Introduksi Trauma Muskuloskeletal Fraktur Tertutup & Terbuka Menkher Manjas Bahagian Bedah Tulang RS Dr M Djamil Padang/ Fakultas kedokteran UnandKuliah 8 April 2013. Jam 11.00-12,50*

Kerusakan fisik / mental akibat dari suatu kekerasan (Violence)Dua pertiga trauma pada tubuh adalah trauma pada muskuloskeletal Sifat trauma: High morbidity & Low mortality.Trauma paling seringTulang : FrakturSendi : Dislokasi, Sprain Strain dllJar. Lunak : Luka ,Ruptur tendon dll

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Masalah Transportasi Jumlah & kecepatan kendaraan Jalan semakin sempit (Perampasan)Political Will government Jenis olah raga Semakin beratJadi prestasi daerah / negaraJumlah Lansia Osteoporosis Kesigapan yang menurun*

Kulit Jejas, luka, skin loss dllOtot Memar, ruptur dll Tendon Laserasi, ruptur dllSyaraf Neuropraksia, Neurometsis, AxonometsisTulang Fissure, fraktur dllSendi Dislokasi*

Terjadinya diskontinuitas (Ketidak Sinambungan) jaringan tulang / tulang rawan. Simbol fraktur #Penyebab: Trauma Berat Ringan*

1. AnamnesaKeluhan Utama Tulang (Organ) Bengkok, Bengkak, Pendek sesudah traumaMekanisme trauma (History of accident) Langsung / Tidak langsungRiwayat Penyakit dahulu & Peny keluarga Untuk menjelaskan penyakit dasar*

Pemeriksaan UmumBerat : Bisa shockTrauma penyerta lainLokalDeformitas Luka / TidakNyeri Tekan & Nyeri sumbuBahagian acral/ distal : A, V, N

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3. Pemeriksaan Penunjang Laboratorium DarahUrineRadiologisRontgen FotoCT ScanMRI

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Pemeriksaan Rontgen Foto Syarat Foto Rule of twoTwo view (dua arah) AP & LateralTwo Joint Dua sendiTwo Occasion / Time Dua waktuDari hasil radiologis dapat diklasifikasiLokasi anatomiKonfigurasi Aligment garis fraktur

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Luasnya Fraktur Fr Komplet (patah total) Fr Inkomplete (Mis :Greenstick Fr) Garis Fracture

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Klasifikasi Lokasi AnatomiTulang Panjang 1/3 proximal, 1/3 tengah & 1/3 distal Tulang Pendek Kaput, Batang, Basis

Aligment Fr,Aposisi garis FrakturContoh D/ Fraktur Cruris Sinistra terbuka dislokasi adaxin cum kontractionum*

Berdasarkan adanya lukaFraktur tertutup : Tidak ada luka (Fragmen fr tidak berhub dengan bhg luar) Fraktur terbuka (Grade Gustilo) Grade I : Luka terbuka < 1 cm (Pin Point Fr)Grade II : Luka terbuka > 1 cmGrade III : A Luka yang masih bisa ditutupB Luka yang tidak bisa ditutupC Disertai kerusakan Neurovasculer*

Fase Hematoma ( 2-8 jam ssd trauma)Fase Resorbsi hematoma (Sp 1 minggu)Hematoma diisi oleh sel-sel tulang baruFase calus ( tulang muda) (ssd 3 minggu) Osteoblasts membentuk spongy boneFase Konsolidasi ( 6-12 minggu)Tulang spongiosa menjadi padat

Fase Remodelling (12-24 bulan)Spongy bone berobah jadi tulang normalTak tampak lagi garis fraktur*

Faktor Umum UmurGiziAdanya peny. Sitemik / tidak Faktor Lokal Posisi garis patah tulangPerdarahanCara imobilisasi dll Adanya infeksi

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Good Union Menyambung sempurnaBentuk, Ukuran anatomis & Fungsi kembali normalDelayed union Menyambung lamaNon-union Ssd 5 bl.Malunion Salah sambung*

Shock & PerdarahanSindroma Emboli Lemak Compartment syndromeInfeksi OsteomyelitisGangguan pertumbuhan Fr EpifisisKecacatan*

Ggn perdarahan bgh distal fr. krn bendungan akibat peningkatan tekanan intra compartment sekitar fr Penyebab Internal / Ekternal (balutan sangat ketat)Gejala P5Pulselessness (Nadi melemah)Pain saat ektensi.Pallor (pucat) (Slow capillary return).Paresthesia.Puffiness (edema).Penanganan Lepaskan spalk, ElevasiFasciotomi*

Lemak sumsum tl masuk p. darah & menyumbat jantung, paru, otak kematianSering dari fraktur panggul atau fraktur femurGejala timbul ssd 12-36 jam dengan:KU memburukTimbul bintik- bintik dikulitComa , hypoxia Prognosa Jelek*

Ukuran pendekBentuk bengkokSendi kakuJalan pincangAmputasi dll.*

Penanganan FrakturKonservatif & OperativMenkher Manjas Bahagian Bedah Tulang RS Dr M Djamil Padang/ Fakultas kedokteran UnandKuliah Selasa 9 April 2013. Jam 071.00-082,50*

Tempat kejadian (Injury Disarter) Masyarakat, Sosial worker, Polisi, petugas medis dllPra Hospital (Transportation) Hospital Emergency Room, Operating Room, ICU, Ward Care Rehabilitasi Physical, Psycological *

Life saving Prioritas utama Limb savingPenanganan Nyeri (Relieve pain)Mengembalikan fungsi (Restore optimum function)Tindakan Non OperatifTindakan Operative

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UmurKelamin PekerjaanKeadaan Fraktur Patologis non Patologis Penyakit penyerta

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Jika tak ditolong segera bisa terjadi Fraktur terbukaFraktur disertai hancurnya jaringan (Major crush injury)Fraktur dengan amputasiFraktur dengan ggn neurovaskuler (Compartmen Syndrome)Dislokasi sendi*

Life Saving ABCDObstructed AirwayShock : Perdarahan Interna /External Limb SavingReliave pain Splint & analgeticPergerakan fragmen fr Spasme otot Udema yang progresif.Transportasi penderita Dont do harm*

Prinsip : 4 RR 1 = Recognizing = DiagnosaAnamnesa, PE, PenunjangR 2 = Reduction = ReposisiMengembalikan posisi fraktur keposisi sebelum frakturR 3 = Retaining = Fiksasi /imobilisasiMempertahankan hasil fragmen yg direposisiR 4 = RehabilitationMengembalikan fungsi kesemula *

Mengembalikan posisi fraktur keposisi semulaIdealnya: Kembali ke posisi anatomisKontak 100 %Angulasi tidak adaRotasi tidak adaMetode reposisiReposisi tertutup Reposisi terbuka Dengan pembedahan

