RS BINA HUSADA 1 SMF Bedah FK UKI 2 FRAKTUR SMF Bedah FK UKI 3 Putusnya hubungan kesinambungan/ diskontinuitas tulang dan atau tulang rawan
Fraktur tertutup :Bila kulit sekitar intak Fraktur terbuka :Bila ada luka, sehingga kemungkinan terjadi kontaminasi atau infeksi KLASIFIKASI SMF Bedah FK UKI 4 I. Berdasarkan hub dengan dunia luar :
1.Fraktur tertutup 2. Fraktur terbuka KLASIFIKASI SMF Bedah FK UKI 5 Gustillo Anderson : I. Luka < 1 cm II. Luka 1 10 cm III. Luka > 10 cm A. Soft tissue coverage B. Bone exposed C. Neurovascular injury KLASIFIKASI SMF Bedah FK UKI 6 Gustillo Anderson :
Fractures due to a traumatic incident SMF Bedah FK UKI 7 Caused by sudden and exessive force, which may be tapping, crushing, bending, twisting or pulling.
Direct violence : blow on the arm which shatters the ulna at the point of impact Indirect violence: forcible traction by a tendon or ligament which literally pulls the bone apart Fatigue or stress fractures SMF Bedah FK UKI 8 Due to repetitive stress Most often seen in the tibia or fibula or metatarsals, especially in atheletes, dancers and army recruits. Pathological fractures SMF Bedah FK UKI 9 Fractures may occur even with normal stresses if the bone has been weakened (by a tumor) or if it is excessivelly brittle (pagets disease) How fractures are disposed SMF Bedah FK UKI 10 Complete fractures The bone is compeletely broken into 2 or more fragments. Transverse oblique or spiral, Impacted fracture Comminuted fracture SMF Bedah FK UKI 11 Incomplete fracture The bone is incompeletely divided and the periosteum remains in continuity. Greenstick fracture Compression fracture
KLASIFIKASI II. Berdasarkan garis patah SMF Bedah FK UKI 12 1.Komplet 2.Inkomplet KLASIFIKASI SMF Bedah FK UKI 13 III. Jumlah garis patah 1. Simple 2. Komunitif 3. Segmental KLASIFIKASI SMF Bedah FK UKI 14 IV. Arah garis patah 1. Transversal 2. Oblique 3. Spiral 4. Kompresi KLASIFIKASI SMF Bedah FK UKI 15 V. Lokasi 1. Tulang Panjang 1/3 proksimal 1/3 tengah 1/3 distal 2. Tulang Melintang 1/4 medial 1/4 lateral KLASIFIKASI SMF Bedah FK UKI 16 VI. Dislokasi Fragmen Undisplaced Displaced Fragmen tlg searah (ad latus) Fragmen tlg membentuk sudut (ad axim) Fragmen distal memutar (ad periferum) How fractures heal SMF Bedah FK UKI 17 Tissue destruction and haematoma formation Inflamation and cellular proliferation Callus formation Consolidation Remodelling Stadium Penyembuhan Fraktur SMF Bedah FK UKI 18 Healing by direct repair SMF Bedah FK UKI 19 Fractures of cancellous bone Fractures treated by rigid internal fixation The time factor SMF Bedah FK UKI 20 Rate of repair depends upon : the type of bone (cancellous bone heals faster than cortical bone. type of fracture (transverse fracture takes longer than spiral fracture) Blood supply (poor circulation means slow healing) General constitution (healthy bone heals faster Age (healing is almost twice as fast in children as in adults) Time table Upper limb Lower limb Callus visible on x-ray 2-3 weeks 2 - 3 weeks Union (fracture firm) 4-6 weeks 8 - 12 weeks Consolidation (bone secure) 6-8 weeks 12 - 16 weeks SMF Bedah FK UKI 21 Fractures that fail to unite SMF Bedah FK UKI 22 Causes of non union Distraction and separation of the fragments Interposition of soft tissue between the fragments Excessive movement at fracture line Poor blood supply Most fracture will unite provide the bone fragments are SMF Bedah FK UKI 23 Placed in contact with each other and Held more or less immobile until new bone formation is apparent Anamnesa SMF Bedah FK UKI 24 The fracture is not always at the site of the injury ANAMNESIS SMF Bedah FK UKI 25 - Umur, jenis kelamin - Pekerjaan - Pendidikan - Lingkungan rumah - Riwayat trauma: Arah Jenis - Lokalisasi nyeri - Gangguan fungsi Examination SMF Bedah FK UKI 26 General signs A broken bone is part of a patient. It is important to look for evidence of : (1) shock or haemorrhage; (2) associted damage to brain, spinal cord or viscera; and (3) a prediposing cause Look SMF Bedah FK UKI 27 Swelling, bruising, Deformity Skin intact ? Feel SMF Bedah FK UKI 28 Local tenderness Examine distal to the fracture in order to feel the pulse and test the sensation Compartement syndrome ?
