerusakan jaringan lunak yang luas, meliputi struktur kulit, otot,

dan neurovaskular serta kontaminasi derajat tinggi. Fraktur terbuka derajat III

terbagi atas:

i. Jaringan lunak yang menutupi fraktur tulang adekuat, meskipun terdapat

laserasi luas/flap/avulsi atau fraktur segmental/sangat kominutif yang

disebabkan oleh trauma berenergi tinggi tanpa melihat besarnya ukuran

luka.

ii. Kehilangan jaringan lunak dengan fraktur tulang yang terpapar atau

kontaminasi masif.

iii.Luka pada pembuluh arteri/saraf perifer yang harus diperbaiki tanpa

melihat kerusakan jaringan lunak.

Berdasarkan bentuk patahan tulang

a) Transversal

Adalah fraktur yang garis patahnya tegak lurus terhadap sumbu panjang

tulang atau bentuknya melintang dari tulang. Fraktur semacam ini biasanya

mudah dikontrol dengan pembidaian gips.

b) Spiral

Adalah fraktur meluas yang mengelilingi tulang yang timbul akibat torsi

ekstremitas atau pada alat gerak. Fraktur jenis ini hanya menimbulkan sedikit

kerusakan jaringan lunak.

c) Oblik

Adalah fraktur yang memiliki patahan arahnya miring dimana garis patahnya

membentuk sudut terhadap tulang.

d) Segmental

Adalah dua fraktur berdekatan pada satu tulang, ada segmen tulang yang retak

dan ada yang terlepas menyebabkan terpisahnya segmen sentral dari suplai

darah.

e) Kominuta

Adalah fraktur yang mencakup beberapa fragmen, atau terputusnya keutuhan

jaringan dengan lebih dari dua fragmen tulang.

f) Greenstick

Adalah fraktur tidak sempurna atau garis patahnya tidak lengkap dimana

korteks tulang sebagian masih utuh demikian juga periosterum. Fraktur jenis

ini sering terjadi pada anak – anak.

g) Fraktur Impaksi

Adalah fraktur yang terjadi ketika dua tulang menumbuk tulang ketiga yang
berada diantaranya, seperti pada satu vertebra dengan dua vertebra lainnya.

h) Fraktur Fissura

Adalah fraktur yang tidak disertai perubahan letak tulang yang berarti,

fragmen biasanya tetap di tempatnya setelah tindakan reduksi.

Berdasarkan lokasi pada tulang fisis

Tulang fisis adalah bagian tulang yang merupakan lempeng pertumbuhan,

bagian ini relatif lemah sehingga strain pada sendi dapat berakibat pemisahan fisis

pada anak – anak. Fraktur fisis dapat terjadi akibat jatuh atau cedera traksi. Fraktur

fisis juga kebanyakan terjadi karena kecelakaan lalu lintas atau pada saat aktivitas

olahraga. Klasifikasi yang paling banyak digunakan untuk cedera atau fraktur fisis

adalah klasifikasi fraktur menurut Salter – Harris :

a) Tipe I : fraktur transversal melalui sisi metafisis dari lempeng

pertumbuhan, prognosis sangat baik setelah dilakukan reduksi tertutup.

b) Tipe II : fraktur melalui sebagian lempeng pertumbuhan, timbul

melalui tulang metafisis , prognosis juga sangat baik denga reduksi

tertutup.

c) Tipe III : fraktur longitudinal melalui permukaan artikularis dan

epifisis dan kemudian secara transversal melalui sisi metafisis dari

lempeng pertumbuhan. Prognosis cukup baik meskipun hanya dengan

reduksi anatomi.

d) Tipe IV : fraktur longitudinal melalui epifisis, lempeng pertumbuhan

dan terjadi melalui tulang metafisis. Reduksi terbuka biasanya penting

dan mempunyai resiko gangguan pertumbuhan lanjut yang lebih besar.

e) Tipe V : cedera remuk dari lempeng pertumbuhan, insidens dari

gangguan pertumbuhan lanjut adalah tinggi.