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Tanpa pembiusanFraktur masih fase shockFr. yang sedikit bergeser dllDengan pembiusanAnestesi lokalAnestesi umumTeknik Dengan tarikan, tekanan secara perabaanMemakai C Arm (Portable radiologis)

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Gagal reposisi tertutupAvulsion fractureFr Patela & Fr OlecranonEpiphyseal fractureInterposisi JaringanDisertai gangguan vascular Fraktur Patologis *

TeknikTulang dicapai dengan melalui pembedahanHarus selalu menjaga perdarahanPada fraktur terbuka harus didahului dengan: Dilusi / irigasi Dilution is a solution to polutionDebrideman Reposisi*

Mempertahankan hasil reposisi sampai tulang menyambungKenapa ssd reposisi harus retainingManusia bersifat dinamisAdanya tarikan tarikan otot Agar penyembuhan lebih cepatMenghilangkan nyeri*

IsitrahatPasang splint / SlingCasting / GipsTraksi Kulit atau tulangFiksasi pakai inplant*

Sling : Mis Arm SlingSplint

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Casting / GipsHemispica gipLong Leg GipBelow knee castUmbrical slab *

Traksi Cara imobilisasi dengan menarik bahagian proksimal dan distal secara terus menerus. Kulit Tulang*

Fiksasi pakai inplantInternal fikasasiPlate/ skrewIntra medular nail Kuntsher NailEkternal fiksasi *

Mengembalikan fungsi organ fraktur kembali normal Otot supaya jangan atropi (mengecil)Isometric ExersiceIsotonik ExersiceSendi supaya jangan kakuBentuk latihanLatihan sendiriBantuan orang lain (Fisioterapist)Perangsangan Elektrik & Physical Therapy*

Trauma Pada Sendi Dislokasi Bahu & PanggulMenkher ManjasBahagian Bedah Tulang RS Dr M Djamil Padang/ Fakultas kedokteran UnandKuliah PBL Rabu 10 April 2013. jam 07.00-08,50*

Pertemuan dua tulang untuk mobilisasi Soft Tissue (Jar. lunak) Otot, Tendon ligamen, Kapsul sendi dllHard Tissue (Jaringan keras)Trauma Pada SendiT. Jaringan Lunak (Soft tissue) Sprain TerkilirStrain Keseleo Ruptur ligamen (Putus ligamen)T. Jaringan Keras (Hard tissue) Dislokasi, SubdislokasiFraktur dislokasi*

Penyebab : Trauma dengan gerakan tiba-tiba Klinis Nyeri, bengkak panas, biru, kemerahanGradeGrade 1 teregang sembuh 2- 10 hariGrade 2 putus partial sembuh 10 hr 6 mgGrade 3 putus total (Avulsi) sembuh 3 -10 mgStrain SprainRuptur Laserasi otot pada sendi Laserasi ligament pada sendi putusnya tendon/ ligamen *

Grade 1 & 2 RICER = rest I = iceC = compressE = elevate Anti Inflamasi (NSAIDs)Grade 3 Penyambungan kembali (Tendorafi) *

Dis + LokasiKepala sendi keluar dari mangkok sendiSubluksasi Sbhg kepala sendiFraktur Dislokasi Disertai dengan fr.Fraktur dan Dislokasi

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Trauma Berat dan hebatNon Trauma /Trauma ringan Dislokasi Habitual lebih 4 kali Dislokasi KongenitalBisa mengenai seluruh sendiTersering Bahu, Panggul, siku, lutut jari dll*

Apa yang terjadi jika dislokasi ? Robek kapsul sendi, otot, ligamen dllKerusakan p darah & syarafPerdarahan dalam sendi Avaskular nekrosis kepala sendi Terganggu pertumbuhan sendi *

AnamnesaRiwayat trauma hebatNyeri hebat :Spasme otot sekitar sendiRansangan cairan sendi Terjepit sarafPemeriksaan Deformitas (Perobahan bentuk sendi) Disfungsi Sendi tak bisa digerakkanRadiologis : Rontgen Foto, CT Scan

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Reposisi mengembalikan posisi kaputTertutup Terbuka (Open Reduction), jika Gagal reposisi tertutupInterposisi jaringan Button hole dislocation Dislokasi disertai frakturNeglected cases & Dislokasi lamaRetaining mempertahan hasil reposisiRehabilitation Mengembalikan pada fungsi*

SegeraShockSepsis terutama yang terbukaNekrosis kepala sendiLanjutKaku sendiGangguan pertumbuhan cacat *

Keluarnya caput humerus dari cavum gleinodalis Etio : 99% traumaPembahagianDis. Anterior (98 %) Dis.Posterior (2 %)Dis. InferiorMekanisme TraumaPuntiran sendi bahu tiba-tibaTarikan sendi bahu tiba-tibaTarikan & puntiran tiba-tibaDis.Bahu (D. Glenohumeralis)*

Lengkung (contour) bahu berobah, Posisi bahu abduksi & rotasi ekterna Teraba caput humeri di bhg anteriorBack anestesi ggn n axilarisRadiologis memperjelas DRontgen FotoCT Scan*

Reduction, as quickly and gently as possible Tertutup atau Terbuka Tarikan langsung Teknik Traksi & Teknik kounter traksiTeknik Hippokrates Reposisi sesuai arah traumaTeknik Stimson (Gravitasi), Teknik MilchTeknik Kocher *

Reposisi dengan penarikan langsungTeknik HipokratesPenderita tidur telentangTangan ditarik dan kaki mendorong diketiakTeknik Traksi & Kounter TraksiPenderita dudukTangan ditarik kebawah dan ketiak ditarik keatasKeduanya sangat traumatis n axilaris*

Teknik StimsonReposisi oleh berat tangan & gravitasiTelungkup dipinggir meja, Beban 2,5 kg selama 15- 20 minTeknik MilchReposisi: tarikan dalam posisi telungkupHumerus di abduksi & rotasi ekterna Caput humeri didorong kedalam Teknik KocherReposisi menyesuaikan arah traumaHumerus diputar keluar & siku kedada*

Imobilisasi bahu posisi adduksi & rotasi interna Pelvow sling Latihan ROM sendi.KomplikasiGgn ligament & kapsul sendi Fraktur tulang sekitar sendiTrauma vaskular (a. axilaris)Habitual Dislocation Trauma syaraf (10 %) n. axilaris

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Keluarnya caput femur dari acetabulum.99% penyebab traumaPembahagianDislokasi Posterior: 85%Dislokasi Anterior: 10-15%Dislokasi SentralMekanisme Trauma terbanyak dash board InjuryDislokasi Panggul (D. Kaput Femur)Dis.PosteriorDis. Anterior*

