FRAKTUR UMUM

DR. WAHYU EKO W, SPOTORTHOPAEDI DAN TULANG BELAKANG

RS BINA HUSADA

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Laporan operasi•Pasien posisi supine dalam spinal anastesi•Prosedur steril dan driping•Debridement pada sendi•Amputasi cruris dekstra dengan arteri vena besar diligasi + potong tajam saraf •Cuci luka dan kontrol perdarahan •Jahit dengan satu buah dripingOperasi selesai.

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FRAKTUR

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Putusnya hubungan kesinambungan/ diskontinuitas tulang dan atau tulang rawan

Fraktur tertutup :Bila kulit sekitar intakFraktur terbuka :Bila ada luka,

sehingga kemungkinan terjadi kontaminasi atau infeksi

KLASIFIKASI

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I. Berdasarkan hub dengan dunia luar :

1.Fraktur tertutup

2. Fraktur terbuka

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Gustillo – Anderson :I. Luka < 1 cmII. Luka 1 – 10 cmIII. Luka > 10 cm

A. Soft tissue coverageB. Bone exposedC. Neurovascular injury

KLASIFIKASI

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Gustillo – Anderson :

Fractures due to a traumatic incident

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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

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Due to repetitive stress Most often seen in the tibia or fibula

or metatarsals, especially in atheletes, dancers and army recruits.

Pathological fractures

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

How fractures are disposed

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Complete fracturesThe bone is compeletely broken into 2

or more fragments. Transverseoblique or spiral, Impacted fractureComminuted fracture

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•Incomplete fracture

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

•Greenstick fracture

•Compression fracture

KLASIFIKASI

II. Berdasarkan garis patah

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1.Komplet

2.Inkomplet

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III. Jumlah garis patah

1. Simple 2. Komunitif 3. Segmental

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IV. Arah garis patah

1. Transversal

2. Oblique 3. Spiral 4. Kompresi

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V. Lokasi 1. Tulang Panjang

• 1/3 proksimal• 1/3 tengah • 1/3 distal

2. Tulang Melintang• 1/4 medial• 1/4 lateral

KLASIFIKASI

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VI. Dislokasi Fragmen Undisplaced Displaced

Fragmen tlg searah (ad latus) Fragmen tlg membentuk sudut (ad

axim) Fragmen distal memutar (ad

periferum)

How fractures heal

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Tissue destruction and haematoma formation

Inflamation and cellular proliferation Callus formation Consolidation Remodelling

Stadium Penyembuhan Fraktur

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Healing by direct repair

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Fractures of cancellous bone Fractures treated by rigid internal

fixation

The time factor

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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 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

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Fractures that fail to unite

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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

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Placed in contact with each other and

Held more or less immobile until new bone formation is apparent

Anamnesa

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The fracture is not always at the site of the injury

ANAMNESIS

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- Umur, jenis kelamin - Pekerjaan- Pendidikan - Lingkungan

rumah- Riwayat trauma:

• Arah• Jenis

- Lokalisasi nyeri - Gangguan fungsi

Examination

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General signsA 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

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Swelling, bruising, Deformity Skin intact ?

Feel

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Local tenderness Examine distal to the fracture in

order to feel the pulse and test the sensation

Compartement syndrome ?

Move

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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

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Move : Nyeri gerak Sensorik Motorik

aktif

pasif

Bekas dukun

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Bekas dukun

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Xray

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Special imaging

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Tomography CT- scan MRI Radioisotope scanning

RADIOLOGI

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Rule of 2 : 2 proyeksi 2 sendi 2 ekstremitas 2 waktu

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PRINCIPLES OF FRACTURE TREATMENT

First aid

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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

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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

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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

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Mengembalikan kedudukan tulang

Cara :

• Manual

• Traksi

• Operatif

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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

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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

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Reposisi

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Keberhasilan dinilai dari : Alignment Contact > 50 % Rotation (-) Discrepancy (-) Sudut < 15 °

Indikasi konservatif

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Anak dalam masa pertumbuhan Impending infeksi Jenis fraktur tidak cocok untuk ORIF Toleransi operasi tidak baik Pasien menolak operasi

Indikasi Operasi

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Sukar reposisi tertutup Fraktur multipel Fraktur patologis Fraktur intra artikular

HOLD REDUCTION

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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)

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Fiksasi eksterna Gips Roger Anderson

Fiksasi interna Plate + Screw K-nail

ORIF ; indications

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# 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

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INFECTION NON – UNION IMPLANT FAILURE REFRACTURE

OREF (open reduction external fixation) ; indications

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# associated wih severe soft tissue damage

# associated with nerve or vessel damage

Severely comminuted and unstable # # pelvis Infected #

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Fr Collim Femur

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OREF ; Complication

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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

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EMERGENCY GOLDEN PERIOD 6 – 8 HO

OPEN FRACTURE; assesment

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Is circulation intact ? Peripheral nerve intact ? State of skin arround the wound Does the wound communicate with

# ?

Fraktur Terbuka

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Perbaiki KU Debridement, kultur/resistensi ATS-Toxoid, Antibiotik Tutup luka dengan kasa bersih Reposisi Imobilisasi

ANTIBACTERIAL

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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

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To cleanse the wound of foreign material

Remove devitalized tissue (debridement)

4 C : ColourConsistencyContractilityCapacity of bleeding

Complications of fractureGeneral complication

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Shock Crush syndrome Venous thrombosis and pulmonary

embolism Tetanus Gas gangrene Fat embolism

Complication involving # bone

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Infection Delayed union and non union Malunion Growth disturbance Avascular necrosis

Complication involving soft tissue

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Vascular injury Compartement syndrome (Volkmann”s

ischaemia) Nerve injury Visceral injury Myositis osificans

Compartement syndrome

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Arterial ischaemia reduced painful

Damage blood flow pale

pulseless

paresthetic

paralysed

Direct oedema

Injury fasciotomy

incr comp pressure

Complication involving joints

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Joint stiffness Osteoarthritis Sudeck’s atrophy

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TERIMA KASIH

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Created by : “ Tepeng “

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