Untuk lebih jelasnya tentang pembagian atau klasifikasi fraktur dapat dilihat
pada gambar berikut ini :
http://repository.usu.ac.id/bitstream/123456789/22361/4/Chapter%20II.pdf

1. Klasifikasi

 Berdasarkan hubungannya dengan dunia luar

 Fraktur tertutup (closed)
Bila tidak terdapat hubungan antara fragmen tulang dengan dunia luar

 Fraktur terbuka
Bila terdapat hubungan antara fragmen tulang dengan dunia luar karena
adanya perlukaan di kulit. Menurut R. Gustillo fraktur terbuka ada 3
derajat :

a. Derajat I
o Luka < 1 cm
o Kerusakan jaringan lunak sedikit, tidak ada tanda luka remuk
o Fraktur sederhana, transversal, oblik, atau kominutif ringan
o Kontaminasi minimal
b. Derajat II
o Laserasi > 1 cm
o Kerusakan jaringan lunak tidak luas, flap/avulsi
o Fraktur kominutif sedang
o Kontaminasi sedang
c. Derajat III
Terjadi kerusakan jaringan lunak yang luas meliputi struktur kulit, otot
dan neurovaskuler serta kontaminasi derajat tinggi.Fraktur derajat III
terbagi atas :

o Jaringan lunak yang menutupi fraktur tulang adekuat, meskipun

terdapat laserasi luas/flap/avulsi atau fraktur segmental/sangat
kominutif yang disebabkan oleh trauma berenergi tinggi tanpa
melihat besarnya ukuran luka
o Kehilangan jaringan lunak dengan fraktur tulang yang terpapar
atau kontaminasi masif
o Luka pada pembuluh arteri/saraf perifer yang harus diperbaiki
tanpa melihat kerusakan jaringan lunak
(Mansjoer, Arif et al. 2000. Kapita Selekta Kedokteran ed III Jilid 2. Jakarta: Media
Aesculapius)

Deskripsi Fraktur

a. Komplit/tidak komplit
  Fraktur komplit : bila garis patah melalui seluruh penampang tulang atau melalui
kedua korteks tulang
 Fraktur tidak komplit : bila garis patah tidak melalui seluruh penampang tulang
seperti :
- Hairline fracture (patah retak rambut)
- Buckle fracture atau torus fracture : bila terjadi lipatan dari satu korteks
dengan kompresi tulang spongiosa di bawahnya biasanya pada distal radius
anak-anak
- Greenstick fracture : mengenai satu korteks dengan angulasi korteks lainnya
yang terjadi pada tulang panjang anak

b. Bentuk garis patah dan hubungannya dengan mekanisme trauma

 Garis patah melintang : trauma angulasi atau langsung
 Garis patah oblik : trauma angulasi
 Garis patah spiral : trauma rotasi
 Fraktur kompresi : trauma aksial-fleksi pada tulang spongiosa
 Fraktur avulsi : trauma tarikan / traksi otot pada insersinya di tulang misalnya
fraktur patella
c. Jumlah garis patah
 Fraktur kominutif : garis patah > 1 dan saling berhubunga

 Fraktur segmental : garis patah > 1 tapi tidak berhubungan. Bila 2 garis patah
disebut pula fraktur bifokal

 Fraktur multipel : garis patah > 1 tetapi pada tulang yang berlainan tempatnya
misalnya fraktur femur, fraktur tulang belakang
d. Bergeser/tidak bergeser
 Fraktur undisplaced (tidak bergeser) : garis patah komplit tetapi kedua fragmen
tidak bergeser, periosteumnya masih utuh
 Fraktur displaced (bergeser) : terjadi pergeseran fragmen-fragmen fraktur yang
juga disebut lokasi fragmen, terbagi :
 - Dislokasi ad longitudinum cum contractionum : pergeseran searah sumbu dan
overlapping
- Dislokasi ad axim : pergeseran yang membentuk sudut
- Dislokasi ad latus : pergeseran di mana kedua fragmen saling menjauhi
e. Terbuka – tertutup
f. Komplikasi – tanpa komplikasi
Bila ada harus disebut. Komplikasi dapat berupa komplikasi dini atau lambat, lokal
atau sistemik, oleh trauma atau akibat pengobatan

(Mansjoer, Arif et al. 2000. Kapita Selekta Kedokteran ed III jilid 2. Jakarta: Media
Aesculapius)