AnamnesaRiwayat trauma & Nyeri hebat PemeriksaaanDislokasi Posterior Fleksi, adduksi & Internal rotasiDislokasi Anterior Fleksi abduksi & ekternal rotasi Radiologis Rontgen FotoPenanganan Reposisi tertutup /terbuka*

TeknikTeknik Hippocrates tarikan langsungTeknik Gravitasi Teknik BigelowTeknik StimsonPasca reposisiRetaining Skin traksi sampai hilang udema 2 mingguRehabilitasi latihan gerakan panggulJalan pakai tongkat 12 mingguFolow up sampai 2 th monitor avaskuler caput femur

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Avascular necrosis Paling ditakutiArthritisMyositis ossificans Trauma n ischiadicusKaku sendi (stiffness)*

Trauma Pada Sendi Dislokasi Bahu & PanggulMenkher ManjasBahagian Bedah Tulang RS Dr M Djamil Padang/ Fakultas kedokteran UnandKuliah PBL Rabu 10 April 2013. jam 07.00-08,50*

Pertemuan dua tulang untuk mobilisasi Soft Tissue (Jar. lunak) Otot, Tendon ligamen, Kapsul sendi dllHard Tissue (Jaringan keras)Trauma Pada SendiT. Jaringan Lunak (Soft tissue) Sprain TerkilirStrain Keseleo Ruptur ligamen (Putus ligamen)T. Jaringan Keras (Hard tissue) Dislokasi, SubdislokasiFraktur dislokasi*

Penyebab : Trauma dengan gerakan tiba-tiba Klinis Nyeri, bengkak panas, biru, kemerahanGradeGrade 1 teregang sembuh 2- 10 hariGrade 2 putus partial sembuh 10 hr 6 mgGrade 3 putus total (Avulsi) sembuh 3 -10 mgStrain SprainRuptur Laserasi otot pada sendi Laserasi ligament pada sendi putusnya tendon/ ligamen *

Grade 1 & 2 RICER = rest I = iceC = compressE = elevate Anti Inflamasi (NSAIDs)Grade 3 Penyambungan kembali (Tendorafi) *

Dis + LokasiKepala sendi keluar dari mangkok sendiSubluksasi Sbhg kepala sendiFraktur Dislokasi Disertai dengan fr.Fraktur dan Dislokasi

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Trauma Berat dan hebatNon Trauma /Trauma ringan Dislokasi Habitual lebih 4 kali Dislokasi KongenitalBisa mengenai seluruh sendiTersering Bahu, Panggul, siku, lutut jari dll*

Apa yang terjadi jika dislokasi ? Robek kapsul sendi, otot, ligamen dllKerusakan p darah & syarafPerdarahan dalam sendi Avaskular nekrosis kepala sendi Terganggu pertumbuhan sendi *

AnamnesaRiwayat trauma hebatNyeri hebat :Spasme otot sekitar sendiRansangan cairan sendi Terjepit sarafPemeriksaan Deformitas (Perobahan bentuk sendi) Disfungsi Sendi tak bisa digerakkanRadiologis : Rontgen Foto, CT Scan

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Reposisi mengembalikan posisi kaputTertutup Terbuka (Open Reduction), jika Gagal reposisi tertutupInterposisi jaringan Button hole dislocation Dislokasi disertai frakturNeglected cases & Dislokasi lamaRetaining mempertahan hasil reposisiRehabilitation Mengembalikan pada fungsi*

SegeraShockSepsis terutama yang terbukaNekrosis kepala sendiLanjutKaku sendiGangguan pertumbuhan cacat *

Keluarnya caput humerus dari cavum gleinodalis Etio : 99% traumaPembahagianDis. Anterior (98 %) Dis.Posterior (2 %)Dis. InferiorMekanisme TraumaPuntiran sendi bahu tiba-tibaTarikan sendi bahu tiba-tibaTarikan & puntiran tiba-tibaDis.Bahu (D. Glenohumeralis)*

Lengkung (contour) bahu berobah, Posisi bahu abduksi & rotasi ekterna Teraba caput humeri di bhg anteriorBack anestesi ggn n axilarisRadiologis memperjelas DRontgen FotoCT Scan*

Reduction, as quickly and gently as possible Tertutup atau Terbuka Tarikan langsung Teknik Traksi & Teknik kounter traksiTeknik Hippokrates Reposisi sesuai arah traumaTeknik Stimson (Gravitasi), Teknik MilchTeknik Kocher *

Reposisi dengan penarikan langsungTeknik HipokratesPenderita tidur telentangTangan ditarik dan kaki mendorong diketiakTeknik Traksi & Kounter TraksiPenderita dudukTangan ditarik kebawah dan ketiak ditarik keatasKeduanya sangat traumatis n axilaris*

Teknik StimsonReposisi oleh berat tangan & gravitasiTelungkup dipinggir meja, Beban 2,5 kg selama 15- 20 minTeknik MilchReposisi: tarikan dalam posisi telungkupHumerus di abduksi & rotasi ekterna Caput humeri didorong kedalam Teknik KocherReposisi menyesuaikan arah traumaHumerus diputar keluar & siku kedada*

Imobilisasi bahu posisi adduksi & rotasi interna Pelvow sling Latihan ROM sendi.KomplikasiGgn ligament & kapsul sendi Fraktur tulang sekitar sendiTrauma vaskular (a. axilaris)Habitual Dislocation Trauma syaraf (10 %) n. axilaris

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Keluarnya caput femur dari acetabulum.99% penyebab traumaPembahagianDislokasi Posterior: 85%Dislokasi Anterior: 10-15%Dislokasi SentralMekanisme Trauma terbanyak dash board InjuryDislokasi Panggul (D. Kaput Femur)Dis.PosteriorDis. Anterior*

AnamnesaRiwayat trauma & Nyeri hebat PemeriksaaanDislokasi Posterior Fleksi, adduksi & Internal rotasiDislokasi Anterior Fleksi abduksi & ekternal rotasi Radiologis Rontgen FotoPenanganan Reposisi tertutup /terbuka*

TeknikTeknik Hippocrates tarikan langsungTeknik Gravitasi Teknik BigelowTeknik StimsonPasca reposisiRetaining Skin traksi sampai hilang udema 2 mingguRehabilitasi latihan gerakan panggulJalan pakai tongkat 12 mingguFolow up sampai 2 th monitor avaskuler caput femur

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Avascular necrosis Paling ditakutiArthritisMyositis ossificans Trauma n ischiadicusKaku sendi (stiffness)*

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IntrasegmentalLigamentum flavumIntertransverse ligamentInterspinous ligamentIntersegmentalALLPLLSupraspinous ligament*

Incidence: 10,000 new cases/yearPrevalence: 191,000 cases and risingPrime occurrence: males, peak of their productive livesCost: $ 5.6 billion/year in the USCost per person: directly related to the level of SCI and patients age*