Move SMF Bedah FK UKI 29 Crepitus and abnormal movement may be present, but it is more important to ask if the patient can move the joint distal to injury Pemeriksaan Fisik SMF Bedah FK UKI 30 Move : Nyeri gerak Sensorik Motorik aktif pasif Bekas dukun SMF Bedah FK UKI 31 Bekas dukun SMF Bedah FK UKI 32 Xray SMF Bedah FK UKI 33 Special imaging SMF Bedah FK UKI 34 Tomography CT- scan MRI Radioisotope scanning RADIOLOGI SMF Bedah FK UKI 35 Rule of 2 : 2 proyeksi 2 sendi 2 ekstremitas 2 waktu
SMF Bedah FK UKI 36 PRINCIPLES OF FRACTURE TREATMENT First aid SMF Bedah FK UKI 37 Make sure that the airway is clear If there is a wound, cover it with clean material Stop bleeding by local compression Give something for pain If the neck or the bak is injured, prevent flexion which may damage the spinal cord If there is fracture,prevent movement Assesment in hospital SMF Bedah FK UKI 38 Examine the airway and treat asphyxia Make sure the patient can breathe Note the obvious haemorrhage and stop it Assess the degree of blood loss and shock Check for spinal cord injury Look for injuries of abdominal or pelvic viscera Examine for the presence of fractures or dislocation Look for soft tissue complications, especially nerve and vascular injury Arrange for an x-ray Definitive treatment of closed fracture SMF Bedah FK UKI 39 Manipulation to improve the position of the fragments, followed by splintage to hold them together until they unite; meanwhile joint movement and function must be preserved Reposisi SMF Bedah FK UKI 40 Mengembalikan kedudukan tulang
Cara : Manual Traksi Operatif SMF Bedah FK UKI 41 Fracture involving an articular surface; this should be reduced as near to perfection as possible because any irregularity will predispose to degenerative arthritis Closed reduction SMF Bedah FK UKI 42 The distal part of limb is pulled in the line of the bone As the fragment disengage, they are repositioned Alignment is adjusted in each plane Reposisi SMF Bedah FK UKI 43 Reposisi SMF Bedah FK UKI 44 Keberhasilan dinilai dari : Alignment Contact > 50 % Rotation (-) Discrepancy (-) Sudut < 15 Indikasi konservatif SMF Bedah FK UKI 45 Anak dalam masa pertumbuhan Impending infeksi Jenis fraktur tidak cocok untuk ORIF Toleransi operasi tidak baik Pasien menolak operasi Indikasi Operasi SMF Bedah FK UKI 46 Sukar reposisi tertutup Fraktur multipel Fraktur patologis Fraktur intra artikular HOLD REDUCTION SMF Bedah FK UKI 47 In order to unite, a fracture must be imobilized We splint most fractures, not to ensure union but (1) to alliviate pain and (2) to ensure that union takes place in good position Immobilisasi (mempertahankan reposisi) SMF Bedah FK UKI 48 Fiksasi eksterna Gips Roger Anderson Fiksasi interna Plate + Screw K-nail ORIF ; indications SMF Bedah FK UKI 49 # that cannot be reduced except by operation # that inherently unstable and prone to redisplacemaent after reduction (#mid shaft forearm) # that unite poorly and take long time (# femoral neck) Pathological # Multiple # # in patients who prsent nursing difficulties (paraplegics, multiple injuries and very elderly ORIF; complications SMF Bedah FK UKI 50 INFECTION NON UNION IMPLANT FAILURE REFRACTURE OREF (open reduction external fixation) ; indications SMF Bedah FK UKI 51 # associated wih severe soft tissue damage # associated with nerve or vessel damage Severely comminuted and unstable # # pelvis Infected # SMF Bedah FK UKI 52 Fr Collim Femur SMF Bedah FK UKI 53 OREF ; Complication SMF Bedah FK UKI 54 Overdistraction Reduced load transmission trough bone, which delays fracture healing causes osteoporosis (EF shoul be removed after 6-8 wo,and replace) Pin tract infection
OPEN FRACTURE SMF Bedah FK UKI 55 EMERGENCY GOLDEN PERIOD 6 8 HO
OPEN FRACTURE; assesment SMF Bedah FK UKI 56 Is circulation intact ? Peripheral nerve intact ? State of skin arround the wound Does the wound communicate with # ? Fraktur Terbuka SMF Bedah FK UKI 57 Perbaiki KU Debridement, kultur/resistensi ATS-Toxoid, Antibiotik Tutup luka dengan kasa bersih Reposisi Imobilisasi ANTIBACTERIAL SMF Bedah FK UKI 58 Antibiotics : asap, combination ampicilline and cloxacillin, given 6ho; if wound heavily contaminated, give gentamycin or metronidazole for 4-5 do Tetanus prophylaxis TREATMENT OF WOUND SMF Bedah FK UKI 59 To cleanse the wound of foreign material Remove devitalized tissue (debridement) 4 C : Colour Consistency Contractility Capacity of bleeding Complications of fracture General complication SMF Bedah FK UKI 60 Shock Crush syndrome Venous thrombosis and pulmonary embolism Tetanus Gas gangrene Fat embolism Complication involving # bone SMF Bedah FK UKI 61 Infection Delayed union and non union Malunion Growth disturbance Avascular necrosis Complication involving soft tissue SMF Bedah FK UKI 62 Vascular injury Compartement syndrome (Volkmanns ischaemia) Nerve injury Visceral injury Myositis osificans Compartement syndrome SMF Bedah FK UKI 63 Arterial ischaemia reduced painful Damage blood flow pale pulseless paresthetic paralysed Direct oedema Injury fasciotomy
incr comp pressure Complication involving joints SMF Bedah FK UKI 64 Joint stiffness Osteoarthritis Sudecks atrophy SMF Bedah FK UKI 65 SMF Bedah FK UKI 66 TERIMA KASIH SMF Bedah FK UKI 67 Created by : Tepeng SMF Bedah FK UKI 68