 Berdasarkan penyebab
a. Ekskoriasi atau luka lecet atau gores: cedera pada permukaan epidermis akibat
bersentuhan dengan benda berpermukaan kasar atau runcing
b. vulnus scissum: luka sayat atau luka iris yang ditandai dengan tepi luka berupa
garis lurus dan beraturan
c. vulnus laceratum atau luka robek: luka dengan tepi yang tidak beraturan atau
compang-camping biasanya karena tarikan atau goresan benda tumpul
d. vulnus punctum atau luka tusuk: luka akibat tusukan benda runcing yang
biasanya kedalaman luka lebih daripada lebarnya
e. vulnus morsum: luka karena gigitan binatang
f. vulnus combutio: luka bakar
 Berdasarkan ada/tidaknya kehilangan jaringan
a. ekskoriasi
b. skin avulsion, degloving injury
c. skin loss
 Berdasarkan derajat kontaminasi
a. luka bersih
- luka sayat elektif
- steril, potensial terinfeksi
- tidak ada kontak dengan orofaring, traktus respiratorius, traktus alimentarius,
traktus genitourinarius
b. luka bersih tercemar
- luka sayat elektif
- potensial terinfeksi : spillage minimal, flora normal
- kontak dengan orofaring, traktus respiratorius, traktus alimentarius, traktus
genitourinarius
- proses penyembuhan lebih lama
- contoh : apendektomi, operasi vaginal
c. luka tercemar
 -potensi terinfeksi : spillage dari traktus respiratorius, traktus alimentarius,
traktus genitourinarius
- luka trauma baru : laserasi, fraktur terbuka, luka penetrasi
d. luka kotor
- akibat pembedahan yang sangat terkontaminasi
- perforasi visera, abses, trauma lama
(Mansjoer, Arif et al. 2000. Kapita Selekta Kedokteran ed III jilid 2. Jakarta: Media Aesculapiu)

5. What are the complications from fracture?

COMPLICATIONS OF FRACTURE

These complications can be immediate delayed or late. Many of these are

preventable and hence great care should be taken to minimise their incidence.

Immediate complications

Immediate complications are usually caused by the violence producing the fracture
and these occur at the time of fracture or immediately after. These can be general
complications like shock or local complications like injury to vessels, injury to nerves or
viscera in the vicinity.

Delayed complications

These are complications, setting in after a few days upto a few weeks. Infection in
open fractues causing non-specific wound infection or specific infections like tetanus
and gas gengrene occur in the first few days. The other complications are Fat embolism,
Volkmann's ischaemia, delayed nerve injury and Myositis ossificans.

Late Complications

These occur as late results of the injury or of its mismanagement. These include (1)
Malunion, (b) Nonunion, (c) Cross union, (d) Stiffness and contracture of joints, (e) Post
traumatic osteoarthrosis, (f) Late nerve palsy (Tardy paralysis).

Sometimes the injuries to the nerves and vessles are caused by the lack of efficient
splinting and injudicious handling of the fractured limb during transport. The most
serious complications is an open fracture is infection. Some of the important
complications are discribed below.

Complications
Complications of casts
Complications of casts include the development of pressure ulcers, thermal burns during plaster hardening, and
thrombophlebitis. The AO ASIF group commented that prolonged cast immobilization, or cast disease, can be responsible for
creating circulatory disturbances, inflammation, and bone disease that result in osteoporosis, chronic edema, soft-tissue
atrophy, and joint stiffness.[12] These problems may be avoided by providing functional aftercare.
 Complications of traction
Complications of traction include the development of pressure ulcers, pulmonary/urinary infections, permanent footdrop
contractures (if the foot is positioned in equinus), peroneal nerve palsy, pin tract infection, and thromboembolic events (eg,
deep venous thrombosis [DVT], pulmonary embolism). These complications stem from a lack of patient mobility, muscle
atrophy, weakness, and stiffness that result from a fracture.

Complications of external fixation

Complications of external fixation include pin tract infection, pin loosening or breakage, interference with joint motion,
neurovascular damage when pins are placed, malalignment caused by poor placement of the fixator, delayed union, and
malunion.

Complications of fractures and surgical management

Complications of fractures and surgical management include neurologic and/or vascular injury, CS, infection, thromboembolic
events, avascular necrosis, and posttraumatic arthritis.

