1. emergency ofthe fracture-kuliah int_dr. tedjo

EMERGENCY OFEMERGENCY OF

THE FRACTURETHE FRACTUREDr. Tedjo Rukmoyo, SpOT, Spine(K)

• Breath A

• Blood B

• Brain C

• Bladder D

• Bowel E

• Bone F

Primary Survey Identifies immediate lifethreatening

A. Airway ObstructionB. PneumathoraxC. HematothoraxD. Pericardialtemponade

Secondary Survey Assessmentidentifies limb threatening

- Evaluation occult hemorrhage- Other injuries

TRAUMA

DETERMINE SEVERITY OF THE INJURIESDETERMINE SEVERITY OF THE INJURIES

• Glasgow Coma scale

• Abbreviated injury score

• Triangle extremity severity score

GCSGCS

ABBREVIATED INJURY SCOREABBREVIATED INJURY SCORE

MESSMESS

INDICATION ABSOLUTE AMPUTATIONINDICATION ABSOLUTE AMPUTATION

• Rupture arteries > 6 hours

• Non reconstructable defect

• If further limb salvage Threaten life

INDENTIFICIES AS SOON AS POSIBLEINDENTIFICIES AS SOON AS POSIBLE

• Arterial disruption

• Nerve disruption

• Neurologic disturbances

ARTERIAL ARTERIAL FRYKMAN SIGNFRYKMAN SIGN::

• HARD SIGN:- Pulselessness- Massive bleeding- Rapidly expanding haematom- Palpable thrill- Audible bruit over haematom

• SOFT SIGN:- History of arterial bleeding- Non pulsatic haematom over artery- Neurologic deficit Adjacent artery- Proximity of wound Over artery

OTHER’S:OTHER’S:

• Acral pale• Hypothermia• Negative capillary refilling• Negative vena back flow• Oxymetri : < 80 – 90• Negative pulse on USG• Negative Blood on puncture• Ankle Brachial index < 0,9

DEFINITIVE EVALUATION OF DEFINITIVE EVALUATION OF ARTERIAL ARTERIAL DISRUPTION:DISRUPTION:

• Angiogram

• Exploration

Arterial Repair:- < 6 hours of injury- Don’t require both vessel- Should be coordinated with skeletal stabilization

COMPARTMENT SYNDROME:COMPARTMENT SYNDROME:

Osseo fascia pressure end Capillary perfusion

pressure < intracompartmental pressure:– Pain on passive stretching– Pale– Pulselessness– Paresthesia– Paralysis

TX: - Evaluation – elevation limb - Fasciotomy

Intracompartment pressure ≥ 30 mmHg Diastolic Pressure

NERVE INJURYNERVE INJURY

• Neuropraxia : Nerve stretch

• Axonotemesis : Partial destruction Axon

Epineurium intact

• Neurotmesis : Complete disruption

SPECIAL ATTENTION:SPECIAL ATTENTION:

Certain fractures pattern & Dislocation Nerve injury

• Anterior Gleohumeral dislocation- Axillary nerve• Humeral shaft fractures – radial nerve• Radial head fractures / monteggia fracture – posterior

interosseous nerve• Supracondylar humerus fractures – anterior interosseous

nerve• Hip dislocation – sciatic nerve• Knee dislocation – peroneal nerve – Tibial nerve

TX:TX:

• Neuropraxia : Conservative

• Axonotmesis : Conservative

Nerve Injury Rupture : Suture Epineurium

DISLOCATIONDISLOCATION

• Recognition

• Reduction

• Retention

• Rehabilitation

Evaluate : Neurovascular state

Emergency inEmergency inFractures & DislocationFractures & Dislocation

• Pain shock neurogenic / spinal• Shock hypovolemic bleeding

– Fr. Pelvis– Malgaigne fr.

• Dispneu - rib fracture- fr. Cervical- haemato/ pneumo thorax- fat emboli

• Disability: - infection open fracture- urinary retention fr. Pubis- neurogenic disturbance

• Dislocation of the head of humerus & femur

• Other dislocation, esp. spine

• Open fractures

• Ruptures tendo

• Ruptures ligament

FracturesFracturesDislocationDislocation

FracturesFracturesDislocationDislocation

DISABILITY

Treatment inTreatment inFractures & DislocationFractures & Dislocation

• Recognition

• Reduction

• Retaining

• Rehabilitation

Diagnostic of FracturesDiagnostic of Fractures

• Deformity

• False movement

• Crepitation

• X-ray / CT Scan

GENERAL PRINCIPLEGENERAL PRINCIPLE

1. Firstly, Do not Harm ≠ Iatrogenic complications

2. Base treatment on accurate diagnosis prognosis

TREATMENT:TREATMENT:

1. First Decision :- Require reduction ?- What type of reduction ?

- Open- Closed

2. Second Decision : Type of immobilization?- External- Internal

SPECIFIC AIMS OF FRACTURES SPECIFIC AIMS OF FRACTURES TREATMENTTREATMENT : :

• To relieve pain

• Obtain and maintain satisfactory position of fragmentation

• To allow & encourage bony union

• To restore optimum function

THE AIMING OF SPESIFIC METHODS OF THE AIMING OF SPESIFIC METHODS OF TREATMENT:TREATMENT:

• Union

• Function

• Anatomical alignment

SPECIFIC METHODS OF TREATMENT:SPECIFIC METHODS OF TREATMENT:

• Protection alone• Immobilization by external splinting• Closed reduction by manipulation• Closed reduction by continuous traction followed by

immobilization• Closed / open reduction followed by external fixation• Closed / open reduction – internal fixation• Closed reduction followed by bracing• Excision of fracture fragment and replacement by an

endoprosthesis

Protection AloneProtection Alone

Protection AloneProtection Alone

Immobilization Immobilization by External Splintingby External Splinting

Fractures treated with External Fractures treated with External Splinting without ReductionSplinting without Reduction

Closed Reduction by ManipulationClosed Reduction by Manipulation

Fracture can be treated by Closed Fracture can be treated by Closed Reduction followed by ImmobilizationReduction followed by Immobilization

Continuous Skin Continuous Skin TractionTraction

Continuous Skin Continuous Skin TractionTraction

Fractures can be treated by continuous Fractures can be treated by continuous tractiontraction

Must be Must be treated by treated by open open reduction – reduction – internal internal fixationfixation(ORIF)(ORIF)

Excision – Replaced by ProsthesisExcision – Replaced by Prosthesis