Compression FlexionExtensionRotationLateral bendingDistractionPenetration*

Whiplash injury*

Sudden decelerations (MVCs, falls) Compression injuries (diving, falls onto feet/buttocks) Significant blunt trauma (football, hockey snowboarding, jet skis)Very violent mechanisms (explosions, cave-ins, lightning strike) Unconscious patient Neurological deficit Spinal tenderness*

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Protect further injury during evaluation and management

Identify spine injury or document absence of spine injury

Optimize conditions for maximal neurologic recovery

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Maintain or restore spinal alignment

Minimize loss of spinal mobility

Obtain healed & stable spine

Facilitate rehabilitation*

Protect spine at all times during the management of patients with multiple injuries

Up to 15% of spinal injuries have a second (possibly non adjacent) fracture elsewhere in the spine

Ideally, whole spine should be immobilized in neutral position on a firm surface

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PROTECTION PRIORITYDetection Secondary

Log-rolling

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Cervical spine immobilization

Transportation of spinal cord-injured patients

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Safe assumptionsHead injury and unconsciousMultiple traumaFall Severely injured workerUnstable spinal column

Hard backboard, rigid cervical collar and lateral support (sand bag)

Neutral position*

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Emergency Medical Systems (EMS)Paramedical staffPrimary trauma centerSpinal injury center

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Advance Trauma Life Support (ATLS) guidelinesPrimary and secondary surveys Adequate airway and ventilation are the most important factorsSupplemental oxygenationEarly intubation is critical to limit secondary injury from hypoxia

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Inspection and palpation Occiput to CoccyxSoft tissue swelling and bruisingPoint of spinal tendernessGap or Step-offSpasm of associated muscles

Neurological assessmentMotor, sensation and reflexesPR

Do not forget the cranial nerve (C0-C1 injury)

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Temporary loss of autonomic function of the cord at the level of injuryresults from cervical or high thoracic injuryPresentationFlaccid paralysis distal to injury siteLoss of autonomic functionhypotensionvasodilatationloss of bladder and bowel controlloss of thermoregulationwarm, pink, dry below injury sitebradycardia

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*Comparison of neurogenic and hypovolemic shock

Neurogenic Hypovolemic Etiology Loss of sympathetic outflowLoss of blood volumeBlood pressureHypotension Hypotension Heart rateBradycardiaTachycardia Skin temperatureWarm Cold Urine outputNormal Low

Spinal shockBulbocavernosus reflex

Complete VS incomplete cord injury spinal shock Sacral sparingVoluntary anal sphincter controlToe flexorPerianal sensationAnal wink reflex

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American Spinal Injury Association gradeGrade A E

American Spinal Injury Association scoreMotor score (total = 100 points)Key muscles : 10 musclesSensory score (total = 112 points)Key sensory points : 28 dermatomes

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Anterior cord syndromeBrown-Sequard syndromeCentral cord syndrome

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Loss of motor, pain and temperature

Preserved propioception and deep touch

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Loss of ipsilateral motor and propioception

Loss of contralateral pain and temperature

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Weakness : upper > lower

Variable sensory loss

Sacral sparing

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Numerous large prospective studies havedescribed the large cost and low yield ofthe indiscriminate use of c-spine radiologyin trauma patients.

WHO NEEDS AN X-RAY???*

Absence of tenderness in the posterior midlineAbsence of a neurological deficitNormal level of alertness (GCS15)No evidence of intoxicationNo distracting pain elsewhere*

Any patient who fulfilled all 5 of the aforementioned criteria were considered low risk for C-spine injury and as such did not receive C-spine radiographyFor patients who had any of the 5 criteria,radiographic imaging was indicated in the form of AP, lateral, and odontoid C-spine views*

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The standard 3 view plain film series is the lateral, antero-posterior, and open-mouth view The lateral cervical spine film must include the base of the occiput and the top of the first thoracic vertebraThe lateral view alone is inadequate and will miss up to 15% of cervical spine injuries.*

X-ray Guidelines (cervical)Adequacy, AlignmentBone abnormality, Base of skullCartilage, ContoursDisc spaceSoft tissue*

AdequacyShould see C7-T1 junctionIf not get swimmers view or CT

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AlignmentAnterior vertebral lineFormed by anterior borders of vertebral bodiesPosterior vertebral lineFormed by posterior borders of vertebral bodiesSpino-laminar LineFormed by the junction of the spinous processes and the laminaePosterior Spinous LineFormed by posterior aspect of the spinous processes

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Predental Space should be no more than 3 mm in adults and 5 mm in childrenIncreased distance may indicate fracture of odontoid or transverse ligament injury*

Disc SpacesShould be uniform Assess spaces between the spinous processes

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Nasopharyngeal space (C1) - 10 mm (adult)Retropharyngeal space (C2-C4) - 5-7 mmRetrotracheal space (C5-C7) - 14 mm (children), 22 mm (adults)Extremely variable and nonspecificMeasurements anterior to the mid-cervical spine up to 7 mm are common. > 7 mm,-a fracture is likely and the neck should be immobilized.*

Spinous processes should line up Disc space should be uniformVertebral body height should be uniform. Check for oblique fractures.*

Adequacy: all of the dens and lateral borders of C1 & C2Alignment: lateral masses of C1 and C2Bone: Inspect dens for lucent fracture lines*

Thin cut CT scan should be used to evaluate abnormal, suspicious or poorly visualized areas on plain film

The combination of plain film and directed CT scan provides a false negative rate of less than 0.1%*

Ideally all patients with abnormal neurological examination should be evaluated with MRI scan*

Primary GoalPrevent secondary injury

Immobilization of the spine begins in the initial assessmentTreat the spine as a long boneSecure joint above and belowCaution with partial spine splinting

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Spinal motion restriction: immobilization devicesABCsIncrease FiO2Assist ventilations as needed with c-spine control Indications for intubation :Acute respiratory failureGCS 50 VC < 10 mL/kg IV Access & fluids titrated to BP ~ 90-100 mmHg*

Look for other injuries: Life over LimbTransport to appropriate SCI center once stabilizedConsider high dose methylprednisoloneControversial as recent evidence questions benefitMust be started < 8 hours of injuryDo not use for penetrating trauma30 mg/kg bolus over 15 minute After bolus: infusion 5.4mg/kg IV for 23 hours*

Spinal alignmentdeformity/subluxation/dislocation reduction

Spinal column stabilityunstable stabilization

Neurological statusneurological deficit decompression*

Complete - Absence of sensory and motor functions in the lowest sacral segments Incomplete - Preservation of sensory or motor function below the level of injury, including the lowest sacral segments*

A complete paralysis B sensory function only below the injury level C incomplete motor function below injury level D fair to good motor function below injury level E normal function *

