fraktur umum

SMF Bedah FK UKISMF Bedah FK UKI 11

FRAKTUR UMUMFRAKTUR UMUM


FRAKTURFRAKTUR

The golden rule is Treat the patient, not

simply the part


FRAKTURFRAKTUR

Putusnya hubungan kesinambungan/ Putusnya hubungan kesinambungan/ diskontinuitas tulang dan atau tulang diskontinuitas tulang dan atau tulang rawanrawan

Fraktur tertutupFraktur tertutup :Bila kulit sekitar :Bila kulit sekitar intakintak

Fraktur terbukaFraktur terbuka :Bila ada luka, :Bila ada luka, sehingga kemungkinan terjadi sehingga kemungkinan terjadi kontaminasi atau infeksi kontaminasi atau infeksi


KLASIFIKASIKLASIFIKASI

I.I. Berdasarkan hub dengan dunia Berdasarkan hub dengan dunia luar :luar :

1.Fraktur tertutup

2. Fraktur terbuka



• Gustillo – Anderson :Gustillo – Anderson :I.I. Luka < 1 cmLuka < 1 cmII.II. Luka 1 – 10 cmLuka 1 – 10 cmIII.III. Luka > 10 cmLuka > 10 cm

A.A. Soft tissue coverageSoft tissue coverageB.B. Bone exposedBone exposedC.C. Neurovascular injuryNeurovascular injury



• Gustillo – Anderson :Gustillo – Anderson :


Fractures due to a traumatic Fractures due to a traumatic incidentincident

Caused by sudden and exessive force, Caused by sudden and exessive force, which may be tapping, crushing, which may be tapping, crushing, bending, twisting or pullingbending, twisting or pulling..

• Direct violence : blow on the arm Direct violence : blow on the arm which shatters the ulna at the point of which shatters the ulna at the point of impactimpact

• Indirect violence: forcible traction by a Indirect violence: forcible traction by a tendon or ligament which literally pulls tendon or ligament which literally pulls the bone apart the bone apart


Fatigue or stress fracturesFatigue or stress fractures

• Due to repetitive stressDue to repetitive stress

• Most often seen in the tibia or Most often seen in the tibia or fibula or metatarsals, especially in fibula or metatarsals, especially in atheletes, dancers and army atheletes, dancers and army recruits.recruits.


Pathological fracturesPathological fractures

• Fractures may occur even with Fractures may occur even with normal stresses if the bone has normal stresses if the bone has been weakened (by a tumor) or if been weakened (by a tumor) or if it is excessivelly brittle (paget’s it is excessivelly brittle (paget’s disease)disease)


How fractures are How fractures are disposeddisposed

• Complete fracturesComplete fractures

The bone is compeletely broken into The bone is compeletely broken into 2 or more fragments. 2 or more fragments.

TransverseTransverse

oblique or spiraloblique or spiral, ,

Impacted fractureImpacted fracture

Comminuted fractureComminuted fracture


•Incomplete fracture

The bone is incompeletely divided and the periosteum remains in continuity.

•Greenstick fracture

•Compression fracture



II.II. Berdasarkan Berdasarkan garis patahgaris patah

1.Komplet

2.Inkomplet



III.III. Jumlah garis patahJumlah garis patah

1. Simple 2. Komunitif 3. Segmental



IV.IV. Arah garis patahArah garis patah

1. Transversal

2. Oblique 3. Spiral 4. Kompresi



V.V. Lokasi Lokasi 1.1. Tulang PanjangTulang Panjang

• 1/3 proksimal1/3 proksimal• 1/3 tengah 1/3 tengah • 1/3 distal1/3 distal

2.2. Tulang MelintangTulang Melintang• 1/4 medial1/4 medial• 1/4 lateral1/4 lateral



VI.VI. Dislokasi FragmenDislokasi Fragmen– UndisplacedUndisplaced– Displaced Displaced

• Fragmen tlg searah (ad latus)Fragmen tlg searah (ad latus)

• Fragmen tlg membentuk sudut (ad Fragmen tlg membentuk sudut (ad axim)axim)

• Fragmen distal memutar (ad Fragmen distal memutar (ad periferum)periferum)


How fractures healHow fractures heal

• Tissue destruction and haematoma Tissue destruction and haematoma formation formation