 Neurologic and vascular injury

o Neurologic and vascular injuries can occur in any fracture and are more likely in cases with increasing
fracture deformity. Peripheral nerve injury is suspected if a patient experiences motor or sensory deficiencies. Management
of neurologic injury involves immediate reduction of the fracture and possible nerve exploration, with subsequent follow-up
to assess whether or not neurologic function returns.
o Arterial injury is suspected if the patient’s pulses are diminished or absent in the affected limb. If there is
evidence of arterial injury, immediate realignment of the limb is performed, and the pulses and perfusion are checked again.
If the pulses do not return, angiography is indicated, with concomitant involvement of vascular surgeons. Arterial injuries are
especially prevalent in cases of knee dislocations, proximal tibial fractures, and supracondylar humerus fractures.
 Compartment syndrome
o CS, initially reported by von Volkmann in 1872,[46] is a potentially limb- and life-threatening condition. CS
occurs when tissue pressure exceeds perfusion pressure in a closed anatomic space. This condition can occur in any
compartment, such as the hand, forearm, upper arm, abdomen, buttock, thigh, and leg, but it most commonly occurs in the
anterior compartment of the leg.
o The natural history of CS involves tissue necrosis, functional limb impairment, and renal failure secondary
to rhabdomyolysis, which may lead to death if untreated. CS can occur after traumatic injury to an extremity, after ischemia
(eg, after hemorrhage or thromboembolic event), and, in rare cases, with exercise. Clinically, patients experience pain that
is out of proportion to the degree of injury and pain with passive stretching of the involved muscles, as well as pallor,
paresthesia, and poikilothermia. Pulselessness, however, is a late finding of CS.
o Compartment pressures can be objectively measured. Intracompartmental pressures greater than 30 mm
Hg or a diastolic blood pressure minus intracompartmental pressure that is greater than 30 mm Hg is an indication for
surgical intervention. Definitive therapy consists of surgical fasciotomy of the affected compartments.
 Infection: Complications of surgical intervention include local infection in the form of cellulitis or osteomyelitis and
systemic infection in the form of sepsis. Early recognition of a local infection may prevent the development of sepsis and,
thus, decrease patient morbidity. The most common pathogen isStaphylococcus aureus. Other pathogens include group A
streptococci, coagulase-negative staphylococci, and enterococci. Appropriate antibiotics should be administered if an infection
is suspected. Serial C-reactive protein and erythrocyte sedimentation rate measurements should be obtained and may be
used to assess treatment response to antibiotics. If infection cannot be eradicated with antibiotics, I&D of the surgical wound
may be necessary, with removal of orthopedic hardware, but only if the hardware is not performing its role.
 Thromboembolic events: Thromboembolic events may occur after orthopedic trauma with prolonged patient
immobilization. Patients with significant fractures who are immobile for 10 days or longer have a 67% incidence of thrombosis.
[14]
Prophylaxis is effective in decreasing the incidence of DVT in the immobilized extremity,[47] but it has not been shown to be
effective in decreasing the incidence of fatal pulmonary embolism. In addition, prophylactic anticoagulation carries with it its
own set of serious and life-threatening complications, such as bleeding. Before using DVT prophylaxis, the risks and benefits
of such therapy must be thoroughly explained to the patient.
 Avascular necrosis: Avascular necrosis (AVN) is caused by disruption of the blood supply to a region of bone.
Revascularization of the avascular bone can lead to nonunion, bone collapse, or degenerative changes. AVN is most
commonly associated with fractures of the femoral head and neck, scaphoid, talar neck and body, and proximal humerus.
 Posttraumatic arthritis: Posttraumatic arthritis is common in intra-articular fractures, particularly in intra-articular
fractures that are not adequately reduced. Management of posttraumatic arthritis depends on the joint involved and can
include arthroscopic debridement, osteotomy, arthroplasty, or arthrodesis.
 Complications of bone healing
o Delayed union is defined as a fracture that has not healed after a reasonable time period (the time in which
it was expected to heal) has passed.
o Nonunion is defined as a fracture with no possible chance of healing, no matter how long the initial
treatment is carried out. Risk factors for nonunion are summarized in the Table. Management consists of treatment of the
cause of the nonunion and can include eradication of infection,[48] stabilization of the fracture, removal of interfering soft
tissues, bone grafting,[49] and medical/nutritional modifications of comorbidities.
o Malunion is defined as healing of bone in an unacceptable position in any plane, which leads to a disability
for the patient, cosmesis, or the potential for the development of posttraumatic arthritis. Treatment involves surgical
correction of the anatomic abnormality.

