Review Sistem Gerak

8/8/2019 Review Sistem Gerak

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REVIEW SISTEMREVIEW SISTEMGERAKGERAK

CompartmentCompartmentSyndromeSyndrome

zainuri


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Review

Definisi Pening tekanan di dalam ruang kompartemenfascial

Pathophysiology

y Intracellular swelling/Hematomay Pressure rises and capillary perfusion drops

y Tissues vary in susceptibility to damage

Nerve < 4 hours

Muscle < 8 hours

y After 8 hours irreversible damagey Experimentally

Within 10mmHg of diastolic pressure

Injured tissue 20 mmHg


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Review

Etiologyy Temporary vascular occlusion

Trauma, thrombus

Clinical Presentationy History of injury / energy absorbedy Swelling, Pain

y Passive stretch

y Pallor, paresthesia, pulselessness, paralysis

Investigationy Compartmental pressure measurements

y Dont delay getting measurements if diagnosis is obvious (20mmHG less than diastolic)


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Review

Treatmenty Remove dressings

y Do not excessively elevate the foot

Level of the heart

y Analgesia

y Have low threshold to proceed surgically

y Emergency fascial release

y 3 incisions

1 medial 2 Dorsal

yDivide fascia

y Delayed closure

+/- skin grafting

y Prophylactic releases


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komplikasi

Early

y Myonecrosis

y Renal concerns

Late

y Deformities from contracture of necrotic

muscle

y Nerve Injury Ulcerations


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osteomyelitisosteomyelitis

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Review

Definisi INFLAMMATORY PROCESS IN BONE & BONEMARROW ACUTE & CHRONIC

Pathophysiology Hematogenous Osteomyelitis

Contiguous-Focus Osteomyelitis

Peripheral Vascular Disease-associated

Bacteria escape host defenses by: Adhering tightly to damage bonePersisting in osteoblastsProtective polysaccharide-rich biofilm


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PATHOPHYSIOLOGYPATHOPHYSIOLOGYMicroorganisms enter bone (Phagocytosis).

Phagocyte contains the infection

Release enzymes

Lyse bone


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PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Pus spreads into vascular channels

Raising intraosseous pressure

Impairing blood flow

Chronic ischemic necrosis

Separation of large devascularized fragment

New bone formation

(involucrum)

(Sequestra)(Sequestra)


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PATHOLOGYPATHOLOGY

Acute Infiltration of PMNsCongested or thrombosed vessels

Chronic Necrotic bone Absence of living osteocyteMononuclear cells predominateGranulation & fibrous tissue


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HEMATOGENOUS OSTEPMYELITISHEMATOGENOUS OSTEPMYELITIS

Rapidly growing boneRapidly growing boneChildren:Children:

Long bone, Femur, Tibia,Long bone, Femur, Tibia, HumerusHumerus

Older patients: Vertebral boneOlder patients: Vertebral bone

Neonate & infant < 1 year oldNeonate & infant < 1 year old

Septic arthritis is common.Septic arthritis is common.Growth deformities is common.Growth deformities is common.Soft tissue involvement is common.Soft tissue involvement is common.


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HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS

Clinical manifestationClinical manifestationClassic presentation: Sudden onsetClassic presentation: Sudden onsetUsually presentation: Slow, insidiousUsually presentation: Slow, insidious

High fever, Night sweatsHigh fever, Night sweatsFatigue, Anorexia, Weight lossFatigue, Anorexia, Weight loss

Restriction of movementRestriction of movementLocal edema, Erythema, &Local edema, Erythema, & TenderrnessTenderrness


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DifferentialsDifferentialsCellulitisCellulitis

Gas gangreneGas gangreneNeoplasmNeoplasm Aseptic bone infection Aseptic bone infection


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Clenched fistClenched fist

osteomyelitisosteomyelitis


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Diagnosis & workDiagnosis & work--upupLab study:Lab study:WBCWBC May be elevated, Usually normalMay be elevated, Usually normal

CC--Reactive Protein (CRP)Reactive Protein (CRP)

Erythrocyte Sedimentation RateErythrocyte Sedimentation Rate(Usually is elevated at presentation(Usually is elevated at presentationFalls with successful therapy)Falls with successful therapy)

Blood cultureBlood culture( Acute osteomyelitis + ve > 50% )( Acute osteomyelitis + ve > 50% )

{{


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Diagnosis & workDiagnosis & work--upupImagingImaging

Radiology:Radiology:NormalNormalSoft tissue swellingSoft tissue swellingPeriosteal elevationPeriosteal elevationLytic changeLytic changeSclerotic changewSclerotic changew


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Diagnosis & workDiagnosis & work--upupUltrasonographyUltrasonography

Simple & inexpensiveSimple & inexpensive

Demonstration anomaly 1Demonstration anomaly 1 2 days after onset2 days after onset

Soft tissue abscess, Fluid collection, &Soft tissue abscess, Fluid collection, &Periosteal elevationPeriosteal elevation

It allows for aspirationIt allows for aspiration

It doesnt allow for evaluation of bone cortex.It doesnt allow for evaluation of bone cortex.