• Inflamation and cellular Inflamation and cellular proliferationproliferation

• Callus formationCallus formation

• ConsolidationConsolidation

• RemodellingRemodelling


Stadium Penyembuhan Stadium Penyembuhan FrakturFraktur


Healing by direct repairHealing by direct repair

• Fractures of cancellous boneFractures of cancellous bone

• Fractures treated by rigid internal Fractures treated by rigid internal fixationfixation


The time factorThe time factor

Rate of repair depends upon :Rate of repair depends upon :• the type of bone (cancellous bone heals the type of bone (cancellous bone heals

faster than cortical bone.faster than cortical bone.• type of fracture (transverse fracture takes type of fracture (transverse fracture takes

longer than spiral fracture)longer than spiral fracture)• Blood supply (poor circulation means slow Blood supply (poor circulation means slow

healing)healing)• General constitution (healthy bone heals General constitution (healthy bone heals

fasterfaster• Age (healing is almost twice as fast in Age (healing is almost twice as fast in

children as in adults)children as in adults)


Time tableTime table

Upper limbUpper limb Lower limbLower limb

Callus visible Callus visible on x-rayon x-ray

2-3 weeks2-3 weeks 2 - 3 weeks2 - 3 weeks

Union Union (fracture (fracture firm)firm)

4-6 weeks4-6 weeks 8 - 12 8 - 12 weeksweeks

Consolidation Consolidation (bone secure)(bone secure)

6-8 weeks6-8 weeks 12 - 16 12 - 16 weeksweeks


Fractures that fail to uniteFractures that fail to unite

Causes of non unionCauses of non unionDistraction and separation of the Distraction and separation of the

fragmentsfragmentsInterposition of soft tissue between Interposition of soft tissue between

the fragmentsthe fragmentsExcessive movement at fracture lineExcessive movement at fracture linePoor blood supplyPoor blood supply


Most fracture will unite Most fracture will unite provide the bone fragments provide the bone fragments areare• Placed in contact with each other Placed in contact with each other

andand

• Held more or less immobile until Held more or less immobile until new bone formation is apparentnew bone formation is apparent


AnamnesaAnamnesa

• The fracture is not always at the The fracture is not always at the site of the injurysite of the injury


ANAMNESISANAMNESIS

- Umur, jenis kelaminUmur, jenis kelamin - Pekerjaan- Pekerjaan

- Pendidikan Pendidikan - Lingkungan - Lingkungan rumahrumah

- Riwayat trauma:Riwayat trauma:• ArahArah• JenisJenis

- Lokalisasi nyeri- Lokalisasi nyeri - Gangguan - Gangguan fungsifungsi


ExaminationExamination

• General signsGeneral signs

A broken bone is part of a patient. A broken bone is part of a patient. It is important to look for evidence It is important to look for evidence of : (1) shock or haemorrhage; (2) of : (1) shock or haemorrhage; (2) associted damage to brain, spinal associted damage to brain, spinal cord or viscera; and (3) a prediposing cord or viscera; and (3) a prediposing causecause


LookLook

• Swelling, Swelling,

• bruising, bruising,

• DeformityDeformity

• Skin intact ?Skin intact ?


FeelFeel

• Local tendernessLocal tenderness

• Examine distal to the fracture in Examine distal to the fracture in order to feel the pulse and test order to feel the pulse and test the sensationthe sensation

• Compartement syndrome ?Compartement syndrome ?


MoveMove

• Crepitus and abnormal movement Crepitus and abnormal movement may be present, but it is more may be present, but it is more important to ask if the patient can important to ask if the patient can move the joint distal to injurymove the joint distal to injury


Pemeriksaan FisikPemeriksaan Fisik

Move :Move :– Nyeri gerakNyeri gerak– SensorikSensorik– MotorikMotorik

aktif

pasif


Special imagingSpecial imaging

• TomographyTomography

• CT- scanCT- scan

• MRIMRI

• Radioisotope scanningRadioisotope scanning


RADIOLOGIRADIOLOGI

Rule of 2 :Rule of 2 :