Komplikasi lanjut:
 Mal-union = sudah diobati, tapi tidak bisa kembali ke keadaan semula
 Delayed union = healing process lebih lama
  Non-union = tidak bisa reposisi

6. What are the clinical manifestations?

1. Continuous pain until the bone is immobilized

2. After the fracture, the parts that can not be used and are not naturally
inclined to move (move exceptional)rather than remain rigid as normal.
3. Fracture fragments shift in the arms or legs causing deformity (visible or
palpable) extremity which can be determined by comparing with the
normal limb, extremity can not function properly due to normal muscle
function depends on the integrity of the bone where the muscles attach.
4. On fracture length, the actual bone shortening occurs
due to contraction of muscles attached above and below the fracture
5. When extremities in check by hand, snapping bones palpable called
crepitus palpable due to friction between multiple fragments to one
another.
6. Local swelling and discoloration, the skin occurs as a result of bleeding
following trauma and fractures. This marks a new can happen after a
few hours or days after the injury. (Smeltzer, Suzanne C. 2001)

http://digilib.unimus.ac.id/files/disk1/108/jtptunimus-gdl-sitifatima-5395-2-
07.bab-r.pdf

1. Nyeri terus menerus sampai tulang diimobilisasi

2. Setelah terjadi fraktur, bagian –bagian yang tidak dapat digunakan dan
cenderung bergerak secara tidak alamiah ( gerakan luar biasa )
bukannya tetap rigid seperti normalnya. Pergeseran fragmen pada
fraktur lengan atau tungkai menyebabkan deformitas ( terlihat maupun
teraba ) ekstermitas yang dapat diketahui dengan membandingkan
dengan ekstremitas yang normal, ekstermitas tak dapat berfungsi
dengan baik karena fungsi normal otot tergantung pada integritas
tulang tempat melekatnya otot.
3. Pada fraktur panjang, terjadi pemendekan tulang yang sebenarnya
karena kontraksi otot yang melekat diatas dan bawah tempat fraktur.
4. Saat ekstremitas di periksa dengan tangan, teraba adanya derik tulang
yang dinamakan krepitus yang teraba akibat gesekan antra fragmen
satu dengan yang lainnya.
5. Pembengkakan dan perubahan warna lokal, pada kulit terjadi sebagai
akibat trauma dan perdarahan yang mengikuti fraktur. Tanda ini bisa
baru terjadi setelah beberapa jam atau hari setelah cidera.
( Smeltzer,Suzanne C. 2001 )

Manifestasi Klinis

a.Menurut Smeltzer & Bare (2002), manifestasi klinis fraktur adalah nyeri,
hilangnya fungsi, deformitas, pemendekan ektremitas, krepitus, pembengkakan

lokal, dan perubahan warna yang dijelaskan secara rinci sebagai berikut:

b.Nyeri terus menerus dan bertambah beratnya sampai fragmen tulang

diimobilisasi. Spasme otot yang menyertai fraktur merupakan bentuk bidai

alamiah yang dirancang untuk meminimalkan gerakan antar fragmen tulang.

c.Setelah terjadi fraktur, bagian-bagian tidak dapat digunakan dan cenderung

bergerak secara alamiah (gerakan luar biasa). Pergeseran fragmen pada

fraktur lengan dan tungkai menyebabkan deformitas (terlihat maupun teraba)

ektremitas yang bisa diketahui dengan membandingkannya dengan

ektremitas normal. Ekstremitas tidak dapat berfungsi dengan baik karena

fungsi normal otot tergantung pada integritasnya tulang tempat melekatnya

otot.

d.Pada fraktur panjang, terjadi pemendekan tulang yang sebenarnya karena

kontraksi otot yang melekat di atas dan bawah tempat fraktur. Fragmen

sering saling melengkapi satu sama lain sampai 2,5 sampai 5 cm (1 sampai 2

inci).

Saat ekstremitas diperiksa dengan tangan, teraba adanya derik tulang

dinamakan krepitus yang teraba akibat gesekan antara fragmen satu dengan

lainnya. Uji krepitus dapat mengakibatkan kerusakan jaringan lunak yang

lebih berat.

e. Pembengkakan dan perubahan warna lokal pada kulit terjadi sebagai akibat

trauma dan perdarahan yang mengikuti fraktur. Tanda ini biasa terjadi setelah

beberapa jam atau hari setelah cedera.

Tidak semua tanda dan gejala tersebut terdapat pada setiap fraktur.