SuportifNon OperativeSurgery

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Methylprednisolone given as bolus of 30 mg / kg body wt - followed by infusion at 5.4 mg / kg / hour for 23 hours; Excluded pts: - patients who are more than 8 hours from injury (these patients may actually do worse w/ steroids); Note: up to 40% of spine injured patients who receive steroids can be expected to develop some Gastrointenstinal bleeding

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No treatmentadvice / restrict activity

Spinal immobilisationBed restLumbar pillow / Log rollingTractionCasting / BracingCombination treatment*

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Guilford brace*

Bed Rest until Normal Trunk ControlStanding X Rays? Use extension Brace or Cast*

1.The spinal cord appears to be compressed 2.An progressive neurological deterioration. 3.Dislocation with facet joint locking4.Unstable fracture of spine *

Occipitoatlantoaxial fusion with the Luque rectangle*

C Type Fracture L2*

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A Infection of urinary and genital tract B. Pressure Sores : Prevention is the most important treatment. C. Respiratory Complications : respiratory infection D. Disorder of thermoregulation*

PELVIC RING FRACTURE*

HermansyahBag Bedah/ SMF Orthopedi FK-Unand/ RSUP Dr. M.Djamil Padang*

Pelvic fractures are caused by high energy blunt trauma

Significant mortality and morbidity

Mortality 30% in unstable fractures 10 to 12% due to haemorrhage*

Sacrum and 2 innominate bonesInnominate bones articulate anteriorly at symphysis pubisSacrum articulates with the ilium posteriorly through sacroiliac joints *

Pelvic ring stability is provided by:Iliolumbar ligs.Dorsal sacroiliac ligamentsSacrotuberous ligsVentral sacroiliac ligs.Sacrospinous ligsPosterosuperior interosseous ligs.

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Highly vascular

Iliac vessels run along the inner wall of the pelvis

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Tiles classification system uses radiographic images to ascertain the degree of stability of the pelvis , and hence determine which pelvic injuries require stabilization and which can be managed nonoperatively.

Hence the classification by Tile is more relevant for formulating treatment, but does not give significant information regarding the degree of damage*

Type A: Stable (Posterior Arch Intact)A1:Avulsion injuryA2:Iliac wing or anterior arch fracture caused by a direct blowA3: Transverse sacrococcygeal fractureType B: Partially Stable (Incomplete Disruption of Posterior Arch)B1:Open book injury (external rotation)B2:Lateral compression injury (internal rotation)B2-1:Ipsilateral anterior and posterior injuriesB2-2:Contralateral (bucket-handle) injuriesB3:BilateralType C: Unstable (Complete Disruption of Posterior Arch)C1:UnilateralC1-1:Iliac fractureC1-2:Sacroiliac fracture-dislocationC1-3:Sacral fractureC2:Bilateral, with one side type B, one side type CC3:Bilateral

*

INITIAL MANAGEMENT:ATLS protocol: Primary survey

IV fluids and blood transfusion with wide bore canula

A/P Xray of pelvis, L/S spine, Chest, Cervical spine (lat view)

If blood is seen on external urethral meatus, suprapubic cystostomy is preferable to catheterization.

Multidisciplinary approach

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Rotational instability Binding III 3Vertical instability skeletal traction III 3Non invasive external stabilisation devices or a bed sheet but allow access to laparotomy and femoral access for angiography IVIf Non invasive fails invasive anterior external fixation - IVITIM*

Supine2 WrappersPlacementApplyClamper30 Seconds1234Routt et al, JOT, 2002*

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HAEMODYNAMICALLY STABLE:

Complete secondary survey

Inlet and outlet views, Pelvic CT scan

Pelvic binder for unstable fractures

Definitive fixation*

HAEMODYNAMICALLY UNSTABLE

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Damage control surgery, Minimally invasiveStabilizes rotationally unstable pelvis, in patients with shockBefore laparotomy

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Pelvic clamps*

Exposure not a problemLow complication rateBio mechanically idealDetailed anatomical knowledge requiredTechnically demanding

*

INDICATIONS:Symphyseal diastasis > 2cmContralateral bucket handle injury causing >1.5cm limb length discrepancyRotationally and vertically unstable fractures (Tiles Type C)

TIMING When patient is stabilized, and fit enough to undergo the definitive procedure*

Lag screw, Neutralization plates for Iliac wing fractures

Plate fixation for Symphyseal diastasis*

Plate fixation, sacroiliac screw fixation for Sacral fracturesCancellous screw or Sacroiliac plate fixation for Sacroiliac disruption

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Stabilization of a haemodynamically unstable patient is of paramount importance.

Unstable pelvic fractures should be stabilized externally as soon as possible.

For unresponsive patients, urgent laparotomy with angiography on stand by.

Not all pelvic fractures requires fixation.*

Dr. Hermansyah, SpOTBag. Bedah/ SMF OrthopediFK-Unand/ RSUP Dr. M. Djamil PadangRSUD Lubuk Basung*

*

Bone that has a shaft and 2 ends and is longer than it is wide. Thick outside layer of compact bone and an inner medullary cavity containing bone marrow. The ends of a long bone contain spongy bone and an epiphyseal line. The epiphyseal line is a remnant of an area that contained hyaline cartilage that grew during childhood to lengthen the bone. All of the bones in the arms and legs, except the patella, and bones of the wrist, and ankle, are long bones.*

*

Shaft fractures traditionally treated nonsurgicallyHigh rate of complications?InfectionNonunionRadial nerve palsy.

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Diaphyseal fracture patients present with a painful deformed arm. Associated with a radial nerve palsy.Usually, the radial nerve palsy is reversible.Crepitus may be observed.Shortening of the arm suggests displacement.With all humerus fractures, ensure strong radial and ulnar pulses.*

Cardinal signs: painswellingdeformityLook for associated injuriesDocument neurovascular exam!Radial Nerve Function*

Standard X-rays AP lateral viewJoints above and belowCT/MRI if pathologic fx suspected, x-rays not clear*

Most humeral fractures are amenable to closed, nonsurgical treatmentRigid immobilization is not necessary for healingPerfect alignment is not essential for an acceptable result*

Coaptation splint or a hanging arm cast in EDCoaptation splint is preferred due to the support it offers proximal to the fracture siteConversion to a functional brace in 7 to 10 daysShoulder/elbow have large ROM , acceptable:20 degrees of anterior or posterior angulation30 degrees of varus (less in thin patients)3 cm of shortening

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Massive soft-tissue or bone lossUnreliable or uncooperative patientInability to obtain and maintain acceptable fracture alignmentFracture gap present - increases risk of nonunion*

Surgical intervention is preferable in specific casesInjury Related FactorsPatient Related Factors*

Failed closed treatmentLoss of reductionPoor patient tolerance/compliance(Open fractures)Vascular injury/Change in neuro exam (radial n.)Floating elbow*