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TREATMENTTREATMENT

Initial treatmentInitial treatment shoudshoud be aggressive.be aggressive.Inadequate therapyInadequate therapy Chronic diseaseChronic disease Antibiotic use: Antibiotic use:

ParenteralParenteralHigh dosesHigh doses

Good penetration in boneGood penetration in boneFull courseFull courseEmpiric therapyEmpiric therapy

SurgerySurgeryDiagnosticDiagnosticHip joint involvementHip joint involvementNeurologic complicationNeurologic complicationPoor or no response to IV therapyPoor or no response to IV therapy

SequestrationSequestration


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ContiguousContiguous--focus Osteomyelitisfocus Osteomyelitis

Clinical setting:Clinical setting:Postoperative infectionPostoperative infectionContamination of boneContamination of boneContiguous soft tissue infectionContiguous soft tissue infection

Puncture woundsPuncture wounds

Microbiologic featuresMicrobiologic features

StaphylococciStaphylococci AureusAureus,, EpidermidisEpidermidis

GramGram--negative bacterianegative bacteria Anaerobic infection Anaerobic infectionUnusual organismsUnusual organisms Clostridia,Clostridia, NocardiaNocardia


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ContiguousContiguous--focus Osteomyelitisfocus Osteomyelitis

DiagnosisDiagnosisLeukocyte countLeukocyte countBlood culture (infrequently positive)Blood culture (infrequently positive)ESR & CRPESR & CRP

Radiologic evaluationRadiologic evaluationTechnetium bone scanTechnetium bone scanOpen bone biopsyOpen bone biopsyCulture of wound & draining sinuses??Culture of wound & draining sinuses??

TreatmentTreatmentSurgery is essential.Surgery is essential.

AntibioticsAntibiotics SpecificSpecific

DurationDuration


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ArthritisArthritis

zainuri


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review

l Types ofarthritis

l Symptoms ofarthritis

l Signs ofarthritis

l Treatment ofarthritis


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Types of Arthritis

l Rheumatoid arthritis (RA)

l Osteoarthritis (OA)

l Sero-negative arthritis

l Ankylosing spondylitis

l

Reiters diseasel Crystal arthropathies


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Rheumatoid Arthritis

Pathology

l Synovitis

chronic infl, synovial hypertrophy,effusion

l Destruction

proteolytic enzymes, pannus

l Deformity

articular destruction, capsular stretching,tendon rupture


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extra-articular

l nodules

l tendon sheathl vasculitis

l myopathy and neuropathy

l

reticulo-endothelial systeml visceral - lungs, heart, kidneys, brain, GI


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early symptoms

myopathy, tiredness, weight loss, malaise proximal finger joints wrists, feet, knees, shoulders

start up pain tendon crepitus

late symptoms

joint destruction pain

deformity

instability


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advanced joint changes


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X-ray findings

joint space narrowing

peri-articular osteopenia

erosions


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treatment stop synovitis prevent deformity

reconstruct

Rehabilitate

Prognosis

10% improve

60% intermittent, slowly worsening

20% severe joint erosion, multiple surgery

10% completely disabled


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Osteoarthritis

A chronic joint disorder in which there is

progressive softening and disintegration

of articular cartilage accompanied by

new growth of cartilage and bone at the

joint margins (osteophytes) and capsular

fibrosis


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Osteoarthritis

classification

Primary or idiopathic

Secondary - infection

- dysplasia

- Perthes

- SUFE

- trauma

- AVN


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Osteoarthritis

aetiology

Genetic

metabolic hormonal

mechanical

ageing


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Osteoarthritis

mechanism 1

Disparity between:-

stress applied to articular cartilage

and

strength of articular cartilage


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Osteoarthritis

mechanism 2

Increased stress (F/A)