Kebanyakan justru tidak ada pada fraktur linear atau fisur atau fraktur impaksi
(permukaan patahan saling terdesak satu sama lain). Diagnosis fraktur bergantung

pada gejala, tanda fisik, dan pemeriksaan sinar-x pasien. Biasanya pasien

mengeluhkan mengalami cedera pada daerah tersebut.

http://repository.usu.ac.id/bitstream/123456789/24614/4/Chapter%20II.pdf

Sumber : http://www.library.upnvj.ac.id/pdf/2s1keperawatan/205312001/bab2.pdf

7. How to diagnose a fracture?

 http://id.scribd.com/doc/91782344/Penegakan-Diagnosis-F
raktur
8. What is the supporting examination from the scenario?

Radiological examination: The injured part, including the joint above and below, should
be radiographed in two views. The radiograph will confirm the presence of the fracture
and will also show the displacement of the fragments.

a) Local circumstances

Examination of the musculoskeletal system are as

the following:
1. Look (inspection)
 Pay attention to what can be seen as follows:
(A) Sikatriks (scar tissue either natural or man-made such as scar).
(B) Fistula reddish or bluish color (livide) or hyperpigmentation.
(C) A lump, swelling, or basin with things that are not normal
(abnormal)
(D) The position and shape of the extremities (deformity)
(E) The position of the (gait, in time to check the room)
2. Feel (palpation)
At the time of going to palpation, the patient improved first position
from the neutral position (anatomical position). Basically this is an
examination
which provide information in both directions, both the examiner and
the client.
To be noted are:
(A) Changes in trauma surrounding temperature (warm) and
moisture.
(B) If there is swelling, if there are fluctuations or edema especially
around joints
(C) tenderness (tenderness), crackles, note the location of
abnormalities (1/3 proximal, middle, or distal)
(D) Muscle: tone at a time of relaxation or contraction, lumps
contained in or attached to the bone surface. It also examined
neurovascular status. If there are lumps, bumps have described the
nature of the surface, consistency, the base or surface movement,
pain or not, and its size.
(E) Muscle strength: the muscle can not contract (1), contraction and
there is little time pressure fall (2), is able to withstand gravity but
with a touch of fall (3), less muscle strength (4), muscle strength
intact (5). (Carpenito, 1999)
3. Move (especially the movement range of motion)
After checking the feel, then forwarded by moving extremities and
note whether there is a complaint of pain. This examination is to
determine whether there is a movement disorder (mobility) or not.
Movement is seen active and passive movements. (Arif Muttaqin,
2008)

Pemeriksaan penunjang :

 Foto polos
 Tomografi,misalnyapada fraktur vertebra atau kondilus tibia
 CT-SCAN
 MRI
  Radioisotop scanning.

(Djuwantoro Dwi 1997.Fraktur Batang

Femur.http://www.kalbe.co.id/files/cdk/files/16FrakturBatangFemur120.pdf/16Frakt
urBatangFemur120.html.di akses tanggal 4 Juli 2011)

9. What happened to her left hip after she felt so she can’t move her left leg? (Differential
Diagnosis)

 Dislocation = kehilangan permukaan antara 2 permukaan persendian

 Fraktur = diskontinuitas

Hip fracture

10. How is the fracture healing process?

BIOLOGY OF FRACTURE HEALING

It is important to understand the biological process of fracture healing and the

factors influencing, as it helps one to understand the principles of treatment. This
process varies in cortical and cancerous bone.

Fracture healing in cortical bone

The process of healing of a fracture is in many respects similar to the process of

healing of an incised wound. In the healing of an incised wound, the gap is first filled
with blood which clots and later the haematoma is invaded and replaced by granulation
tissue. As the epithelium grows over the gap, the granulation tissue becomes a fibrous
scar. In the healing of a fracture a similar staging can be seen in the earlier phases.
However, the end result in the healing of a bone is the formation of mineralised
mesenchymal tissue (callus) uniting the broken ends of bone.

Fracture healing will be considered as a series of phases which occur in sequence

but also overlap to a certain extent.

(I) Inflammatory Phase.

a. Stage or haematoma formation.

b. Stage of granulation tissue.

(II) Reparative Phase.

a. Stage of fibrocartilaginous callus.

b. Stage of bony callus.

(III) Remodelling Phase.

 Stage of Haematoma: When a bone breaks, the gap is filled with blood from the
ruptured periosteal and endosteal vessels. This blood distends the soft tissues and clots
to form a haematoma. This process takes about 1-2 days.

Stage of granulation tissue: The soft tissues in the region undergo the usual changes
of acute aseptic inflammation with vasodilatation and exudation of plasma and
leucocytes. The clotted blood is invaded by fine capillaries and young connective tissue
cells and converted into granulation tissue in about 2 weeks. The cellular element in this
mass consists of multipotent mesenchymal cells which are capable of differentiating into
fibroblasts, chondroblasts and osteoblasts.