Associated intra-articular fracturesAssociated injuries to the brachial plexusSecondary palsies developing after a closed reductionChronic problemsDelayed unionNonunion/malunionInfection

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Polytrauma-requiring arm for mobilizationHead injuriesBurnsChest traumaMultiple fracturesPatient unable to be upright

*

Operative:

Plate osteosynthesisLag screws alone are not strong enoughIM fixationExternal fixation

*

The best functional results: use of plates and screwsDirect fracture reductionStable fixation of the humeral shaftNo violation of the rotator cuffVisualization of radial nerve*

BenefitsSupine positioningProximal extension possible via deltopectoral interval

Drawbacksless direct exposure of radial nerve (posterior to intermuscular septum)Difficulty in applying plate to lateral aspect of humerus for distal fracturesProximal and middle third*

Benefits of posterior approach:Allows more direct exposure of the radial nerveAllows application of a broad plate to flat surface of distal humerus for distal third fracturesDrawbacks to posterior approach:Requires lateral or prone positioning which may be problematic for polytrauma patientRequires nerve mobilization for plate application, theoretically increasing risk of iatrogenic palsy*

Benefits of posterior approach:Allows direct exposure of the radial nerveExtensileSupine positionDrawbacks to posterior approach:Less familiar to surgeonsPosterior antebrachial cutaneous nerve at riskMills WJ, Hanel DP, Smith DG, J Orthopedic Trauma 10: 81-6, 1996.*

Radial nerve injuryVascular injuryNonunion

*

Spontaneous recovery: ~90%Even secondary palsies, have a high rate of spontaneous recoveryEMG and nerve conduction studies can help, (but not acutely!)If no recovery, tendon transfers very reliable

*

UncommonKey is clinical diagnosisDebate:Shunt, ORIF, then bypass/repair ORIF then bypass/repair*

transverse fracture patternolder agepoor nutritional statusosteoporosisendocrine abnormality affecting calcium balanceuse of steroidsanticoagulationprevious RT*

Results very good for functional bracingNeed to carefully document radial nerve examMost radial nerves injuries recoverMost prefer plates over nailsLook for prospective study of immediate fixation vs. functional bracing

*

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Epidemiology more common in men than womenratio of open to closed fractures is higher than for any other bone except tibiaMechanism direct trauma often while protecting one's headindirect trauma motor vehicle accidentsfalls from heightathletic competition

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Associated conditions elbow injuries evaluate DRUJ and elbow forGaleazzi fractures Monteggia fractures compartment syndrome evaluate compartment pressures if concern for compartment syndromePrognosis functional results depend onrestoration of radial bow*

*

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Symptoms gross deformity, pain, swellingloss of forearm and hand functionPhysical exam inspection open injuriescheck for tense forearm compartmentsneurovascular exam assess radial and ulnar pulsesdocument median, radial, and ulnar nerve functionpain with passive stretch of digits alert to impending or present compartment syndrome*

*

Radiographs recommended views AP and lateral views of the forearm additional views oblique forearm views for further fracture definitionipsilateral wrist and elbow to evaluate for associated fractures or dislocationRadial head must be aligned with the capitellum on all views*

*

A1Simple fracture of the ulna, radius intact1 oblique2 transverse3 with dislocation of the radial head (Monteggia)

A2Simple fracture of the radius, ulna intact1 oblique2 transverse3 with dislocation of the distal radio-ulnarjoint (Galeazzi)

A3Simple fracture of both bones1 radius, proximal zone2 radius, middle zone3 radius, distal zone

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1814*

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1967*

1934*

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Common high energy traumaUsually gustillo grade II and IIIExt for soft tissue lost and maintain lenght*

SynotosisInfectionCompartment syndromeMalunionNeurovascular injuryRefracture*

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Common injury due to major violent trauma1 femur fracture/ 10,000 peopleMore common in people < 25 yo or >65 yoFemur fracture leads to reduced activity for 107 days, the average length of hospital stay is 25 daysMotor vehicle, motorcycle, auto-pedestrian, aircraft, and gunshot wound accidents are most frequent causes*

The Proximal femoral shaft is well padded with powerful muscles

Advantage This protects the femur from most forces

Disadvantages This makes the reduction difficult, the displacement is often so severe

*

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Struck by car- triad of femur fracture, torso injuries, head injuryPotential damage to physes of femur and proximal tibia in childrenHead Injury spasticity can make traction and cast treatment difficultAbdominal injury spica cast can constrict abdomen and limit ability to examine*

Complete exam: head, chest, abdomen, and other skeletal segments Document distal neurologic and vascular functionPalpate all bonesFirst Aid principles - Splint or traction, especially prior to transfer to another institution*

PAINSWELLINGDEFORMITYINABILITY TO BEAR WEIGHTSHOCK AND ITS SYMPTOMSBEWARE! MULTISYSTEM INURY*

AP PelvisAP/Lat femurVisualize hip & knee joints*

Open or closedLocation of fracture- subtrochanteric, diaphyseal (proximal, mid, distal third), supracondylarFracture pattern- transverse, spiral, oblique, comminuted, greenstickAmount of shorteningAngular deformity*

AgeMechanism of injuryFracture pattern & locationAssociated InjuriesSurgeon preference*

Most femoral shaft fractures have some degree of communition, although it may not be readily apparent on x-ray.

In closed communited fractures, the small fagemnts are live bony pieces with intact soft tissue attachments and blood supply

*

This forms the basis of the Winquist classification.

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X rays can be postponed until shock is taken care of.

Remember to immobilize the facture first, the attempt to take the radiographs

Never forget to X ray the pelvis.- hip fractures and dislocation- pelvic fractures and disruption get a baseline chest X-ray done ARDS and Fat embolism may supervene

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FAT EMBOLISM AND ARDSSHOCK NOT RESONDING TO RESUSCITATION*

Gallows and Russels tractions need a spica apllication after 4-5 weeks*

*

Plate & screw fixationExternal fixationFlexible nailingRigid nailing*

First IM nailing but not lockingStraight nail with 3 point fixation*

Kempf I, Grosse A: Closed Interlocking Intramedullary Nailing. Its Application to Comminuted fractures of the femur, 1985Locking IM nails in the 1980s*

*

Advantages rigid, technique familiar to most surgeons, allows early motion, favorable results reported in children with associated head injuries Disadvantages- large scar, possible refracture after plate removed, higher infection rate in some earlier series*

*

*

IV antibiotics, tetanus prophylaxisemergent irrigation & debridementskeletal stabilizationExternal fixation best option with severe soft tissue injurysoft tissue coverage*

Early :Shock

Fat embolism and ARDS

Thromboembolism

Late :Delyed or non union

Malunion

Joint stiffness

Refracture and implant failure*

*

Most common long bone fracturesIsolated tibial fracture 23 %Both tibia and fibular fractures 77 %77 % of tibial fractures are closed23 % are open fractures