• 2 proyeksi2 proyeksi

• 2 sendi2 sendi

• 2 ekstremitas2 ekstremitas

• 2 waktu2 waktu


PRINCIPLES OF FRACTURE TREATMENT


First aidFirst aid

• Make sure that the airway is clearMake sure that the airway is clear• If there is a wound, cover it with clean If there is a wound, cover it with clean

materialmaterial• Stop bleeding by local compressionStop bleeding by local compression• Give something for painGive something for pain• If the neck or the bak is injured, prevent If the neck or the bak is injured, prevent

flexion which may damage the spinal flexion which may damage the spinal cordcord

• If there is fracture,prevent movementIf there is fracture,prevent movement


Assesment in hospitalAssesment in hospital

• Examine the airway and treat asphyxiaExamine the airway and treat asphyxia• Make sure the patient can breatheMake sure the patient can breathe• Note the obvious haemorrhage and stop itNote the obvious haemorrhage and stop it• Assess the degree of blood loss and shockAssess the degree of blood loss and shock• Check for spinal cord injuryCheck for spinal cord injury• Look for injuries of abdominal or pelvic visceraLook for injuries of abdominal or pelvic viscera• Examine for the presence of fractures or Examine for the presence of fractures or

dislocationdislocation• Look for soft tissue complications, especially nerve Look for soft tissue complications, especially nerve

and vascular injuryand vascular injury• Arrange for an x-rayArrange for an x-ray


Definitive treatment of closed Definitive treatment of closed fracturefracture

• Manipulation to improve the Manipulation to improve the position of the fragments, followed position of the fragments, followed by splintage to hold them by splintage to hold them together until they unite; together until they unite; meanwhile joint movement and meanwhile joint movement and function must be preservedfunction must be preserved


Reposisi Reposisi

Mengembalikan kedudukan tulangMengembalikan kedudukan tulang

Cara :

• Manual

• Traksi

• Operatif


Fracture involving an articular surface; this should

be reduced as near to perfection as possible

because any irregularity will

predispose to degenerative arthritis


Closed reductionClosed reduction

• The distal part of limb is pulled in The distal part of limb is pulled in the line of the bonethe line of the bone

• As the fragment disengage, they are As the fragment disengage, they are repositionedrepositioned

• Alignment is adjusted in each planeAlignment is adjusted in each plane


ReposisiReposisi


ReposisiReposisi

Keberhasilan dinilai dari :Keberhasilan dinilai dari :

• AlignmentAlignment

• Contact > 50 %Contact > 50 %

• Rotation (-)Rotation (-)

• Discrepancy (-)Discrepancy (-)

• Sudut < 15 °Sudut < 15 °


Indikasi konservatifIndikasi konservatif

• Anak dalam masa pertumbuhanAnak dalam masa pertumbuhan

• Impending infeksiImpending infeksi

• Jenis fraktur tidak cocok untuk ORIFJenis fraktur tidak cocok untuk ORIF

• Toleransi operasi tidak baikToleransi operasi tidak baik

• Pasien menolak operasiPasien menolak operasi


Indikasi OperasiIndikasi Operasi

• Sukar reposisi tertutupSukar reposisi tertutup

• Fraktur multipelFraktur multipel

• Fraktur patologisFraktur patologis

• Fraktur intra artikularFraktur intra artikular


HOLD REDUCTIONHOLD REDUCTION

• In order to unite, a fracture must In order to unite, a fracture must be imobilized be imobilized

• We splint most fractures, not to We splint most fractures, not to ensure union but (1) to alliviate pain ensure union but (1) to alliviate pain and (2) to ensure that union takes and (2) to ensure that union takes place in good positionplace in good position


Immobilisasi Immobilisasi (mempertahankan reposisi)(mempertahankan reposisi)

•Fiksasi eksternaFiksasi eksterna– GipsGips– Roger AndersonRoger Anderson

•Fiksasi internaFiksasi interna– Plate + ScrewPlate + Screw– K-nailK-nail


ORIF ; indicationsORIF ; indications

• # that cannot be reduced except by # that cannot be reduced except by operationoperation

• # that inherently unstable and prone to # that inherently unstable and prone to redisplacemaent after reduction (#mid shaft redisplacemaent after reduction (#mid shaft forearm)forearm)

• # that unite poorly and take long time (# # that unite poorly and take long time (# femoral neck)femoral neck)

• Pathological #Pathological #• Multiple #Multiple #• # in patients who prsent nursing difficulties # in patients who prsent nursing difficulties