Stage of callus: The granulation tissue next matures into a fibrocartilaginous mass
which holds the fragments together.

Because of the peculiarities of microcirculation in cortical bone there is some

degree of cellular death in the ends of the fracture bone. The fundamental healing
response of bone to injury is by the primary callus response.

Anchoring callus forms a little distance away from fracture site to stabilise the
fragments. In order to bridge gaps, the bridging external callus forms to establish
contact between fracture ends and promote union. Medullary callus forms late from the
medullary cavity to unite with the callus from the opposite end. Thus, according to the
situation and function of callus distributed around the fracture site the callus is
described as follows. a) Anchoring callus, b) Bridging callus, c) Uniting callus and d)
Sealing callus(Fig. 14. 5).

The fibrocartilaginous mass is converted first into spongy immature bone and later
into mature lamellar bone, producing bony union between the fragments in about 8-12
weeks. This conversion takes place in some areas by membranous ossification and in
other areas by endochondral ossification. By this time clinical union of the fracture is
complete.

Stage of Remodeling: Once the fracture has been satisfactorily bridged, the newly
formed bone adapts to its new function. The site of fracture undergoes remodeling by
muscular and weight bearing stresses and any slight deformity gets corrected by
moulding. This remodeling process takes up to a year and is seen better in children.

Primary bone healing: Healing of fractures has also been achieved by artificial
methods of mechanical compression between the fracture fragments. In this, external
birdging callus is suppressed and healing is dependent one of the activity of medullary
callus and direct osteonal penetration. Hence, there is no radiologically visible callus.
This has been called ‘Primary bone healing’ in the technique of compression plating of
fractures.

Fracture healing in Cancellous bone

In fractues at the metaphyseal ends of long bones and in solid bones like vertebrae,
the healing process is different. There is no terminal bone death as in cortical fractures.
 When there is direct contact of fragments, healing occurs by the process of creeping
substitution. New trabeculae formed by intramembranous ossification are laid down on
the original trabeculae to produce bone between the two fragments. No bridging callus
is formed. Once union is estabilished remodelling occurs.

FACTORS WHICH INFLUENCE FRACTURE HEALING

Fracture treatment is not purely a question of effective fracture reduction and

fixation built a complex biological process. The natural tendency for a fracture is to
unite . When delay or failure of union occurs, the causes are either local factors at the
site of fracture or defects in the methods employed in treatment. Causes interfering with
the healing of fractures are:

a) Imperfect immobilisation: (i) Too little extent of immobilisation. and (ii) Too
short a
period of immobilisation.

b) Distraction : Too heavy a pull of the distal fragment by skeletal traction.

c) Surgical intervention : This empties the frcture haematoma and strips the
periosteum,
interfering with the blood supply and slowing the healing process.

Local causes

a) Infection : This is the commonest cause for delayed union or non-union in

open fractures.

b) Inadequate blood supply to one fragment: Certain sites are notorious for slow
union or
non-union e.g. (i) Fracture neck of femur. The blood supply to the head of the
femur is
poor. (ii) Fracture scaphoid. The blood supply to the proximal fragment is
poor.

c) Interposition of soft tissues between the fragment prevents bony apposition

and interferes
with healing.

d) Type of fracture: Transverse fractures unite slowly compared to oblique or

spiral
fractures.

e) Type of bone: Fracture at the cancerous ends of bone unite better than those in
the mid
shaft of long bones where cancellous bone is minimal.

General Causes
 Fractures in children unite very rapidly whereas delayed union is common in the
aged. Other factors like protein and vitamin deficiences, general diseases like syphilis
and diabetes play only a small part in influencing the rate of healing.

Bio-Compression at the fracture site through protected weight bearing at

the proper time promotes healing of the fractures.
11. What is the treatment?