*

Patient Assessment1.Polytrauma ?2.Open injury ?3.Vascular compromise ?4.Neural injury ?5.Safe to cast ?*

RTA 37 %Sports 25 % Assaults 5 %Falls rest Direct voilence due to RTA (common ) , fall , assault , etc. Open fractures are common Indirect voilence due to falls , twisting force due to sports injuries .*

Grades of severity 1 minor

2 moderate

3 major FeaturesUndisplacedNot angulatedMinor comminutionMinor open fracture

Total displacementSmall degree of comminutionMinor open wound

Complete displacementMajor comminutionMajor open fracture*

*

Pain DeformityInvestigation :Acute cases : AP and Lateral viewDelayed cases : AP ,Lateral and oblique view showing knee joint and ankle joints*

*

Conservative management : -Closed reduction under general anaesthesia and a long leg cast application Indication : Closed fracturesUndisplaced fractureLow energy traumaYoung adults# with minor or moderate displacements*

Acceptable Alignment < 5 degrees varus-valgus angulation< 10 degrees anterior/posterior angulation> 50% cortical apposition< 1 cm shortening< 10 degrees rotational alignmentif displaced performclosed reduction under general anesthesiaHigh risk of shortening with oblique fracture patterns*

Fixation of Diaphyseal FracturesSURGICAL OPTIONS*

Fixation of Diaphyseal FracturesCOMBINED IMPLANTS*

External FixationMost open fracturesAll delayed contaminated fracturesClosed fractures with severe skin injuryInfected fracture/non-unionSegmental bone transportINDICATIONS*

External FixationSevere soft tissue injuryRole of primary/delayed flap cover

Grade IIIB fracturesWork closely with plastic surgeonRisks of exchange to plate or nail*

Role of AmputationPre-existing PVDAvulsions/Blast injuryToxic Crush SyndromeHeavy farm soil contaminationAmputation is not failure of treatment !*

Intramedullary NailingMost closed fracturesSome (grade 1-2) open fracturesDelayed unionPathological fracturesSome lengthening proceduresINDICATIONS*

Intramedullary NailingSURGICAL TECHNIQUE: UTN*

PlatingMost closed fracturesSome open (grade 1-2) fracturesDelayed union in castNon-unionsMalunionsINDICATIONS*

Open PlatingSurgical approachesMedial placement devitalises leastLateral placement protects the plate*

Minimally-Invasive Plate Osteosynthesis (MIPO)Reduction aids (+/-)Fluoroscopy control (-)Number/Placement of incisions (?)CONSIDERATIONS*

Complications of PlatingPROBLEMDelayed UnionNon-UnionInfectionMalunionExposed plateRefractureSOLUTIONWeight-bearBone graftingExchange to ExfixLengthening/OsteotomyLocal/Distant flap ExfixReplate + bonegraft? Nail*

Summary1.Tibia is most commonly operated long bone2.Nailing most popular3.Plates most widely available & cheaper4.Biological plating behaves like nailing5.Plating still recommended over nailing in polytrauma and vascular injury6.Cast and Ex-fix still safe and reliable*

1. Dilindungi/ didiamkan saja(Protection alone)

*

2. Didiamkan dengan bidai dari luar, tanpa reduksi (Eksternal splinting without reduction)*

3. Reduksi tertutup dan diamkan (Closed reduction, following immObilization)*

4. Reduksi tertutup dg traksi kontiniu diikuti dg immobilisasi (Closed reduction by conuntinous traction followed by immobilization)

*

5. Reduksi tertutup diikuti dg penyangga fungsional (Closed reduction followed by functional fracture bracing)*

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Internal dan Eksternal, Plate dan Eksternal fiksasiWire dan Eksternal FiksaiPlate dan Nailingdll*

dr.Rika Susanti,SpF*

Keadaan terjadinya diskontinuitas jaringanDapat ditimbulkan oleh berbagai macam sebab*

KEKERASAN SERING KALI MENYERTAI TINDAK PIDANA. KARENANYA, PADA PEMERIKSAAN KORBAN KEJAHATAN, KITA SERING MENEMUKAN AKIBAT DARI KEKERASAN INI.*

PELBAGAI JENIS KEKERASAN

KEKERASAN BERSIFAT MEKANIKKEKERASAN TUMPULKEKERASAN TAJAMTEMBAKAN SENJATA API

KEKERASAN BERSIFAT ALAMLUKA AKIBAT APILUKA AKIBAT LISTRIK

KEKERASAN BERSIFAT KIMIAWILUKA AKIBAT ASAM KERASLUKA AKIBAT BASA KUAT*

LUKA AKIBAT KEKERASAN TUMPUL

LUKA LUKA MEMAR

LUKA LECET LUKA LECET JENIS TEKAN LUKA LECET JENIS GESER

LUKA ROBEK*

LUKA AKIBAT KEKERASAN TAJAM

LUKA TUSUK

LUKA IRIS/SAYAT

LUKA BACOK*

LUKA AKIBAT TEMBAKAN SENJATA API

LUKA TEMBAK MASUKLUKA TEMBAK MASUK JARAK JAUHLUKA TEMBAK MASUK JARAK DEATLUKA TEMBAK MASUK JARAK SANGAT DEKATLUA TEMBAK TEMPEL*

LUKA AKIBAT SUHU TINGGI LUKA AKIBATNYALA API LUKA AKIBAT BENDA CAIR PANAS

LUKA AKIBAT LISTRIK LUKA MASUK LISTRIK LUKA AKIBAT PETIR*

LUKA AKIBAT ASAM KERAS

LUKA AKIBAT BASA KUAT*

KEKERASAN PENYEBAB LUKA HUBUNGAN SEBAB AKIBAT LUKA DENGAN KEMATIAN

SAAT PERLUKAAN UMUR LUKA SAAT MASIH HIDUP ? KAPAN LUKA SETELAH MATI

CARA TERJADINYA LUKA PEMBUNUHAN BUNUH DIRI KECELAKAAN*

Gambaran luka yang objektifLokasi luka(regio dan koordinat)Bentuk dan ukuran lukaKeadaan tepi lukaKeadaan dasar lukaKeadaan sekitar luka*

Kekerasan tumpul yang mengenai permukaan tubuh menyebabkan kapiler bawah kulit terputus (akibat teregang melebihi elastisitasnya)Terjadi pengumpulan darah di bawah kulitTampak sebagai bercak, biasanya berbentuk bulat/lonjong*

Bila kekeran menekan kulit agak lama, maka darah yang semula terkumpul dapat terdorong kesamping, dan bercak justru terjadi di sekitar bagian yang terkena kekerasan dan memberikan cetakan negatif bentuk benda penyebab Marginal Haemorrhage*