increased load eg BW or activity decreased area eg varus knee or

dysplastic hip


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Osteoarthritis

mechanism 3

Weak cartilage

age

stiff eg ochronosis

soft eg inflammation

abnormal bony support eg AVN


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Osteoarthritis

X-ray changes


subchondral sclerosis osteophytes

cysts


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Osteoarthritis

X-ray changes


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Arthritis

symptoms

pain

swelling stiffness

deformity

instability

loss of function


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Arthritis

non-surgical treatment

analgesia

disease modifying drugs (RA) altered activity

walking aids

physiotherapy


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Arthritis

surgical treatment

arthroscopy osteotomy

arthrodesis

excision arthroplasty

replacement arthroplasty


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Arthritis

knee arthroplasty


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Joint Replacement

indications

Disabling pain

Functional limitations

History

pain

function medical

expectations


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Joint Replacement

investigation

X-ray - alignment

- deformity

- previous fractures and implants- AVN

- osteophytes

- bone loss CT, MRI, bone scan - rarely


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Ankylosing Spondylitis

0.2% of population

mainly affects spine and SI joints male > female

HLA B27 in 90%

synovitis

enthesopathy


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hips and knees

flexion deformities

arthritis with large osteophytes ankylosis


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X-ray changes


large osteophytes heterotopic bone

ankylosis


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Tumor MusculoskeletalTumor Musculoskeletal

zainuri


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Introduction

PrimaryMusculoskeletal tumorsarise from tissue ofmesenchymal origin (ie.bone, muscle,

connective tissue,adipose.)

These primary tumorsmay spread to othersites, usually other

bones or lung. Secondary bone tumors

arise from a host ofother tissues and in theappropriate age

category must be


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Introduction

The work-up of any tumor must be

thought of in terms ofLocal disease

and Systemic disease.

By doing so you will have a sensible

approach to determining the ultimate

pathologic diagnosis and the extent of

the disease in the body.


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Local Investigations

X-ray.the mosthelpful in focusing ourdifferential and furtherinvestigations.

Cat scan.. Bonearchitecture,neocorticalization,?fracture.

MRI.marrow extent,soft tissue extent,neurovascularinvolvement, skip

lesions.


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Radiographic Features of the

Various Tumors Benign: well circumscribed, narrow transition,

no reaction, sclerotic border, does onething.

Benign Aggressive: neocorticalization,expansion, thinning of cortex, usually lytic,+/-reaction, +/- narrow zone of transition.

Malignant: ++++reaction, large, permeative,moth eaten, does more than one thing.

Conditions/Mets: more than one bone,symmetry.


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Invasive Investigation

Biopsy..the goal is to obtain a piece of

tissue adequate to make a pathologic

diagnosis.

Should be done after all other

investigations are complete

Needle, Tru-cut, incisional.

CT/US guided.


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Primary Bone Tumors

Osteogenic

Fibrous

Chondroid Lipomatous

Other

*****These are thebroadcategories******


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Osteogenic

Benign: Osteoma,Osteoid Osteoma,Bone Islands

Benign Aggressive:Osteoblastoma

Malignant:OsteogenicSarcoma


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Fibrous Tumours

Benign: Fibrous Cortical

Defect, Non-Ossifying

Fibroma, Fibroma of

Bone. Benign Aggressive:

Fibromatosis(desmoid),

Ossifying Fibroma of

bone, Fibrous Dysplasia.

Malignant: Malignant

Fibrous Histiocytoma of

bone, Fibrosarcoma.


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Chondroid

Benign:Enchondroma, Peri-

osteal Chondroma,

Osteochondroma.

Benign Aggressive:

Chondromyxoid

Fibroma,

Chondroblastoma.

Malignant:

Chondrosarcoma.


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Other Bone Tumors

Benign: Bone Cyst,Ganglion,Hemangioma.

Benign Aggressive:

Giant Cell Tumor,Aneurysmal BoneCyst, EOG.

Malignant:

Adamantinoma,Chordoma, Ewings.


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Sites of Tumors

Diaphyseal: Ewings, Osteoid Osteoma,

Mets, Adamantinoma, Fibrous

Dysplasia

Epiphyseal: Chondroblastoma, Clear

Cell Chondrosarcoma, GCT, Ganglion of

Bone.

Metaphyseal: Everything!!!!!!


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Age of Tumors

20>..Osteogenic Sarcoma, Ewings.

40GCT, Chondrosarcoma, MFH,

Lymphoma, Mets.

60Mets, Myeloma,

Chondrosarcoma, late Osteogenic,MFH, Fibrosarcoma.

Review Sistem Gerak

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