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FRAKTUR UMUM
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FRAKTURThe golden rule is Treat the patient, not simply the
part
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FRAKTURPutusnya hubungan kesinambungan/ diskontinuitas tulang
dan atau tulang rawan
Fraktur tertutup :Bila kulit sekitar intakFraktur terbuka :Bila
ada luka, sehingga kemungkinan terjadi kontaminasi atau infeksi
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KLASIFIKASIBerdasarkan hub dengan dunia luar :
1.Fraktur tertutup2. Fraktur terbuka
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KLASIFIKASIGustillo Anderson :Luka < 1 cmLuka 1 10 cmLuka
> 10 cmSoft tissue coverageBone exposedNeurovascular injury
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KLASIFIKASIGustillo Anderson :
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Fractures due to a traumatic incidentCaused 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 impactIndirect violence: forcible traction by a tendon or
ligament which literally pulls the bone apart
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Fatigue or stress fracturesDue to repetitive stressMost often
seen in the tibia or fibula or metatarsals, especially in
atheletes, dancers and army recruits.
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Pathological fracturesFractures may occur even with normal
stresses if the bone has been weakened (by a tumor) or if it is
excessivelly brittle (pagets disease)
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How fractures are disposedComplete fracturesThe bone is
compeletely broken into 2 or more fragments. Transverseoblique or
spiral, Impacted fractureComminuted fracture
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Incomplete fractureThe bone is incompeletely divided and the
periosteum remains in continuity.Greenstick fractureCompression
fracture
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KLASIFIKASIBerdasarkan garis patah1.Komplet 2.Inkomplet
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KLASIFIKASIJumlah garis patah1. Simple2. Komunitif 3.
Segmental
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KLASIFIKASIArah garis patah1. Transversal2. Oblique 3. Spiral 4.
Kompresi
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KLASIFIKASILokasi Tulang Panjang1/3 proksimal1/3 tengah 1/3
distalTulang Melintang1/4 medial1/4 lateral
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KLASIFIKASIDislokasi FragmenUndisplacedDisplaced Fragmen tlg
searah (ad latus)Fragmen tlg membentuk sudut (ad axim)Fragmen
distal memutar (ad periferum)
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How fractures healTissue destruction and haematoma
formationInflamation and cellular proliferationCallus
formationConsolidationRemodelling
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Stadium Penyembuhan Fraktur
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Healing by direct repairFractures of cancellous boneFractures
treated by rigid internal fixation
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The time factorRate 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 fasterAge (healing is almost twice as fast in children
as in adults)
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Time table
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Fractures that fail to uniteCauses of non unionDistraction and
separation of the fragmentsInterposition of soft tissue between the
fragmentsExcessive movement at fracture linePoor blood supply
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Most fracture will unite provide the bone fragments arePlaced in
contact with each other andHeld more or less immobile until new
bone formation is apparent
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AnamnesaThe fracture is not always at the site of the injury
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ANAMNESISUmur, jenis kelamin- PekerjaanPendidikan - Lingkungan
rumahRiwayat trauma:ArahJenis- Lokalisasi nyeri- Gangguan
fungsi
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ExaminationGeneral 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
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LookSwelling, bruising, DeformitySkin intact ?
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FeelLocal tendernessExamine distal to the fracture in order to
feel the pulse and test the sensationCompartement syndrome ?
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MoveCrepitus and abnormal movement may be present, but it is
more important to ask if the patient can move the joint distal to
injury
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Pemeriksaan FisikMove :Nyeri gerakSensorikMotorik aktifpasif
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Special imagingTomographyCT- scanMRIRadioisotope scanning
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RADIOLOGIRule of 2 :2 proyeksi2 sendi2 ekstremitas2 waktu
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PRINCIPLES OF FRACTURE TREATMENT
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First aidMake sure that the airway is clearIf there is a wound,
cover it with clean materialStop bleeding by local compressionGive
something for painIf the neck or the bak is injured, prevent
flexion which may damage the spinal cordIf there is
fracture,prevent movement
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Assesment in hospitalExamine the airway and treat asphyxiaMake
sure the patient can breatheNote the obvious haemorrhage and stop
itAssess the degree of blood loss and shockCheck for spinal cord
injuryLook for injuries of abdominal or pelvic visceraExamine for
the presence of fractures or dislocationLook for soft tissue
complications, especially nerve and vascular injuryArrange for an
x-ray
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Definitive treatment of closed fractureManipulation 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
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Reposisi 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
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Closed reductionThe distal part of limb is pulled in the line of
the boneAs the fragment disengage, they are repositionedAlignment
is adjusted in each plane
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Reposisi
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ReposisiKeberhasilan dinilai dari :AlignmentContact > 50
%Rotation (-)Discrepancy (-)Sudut < 15
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Indikasi konservatifAnak dalam masa pertumbuhanImpending
infeksiJenis fraktur tidak cocok untuk ORIFToleransi operasi tidak
baikPasien menolak operasi
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Indikasi OperasiSukar reposisi tertutupFraktur multipelFraktur
patologisFraktur intra artikular
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HOLD REDUCTIONIn 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
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Immobilisasi (mempertahankan reposisi)Fiksasi eksternaGipsRoger
AndersonFiksasi internaPlate + ScrewK-nail
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ORIF ; indications# 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
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ORIF; complicationsINFECTIONNON UNIONIMPLANT
FAILUREREFRACTURE
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OREF (open reduction external fixation) ; indications#
associated wih severe soft tissue damage# associated with nerve or
vessel damageSeverely comminuted and unstable # # pelvisInfected
#
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OREF ; ComplicationOverdistractionReduced load transmission
trough bone, which delays fracture healing causes osteoporosis (EF
shoul be removed after 6-8 wo,and replace)Pin tract infection
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OPEN FRACTUREEMERGENCYGOLDEN PERIOD 6 8 HO
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OPEN FRACTURE; assesmentIs circulation intact ?Peripheral nerve
intact ?State of skin arround the woundDoes the wound communicate
with # ?
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Fraktur TerbukaPerbaiki KU Debridement,
kultur/resistensiATS-Toxoid, AntibiotikTutup luka dengan kasa
bersihReposisiImobilisasi
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ANTIBACTERIALAntibiotics : asap, combination ampicilline and
cloxacillin, given 6ho; if wound heavily contaminated, give
gentamycin or metronidazole for 4-5 doTetanus prophylaxis
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TREATMENT OF WOUNDTo cleanse the wound of foreign materialRemove
devitalized tissue (debridement)4 C
:ColourConsistencyContractilityCapacity of bleeding
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Complications of fractureGeneral complication ShockCrush
syndromeVenous thrombosis and pulmonary embolismTetanusGas
gangreneFat embolism
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Complication involving # boneInfectionDelayed union and non
unionMalunionGrowth disturbanceAvascular necrosis
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Complication involving soft tissueVascular injuryCompartement
syndrome (Volkmanns ischaemia)Nerve injuryVisceral injuryMyositis
osificans
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Compartement syndromeArterial ischaemia reduced painfulDamage
blood flow pale pulseless paresthetic paralysedDirect oedemaInjury
fasciotomy
incr comp pressure
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Complication involving jointsJoint
stiffnessOsteoarthritisSudecks atrophy
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?
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TERIMA KASIHCreated by : Tepeng
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