*

Luka memar yang baru terjadi tampak sebagai bercak biru kemerahan dan agak menimbulProses penyembuhan menyebabkan warna bercak berubah menjadi kebiruan, kehijauan, kecoklatan, kekuningan dan akhirnya hilang saat terjadi penyembuhan sempurna*

Sembuh sempurna dalam waktu k.l 7-10 hari tanpa pengobatanDari warna dapat diperkirakan saat terjadinya kekerasan

*

Lokasitempat terkena kekrasanBila struktur bawah kulit rata/licin (pada dahi/daerah tulang kering) maka darah yang terkumpul dibawah kulit dapat mengalir ke tempat yang lebih rendah akibat gravitasiDapt terjadi pada organ dalam : contusio jar otak, paru atau ginjal*

Sering pada kasus : KLL,kecelakaan kerja, kasus pembunuhanJarang pada: bunuh diri*

Penekanan/pergeseran benda tumpul pada kulit luka lecetLuka lecet tekan penekanan yang menyebabkan terjadinya pemampatan epidermisLuka lecet geserPergeseran yang menyebabkan terkikisnya epidermis*

Tampak sebagai bagian kulit yang sedikit mencekung, berwarna kecoklatan

Bentukmemberikan gambaran bentuk benda penyebab luka*

Bagian yang pertama bergeser memberikan batas yang lebih rata, dan saat benda tumpul meningalkan kulit yang tergeser berbatas tidak rata.Tampak goresan epidermis yang berjalan sejajarDapat diketahui arah kekerasan penyebab*

LUKA LECET GESER*

Kerusakan sebatas epidermisDapat sembuh sempurna 10-14 hariDapat diperkirakan bentuk benda penyebab atau arah kekerasan

*

Akibat benda tumpulMenekan dan menggeser bagian kulitkulit teregangMelampaui elastisitas kulit kulit terputuscelah pada kulit *

Luka terbuka tepi tidak rata, pada salah satu sisi dpt ditemukan jejas berupa luka lecet tekanArah kekerasan dapat diketahui mulai dari daerah lecet tekan kearah luar dan pada sisi tepi ini kulit terangkat dari dasarnya*

Akibat kekerasan tajam yang mengenai kulit dengan arah kekerasan tegak terhadap permukaan kulitTepi luka rataPada saat benda tajam mengenai kulit, akan terbantuk celah pada kulit yang merupakan sudut lancip*

Pisau bermata dua kedua sudut lancipPisau bermata satubila arah tegak satu sudut lancip, satu tumpulBila arah miring bergerak ke arah mata pisau, punggung pisau tidak berperan membentuk luka kedua sudut lancip

*

Elastisitas kulit dalamnya luka tidak menggambarkan panjangnya pisauSering pada kasus pembunuhanPada bunuh diriditemukan luka percobaan yang dangkal dengan arah yang sejajar*

Akibat kekerasan tajam yang bergerak k.l sejajar dengan permukaan kulitPanjang luka jauh melebihi dalamnya lukaSering pada pembunuhan*

Akibat kekerasan tajam dengan bagian mata senjata yang mengenai kulit dengan arah tegakKedua sudut luka lancip dengan luka yang cukup dalamSering pada kasus pembunuhan*

Luka bakar akibat nyala apiMenimbulkan kerusakan kulit yang bervariasi, tergantung pada tingginya suhu dan lamanya api mengenai kulit*

Luka bakar ringan kelainan hanya pada tebalnya kulit, berupa eritema,vesikel atau bulaLuka bakar sedangkerusakan sudah melewati tebalnya kulitLuka bakar beratPengarangan jaringan/karbonifikasi *

Sering akibat kecelakaanDapat juga pada pembunuhan/bunuh diri dengan jalan membakar diri*

Benda padat panas kerusakan kulit terbatas, sesuai dengan penampang benda yang mengenai kulitBentuk luka sesuai dengan bentuk permukaan benda padatSering pada pembunuhan/kecelakaan*

Suhu cairan panas maksimal adalah pada titik didih kerusakan terjadi tergantung pada tingginya titik didih Cairan mengalir ke tempat yang rendahSaat mengalir benda cair akan melepaskan kalorinya sehingga makin lama, makin rendah suhunya, dan kerusakan terjadi akan makin ringan*

Sering ditemukan pada kecelakaan atau pada pembunuhan*

Benda beraliran listrik saat mengenai kulit, oleh tahanan yang terdapat pada kulit, akan menimbulkan panas yang dapat merusak kulit dalam bentuk luka bakar benda padatBesarnya panas yang timbul berbanding lurus dengan lamanya persentuhan, besarnya arus dan berbanding kuadrat dengan besarnya tahanan kulit*

Pada kulit basah, tahanan kulit menjadi sangat rendah sehingga panas yang timbul tidak meninggalkan kerusakan pada kulitArus listrik akan memasuki tubuh dan sepanjang perjalanannya akan menimbulkan gangguan*

Bila listrik yang masuk tubuh mengalir melewati medula oblongata pusat vital akan tergangguBila melewati daerah jantungirama sinus jantung terganggufibrilasi ventrikelBila melewati otot sela igakejang otot pernafasan*

Sering akibat kecelakaan

Bisa pembunuhan/bunuh diri jarang*

LUKA AKIBAT LISTRIK*

Terjadi akibat sambaran petir yang mengenai tubuh secara langsung maupun tidak langsungDalam petirlistrik bertenaga besar dan tegangan tinggiSaat tubuh tersambar, dapat terjadi ledakan udara yang juga akan menimbulkan kerusakan pada tubuh*

Tubuh yang tersambar petir memberikan gambaran pada kulit seperti cabang pohonarborescent markDapat terjadi pecahnya membrana timpani dengan perdarahan pada liang telingaPakaian compang camping dengan tepi yang terbakar*

*

Asam kuat bersifat higroskopisBila mengenai kulitmenarik air dari jaringankulit mengering dan mencekung, teraba kaku,warna coklat kehitamanKertas lakmus dapat ditunjukkan reaksi asam pada luka yang terjadi*

Ditemukan pada kasus pembunuhan, kecelakaan, bunuh diriBila asam kuat masuk melalui mulut terjadi kerusakan sepanjang saluran cerna dan dapat timbul perforasi*

Larutan basa kuat akan menembus dinding sel menimbulkan kelainan intra sel berupa reaksi penyabunanKulit pada daerah terkena basa kuat berwarna kelabu kekuningan dan menimbul serta licin pada perabaanKertas lakmusdapat ditunjukkan reaksi basa pada luka*

Sering ditemukan pada kasus kecelakaan maupun bunuh diriBila basa kuat masuk melalui mulutterjadi kerusakan sepanjang saluran cerna, dapat terjadi perforasi*

LUKA AKIBAT TEMBAKAN SENJATA API*

LUKA AKIBAT TEMBAKAN SENJATA API*

*

TERIMA KAS H*

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