(paraplegics, multiple injuries and very elderly (paraplegics, multiple injuries and very elderly


ORIF; complicationsORIF; complications

• INFECTIONINFECTION

• NON – UNIONNON – UNION

• IMPLANT FAILUREIMPLANT FAILURE

• REFRACTUREREFRACTURE


OREF (OREF (open reduction external open reduction external fixationfixation) ; indications) ; indications

• # associated wih severe soft tissue # associated wih severe soft tissue damagedamage

• # associated with nerve or vessel # associated with nerve or vessel damagedamage

• Severely comminuted and unstable # Severely comminuted and unstable #

• # pelvis# pelvis

• Infected #Infected #


OREF ; ComplicationOREF ; Complication

• OverdistractionOverdistraction

• Reduced load transmission trough Reduced load transmission trough bone, which delays fracture healing bone, which delays fracture healing causes osteoporosis (EF shoul be causes osteoporosis (EF shoul be removed after 6-8 wo,and replace)removed after 6-8 wo,and replace)

• Pin tract infectionPin tract infection


OPEN FRACTUREOPEN FRACTURE

• EMERGENCYEMERGENCY

• GOLDEN PERIOD 6 – 8 HOGOLDEN PERIOD 6 – 8 HO


OPEN FRACTURE; OPEN FRACTURE; assesmentassesment

• Is circulation intact ?Is circulation intact ?

• Peripheral nerve intact ?Peripheral nerve intact ?

• State of skin arround the woundState of skin arround the wound

• Does the wound communicate with Does the wound communicate with # ?# ?


Fraktur TerbukaFraktur Terbuka

• Perbaiki KU Perbaiki KU

• Debridement, kultur/resistensiDebridement, kultur/resistensi

• ATS-Toxoid, AntibiotikATS-Toxoid, Antibiotik

• Tutup luka dengan kasa bersihTutup luka dengan kasa bersih

• ReposisiReposisi

• Imobilisasi Imobilisasi


ANTIBACTERIALANTIBACTERIAL

• Antibiotics Antibiotics : asap, combination : asap, combination ampicilline and cloxacillin, given ampicilline and cloxacillin, given 6ho; if wound heavily 6ho; if wound heavily contaminated, give gentamycin or contaminated, give gentamycin or metronidazole for 4-5 dometronidazole for 4-5 do

• Tetanus prophylaxisTetanus prophylaxis


TREATMENT OF WOUNDTREATMENT OF WOUND

• To cleanse the wound of foreign To cleanse the wound of foreign materialmaterial

• Remove devitalized tissue Remove devitalized tissue (debridement)(debridement)

4 C :4 C : ColourColour

ConsistencyConsistency

ContractilityContractility

Capacity of bleedingCapacity of bleeding


Complications of fractureComplications of fractureGeneral complicationGeneral complication

• ShockShock

• Crush syndromeCrush syndrome

• Venous thrombosis and pulmonary Venous thrombosis and pulmonary embolismembolism

• TetanusTetanus

• Gas gangreneGas gangrene

• Fat embolismFat embolism


Complication involving # Complication involving # bonebone

• InfectionInfection

• Delayed union and non unionDelayed union and non union

• MalunionMalunion

• Growth disturbanceGrowth disturbance

• Avascular necrosisAvascular necrosis


Complication involving soft Complication involving soft tissuetissue

• Vascular injuryVascular injury

• Compartement syndrome Compartement syndrome (Volkmann”s ischaemia)(Volkmann”s ischaemia)

• Nerve injuryNerve injury

• Visceral injuryVisceral injury

• Myositis osificansMyositis osificans


Compartement syndromeCompartement syndrome

Arterial ischaemia reducedArterial ischaemia reduced painfulpainful

Damage blood flowDamage blood flow palepale

pulselesspulseless

parestheticparesthetic

paralysedparalysed

Direct oedemaDirect oedema

Injury Injury fasciotomyfasciotomy

incr comp pressureincr comp pressure


Complication involving Complication involving jointsjoints

• Joint stiffnessJoint stiffness

• OsteoarthritisOsteoarthritis

• Sudeck’s atrophySudeck’s atrophy


??


TERIMA TERIMA KASIHKASIH

Created by : “ Tepeng “

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