FRACTURE AND DISLOCATION

FRACTURE AND DISLOCATIONAchmad PDeny BudimanJocliedian GLHendrikus BollyfractureDefinitionA fracture is a break in the structural continuity of bone, or cartilage, or epiphyseal plateMust constantly think soft tissue surrounding the bonePhysical factors in the production of fracture

How fractures happen?Fracture due to a traumatic incidentCaused by sudden and excessive forceDirect or IndirectPathologic fractureBone weakened (abnormal)Change in structure : osteoporosis, tumorCan occur even normal stresses

How fracture happen?

Descriptive terms pertaining of FracturesSite. ExtentConfigurationRelationship of the fragmentsRelation to external environmentcomplications1.Anatomical siteDiaphysealMetaphysealEpiphysealIntra-articularFracture dislocation

2. ExtentCompleteIncompleteHard tissue Soft tissue

extent

3. configurationTransverseObliqueSpiralComminutedsegmented

4. Relation of fragmentsUndisplacedDisplacedTranslatedAngulatedRotatedDistractedOverridingimpacted

5. Relationship to external environmentClose fractureThere no contact the external environmentSeverity and configuration depend on energy

Open fractureDirect contact with external non steril environmentClassification of Close fracturewith soft tissue damage (tscherne,1982)Type 0 : minimal ST damage, indirect violence, simple # patternsType 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

Open fractureFractureSoft tissue injuriesContaminant from external environmentHigh risk :Infection, tetanus, gas gangrene, sepsisNonunionLimb threathening

Classification open factureGustilo-Anderson (1984)Type Iwound 1 cm or less, quite clean, inside to outside, minimal muscle contusion, simple # patterns

Type IIlaceration more than 1 cm long, with extensive soft tissue damage, flaps or avulsions, minimal comminution.

Type IIIextensive soft tissue damage including muscles, neurovascular structures, often ahigh velocity injury

IIIAadequate bone coverage, segmental #IIIBperiosteal stripping and bone exposure, with massive contaminationIIICvascular injury requiring repair6. complicationUncomplicatedComplicatedNeurovascularCompartment syndromeinfection

Diagnosis of fractureHistory Mechanism of injury, environment, pre-injury status, finding at the incident site, pre-hospital carePhysical examinationLookFeelMove/askInvestigationLab.X-rayScanning

Mechanism of injury

Physical examinationGeneral conditionsAir wayBreathingCirculation

Local conditionsLookFeelmove

Physical examinations

LookEvidence of painSwellingDeformityWoundsFeelSharply locallized painAggravation of painTest artery & nerveMovecrepitusAbnormal movement

Diagnostic imagingX-ray (rule of Two)Two jointsTwo viewsTwo limbsTwo injuriesTwo occasionsCT ScanMRI

How fractures heal

Similar with wound healing Two types of healing processPrimary (bridging osteon)Secondary (callus formations)InflammationCallus formationconsolidationremodeling

Pre-hospital managementAccording ATLS procedure. Primary surveySecondary surveyA-B-C-D-EReduction ImmobilizationCover the woundstransportation

immobilizationTwo joints minimal include immobilizedSplintagePrevent further injuryRe-evaluation neurovascular distal fracture

Goals treatment fractureRelieve painTo obtain and maintain satisfactory position of the fracture fragmentsTo allow bony unionRestore optimum functionSpecific Methods of treatment for close fractureProtection aloneImmobilization with or without reductionClosed reduction followed by tractionCR followed by external fixationORIFExcision of fragment fracture

Immobilization by traction

Open Reduction and Internal Fixation (ORIF)IndicationsIntra-articular fractureAvulsion fractureSoft tissue interposition

Grossly unstable fractureCoexistent with vascular injuryPathologic fracture# in children cross epiphyseal plate

External Fixation

Excision fragment fracture

Treatment for Open Fractures:

Cleansing of the woundExcision of devitalized tissue (debridement)Treatment of the fractureClosure of the woundAntibacterial drugsPrevention of tetanuscomplicationsImmediatelyBleedingInjury to the nerveSoft tissueEarlyInfectionsDelayed UnionJoints stiffnessLateMalunionOsteoarthritisAVN

Risk AVN in head femur fracture

Fracture specificFracture in childrenFracture incomplete most commonConservative treatmentHeal faster than adultPathologic fractureIn porotic boneAbnormal bone structureAbnormal metabolic process in boneDISLOKASI DISLOKASI SENDI BAHU ( Gleno Humeral Joint ) Stabilitas sendi bahu tergantung dari otot-otot dan kapsul , tendon yang mengitari sendi bahu. Sedangkan hubungan antara kepala humerus dan cekungan glenoid terlalu dangkal Karena susunan anatomi diatas maka sendi bahu merupakan sendi yang mudah mengalami dislokasi. Pada waktu terjadinya dislokasi yang pertama terjadi kerusakan kapsul sendi dibagian anterior Dengan adanya robekan tadi, maka sendi bahu kan mudah mengalami dislokasi ulang bila mengalami cidera lagi, hal ini disebut sebagai Recurrent dislokasi Beberapa bentuk dislokasi sendi bahuAnterior Posterior Superior Inferior ( Luxatio erecta )

Pada luxatio erecta posisi lengan atas dalam posisi abduksi, kepala humerus terletak dibawah glenoid, terjepit pada kapsul yang robek . Karena robekan kapsul sendi lebih kecil dibanding kepala humerus, maka sangat susah kepala humerus ditarik keluar, hal ini disebut sebagai efek lubang kancing ( Button hole effect ) Dislokasi Anterior Sering terjadi pada usia dewasa muda karena KLL atau olahraga Biasanya terjadi karena gerakan puntiran keluar ( ekternal rotasi ) tekanan kearah ekstensi dari sendi bahu Posisi lengan atas dalam posisi abduksi Dalam posisi tersebut diatas akan terjadi regangan yang berat pada kapsul yang melekat pada glenoid bagian depan bawah. Pertemuan kapsul dengan glenoid berupa fibrocartilage. Kalau daya dorongnya terlalu kuat terjadilah alfusi fibrocartilage dibagian bawah dan depan glenoid , lesi ini disebut sebagai BANKART Laesi. Karena terjadi robekan kapsul, kepala humerus akan keluar dari cekungan glenoid kearah depan dan medial, kebanyakan tertahan dibawah coracoid Mekanisme lain terjadinya dislokasi adalah trauma langsung. Penderita jatuh pundak bagian belakang terbentur lantai atau tanah gaya akan mendorong permukaan belakang humerus bagian proksimal kedepan .Gejala Klinik Pundak terasa sakit sekali, bentuk pundak asimetris, dimana bentuk deltoid pada sisi yang cidera tampak mendatar , hal ini disebabkan kepala humerus sudah keluar dari cekungan glenoid ke depan Pada palpasi, didaerah subacromius jelas teraba cekungan Posisi lengan bawah dalam kedudukan abduksi dan eksorotasi Pemeriksaan Penunjang X-ray AP Penanggulangan Dilakukan reposisi tertutup 1. Cara Hippocrates2. Cara Kocher3. Cara Stimson

Dislokasi Hip ( Dislokasi caput femur ) Bisa terjadi : * Anterior * Posterior * Inferior * Sentral Yang paling sering terjadi adalah Dislokasi Posterior Biasanya terjadi trauma langsung pada lutut sehingga caput femur terdorong ke belakang misalnya : Kecelakaan mobil lutut terbentur ke dasboard. Posisi penderita flexi, adduksi, endorotasi

Pemeriksaan Penunjang X-Ray Pelvis AP Penangganan Cara AllisCara BigelowCara 900 90

Bahan bacaanRobert 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) ; Apleys System of Orthopaedics and Fractures. 8th ed.Arnold, London. p: 521-583.