Analgesik yang sering digunakan

Nama Obat Dosis Jadwal

Aspirin 325-1000 mg 4-6 jam sekali

Kalium Diklofenak 50-200 mg 8 jam sekali

Natrium Diklofenak 50 mg 8 jam sekali

Ibuprofen 200-800 mg 4-8 jam sekali

Indometasin 25-50 mg 8-12 jam sekali

Ketoprofen 25-75 mg 6-12 jam sekali

Asam Mefenamat 250 mg 6 jam sekali

Naproxen 250-500 mg 12 jam sekali

Piroksikam 10-20 mg 12-24 jam sekali

Tenoksikam 20-40 mg 24 jam sekali

Meloksikam 75 mg 24 jam sekali

Celecoxib 100 mg 12 jam sekali

Nimesulide 100 mg 12 jam sekali

Ketorolak 10-30 mg 4-6 jam sekali

Asetaminofen 500 mg 6-8 jam sekali

Tramadol* 50-100 mg 8 jam sekali

Dikutip dari: Lucas Meliana 2003

Keterangan: Tramadol termasuk analgesik opioid dengan kerja selektif pada reseptor
MU, kurang/tidak menimbulkan adiksi asetaminofen, daya anti inflamasi lemah.
Waspada hepatotoksik

Bila keadaan penderita stabil dan luka telah diatasi, fraktur dapat diimobilisasi
dengan salah satu dan empat cara berikut ini:
1) Traksi
Comminuted fracture dan fraktur yang tidak sesuai untuk intramedullary nailing
paling baik diatasi dengan manipulasi di bawah anestesi dan balanced sliding skeletal
traction yang dipasang melalui tibial pin. Traksi longitudinal yang memadai
diperlukan selama 24 jam untuk mengatasi spasme otot dan mencegah pemendekan,
dan fragmen harus ditopang di posterior untuk mencegah peleng-
kungan. Enam belas pon biasanya cukup, tetapi penderita yang gemuk memerlukan
beban yang lebih besar dari penderita yang kurus membutuhkan beban yang lebih
kecil. Lakukan pemeriksaan radiologis setelah 24 jam untuk mengetahui apakah berat
beban tepat; bila terdapat overdistraction, berat beban dikurangi, tetapi jika terdapat
tumpang tindih, berat ditambah. Pemeriksaan radiologi selanjutnya perlu dilakukan
dua kali seminggu selama dua minggu yang pertama dan setiap minggu sesudahnya
untuk memastikan apakah posisi dipertahankan. Jika hal ini tidak dilakukan, fraktur
dapat terselip perlahan lahan dan menyatu dengan posisi yang buruk.
2) Fiksasi interna
Intramedullary nail ideal untuk fraktur transversal, tetapi untuk fraktur lainnya
kurang cocok. Fraktur dapat dipertahankan lurus dan terhadap panjangnya dengan
nail, tetapi fiksasi mungkin tidak cukup kuat untuk mengontrol rotasi. Nailing
diindikasikan jika hasil pemeriksaan radiologi memberi kesan bahwa jaringan lunak
mengalami interposisi di antara ujung tulang karena hal ini hampir selalu
menyebabkan non-union. Keuntungan intramedullary nailing adalah dapat
memberikan stabilitas longitudinal serta kesejajaran (alignment) serta membuat
penderita dápat dimobilisasi cukup cepat untuk meninggalkan rumah sakit dalam
waktu 2 minggu setelah fraktur. Kerugian meliput anestesi, trauma bedah tambahan
dan risiko infeksi. Closed nailing memungkinkan mobilisasi yang tercepat dengan
trauma yang minimal, tetapi paling sesuai untuk fraktur transversal tanpa
pemendekan. Comminuted fracture paling baik dirawat dengan locking nail yang
dapat mempertahankan panjang dan rotasi.
3) Fiksasi eksterna
Bila fraktur yang dirawat dengan traksi stabil dan massa kalus terlihat pada
pemeriksaan radiologis, yang biasanya pada minggu ke enam, cast brace dapat
dipasang. Fraktur dengan intramedullary nail yang tidak memberi fiksasi yang rigid
juga cocok untuk tindakan ini.
4) Cast bracing
(Djuwantoro Dwi 1997.Fraktur Batang
Femur.http://www.kalbe.co.id/files/cdk/files/16FrakturBatangFemur120.pdf/16Frakt
urBatangFemur120.html.di akses tanggal 4 Juli 2011)
 http://www.library.upnvj.ac.id/pdf/2s1keperawatan/205312001/bab2.pdf

12. How is the biomechanic of trauma?

13. How is the anatomical structure of cubiti articulation, ante brachii region, lateral side of
cruris?
14. What is the meaning of swelling?
15. What is the cause of this case?
16. What is the mechanism of bruise occurance?
17. What are the signs of fracture?
18. What is the correlation between age and fracture?