FRAKTUR UMUM

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FRAKTUR

The golden rule is Treat the patient, not simply the part

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FRAKTUR
Putusnya hubungan kesinambungan/ diskontinuitas tulang dan atau tulang rawan
Fraktur tertutup :Bila kulit sekitar intak Fraktur terbuka :Bila ada luka, sehingga kemungkinan terjadi kontaminasi atau infeksi
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KLASIFIKASI
I. Berdasarkan hub dengan dunia luar :
1.Fraktur tertutup

2. Fraktur terbuka

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KLASIFIKASI
Gustillo Anderson :
I. Luka < 1 cm II. Luka 1 10 cm III. Luka > 10 cm A. Soft tissue coverage B. Bone exposed C. Neurovascular injury
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KLASIFIKASI
Gustillo Anderson :

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Fractures due to a traumatic incident

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
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Fatigue or stress fractures

Due to repetitive stress Most often seen in the tibia or fibula
or metatarsals, especially in atheletes, dancers and army recruits.

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Pathological fractures
Fractures 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 disposed

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

Transverse oblique or spiral, Impacted fracture Comminuted fracture

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Incomplete fracture

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

Greenstick fracture Compression fracture

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KLASIFIKASI
II. Berdasarkan garis
patah

1.Komplet

2.Inkomplet

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KLASIFIKASI
III. Jumlah garis patah

1. Simple

2. Komunitif
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3. Segmental
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KLASIFIKASI
IV. Arah garis patah

1. Transversal 2. Oblique 3. Spiral

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4. Kompresi
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KLASIFIKASI
V. Lokasi
1. Tulang Panjang
1/3 proksimal 1/3 tengah 1/3 distal Tulang Melintang 1/4 medial 1/4 lateral

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2.

KLASIFIKASI
VI. Dislokasi Fragmen
Undisplaced Displaced Fragmen tlg searah (ad latus) Fragmen tlg membentuk sudut (ad axim) Fragmen distal memutar (ad periferum)

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How fractures heal

Tissue destruction and haematoma
formation Inflamation and cellular proliferation Callus formation Consolidation Remodelling

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Stadium Penyembuhan Fraktur

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Healing by direct repair

Fractures of cancellous bone Fractures treated by rigid internal
fixation

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The time factor

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) FK UKI SMF Bedah

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Time table
Upper limb
Callus visible on x-ray 2-3 weeks

Lower limb
2 - 3 weeks 8 - 12 weeks

Union (fracture 4-6 weeks firm)

Consolidation (bone secure)

6-8 weeks

12 - 16 weeks

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Fractures that fail to unite

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
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Most fracture will unite provide the bone fragments are

Placed in contact with each other and Held more or less immobile until new
bone formation is apparent

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Anamnesa
The fracture is not always at the site
of the injury

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ANAMNESIS
- Umur, jenis kelamin - Pendidikan
rumah - Riwayat trauma:
Arah Jenis

- Pekerjaan - Lingkungan

- Lokalisasi nyeri

- Gangguan fungsi
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Examination
General signs
A 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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Look
Swelling, bruising, Deformity Skin intact ?

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Feel
Local tenderness Examine distal to the fracture in order
to feel the pulse and test the sensation Compartement syndrome ?

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Move
Crepitus 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 Fisik
Move :
Nyeri gerak Sensorik Motorik
aktif pasif

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Special imaging
Tomography CT- scan MRI Radioisotope scanning

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

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PRINCIPLES OF FRACTURE TREATMENT

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First aid
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
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Assesment in hospital

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
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Definitive treatment of closed fracture

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

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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 reduction
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

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Reposisi

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Reposisi
Keberhasilan dinilai dari : Alignment Contact > 50 % Rotation (-) Discrepancy (-) Sudut < 15
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Indikasi konservatif
Anak dalam masa pertumbuhan Impending infeksi Jenis fraktur tidak cocok untuk ORIF Toleransi operasi tidak baik Pasien menolak operasi

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Indikasi Operasi
Sukar reposisi tertutup Fraktur multipel Fraktur patologis Fraktur intra artikular

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HOLD REDUCTION
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

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Immobilisasi (mempertahankan reposisi)

Fiksasi eksterna
Gips Roger Anderson

Fiksasi interna
Plate + Screw K-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; complications
INFECTION NON UNION IMPLANT FAILURE REFRACTURE

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OREF (open reduction external fixation) ; indications

# associated wih severe soft tissue
damage # associated with nerve or vessel damage Severely comminuted and unstable # # pelvis Infected #

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OREF ; Complication
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

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OPEN FRACTURE
EMERGENCY GOLDEN PERIOD 6 8 HO

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OPEN FRACTURE; assesment

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

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Fraktur Terbuka
Perbaiki KU Debridement, kultur/resistensi ATS-Toxoid, Antibiotik Tutup luka dengan kasa bersih Reposisi Imobilisasi
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ANTIBACTERIAL
Antibiotics : asap, combination ampicilline
and cloxacillin, given 6ho; if wound heavily contaminated, give gentamycin or metronidazole for 4-5 do

Tetanus prophylaxis

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TREATMENT OF WOUND
To cleanse the wound of foreign
material Remove devitalized tissue (debridement) 4 C : Colour Consistency Contractility Capacity of bleeding
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Complications of fracture

General complication

Shock Crush syndrome Venous thrombosis and pulmonary

embolism Tetanus Gas gangrene Fat embolism

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Complication involving # bone

Infection Delayed union and non union Malunion Growth disturbance Avascular necrosis

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Complication involving soft tissue

Vascular injury Compartement syndrome (Volkmanns
ischaemia) Nerve injury Visceral injury Myositis osificans

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Compartement syndrome
Arterial Damage ischaemia reduced blood flow painful pale pulseless paresthetic paralysed Direct Injury oedema

fasciotomy
incr comp pressure

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Complication involving joints

Joint stiffness Osteoarthritis Sudecks atrophy

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TERIMA KASIH

Created by : Tepeng

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