diagnosis of muskuloskletal_trauma-rev1.ppt
TRANSCRIPT
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DIAGNOSIS OF MUSKULOSKLETAL TRAUMA
Dwikora Novembri Utomo
Lab/SMF Orthopaedi & Traumatologi FK Unair-RS dr SutomoS U R A B A Y A
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TIU
• PADA AKHIR MODUL PPGD INI,MAHASISWA FK SEMESTER 5 AKAN MAMPU MERENCANAKAN AWAL SECARA MANUAL MAUPUN MENGGUNAKAN ALAT, OBAT PADA KEGAWATDARURATAN TRAUMA MUSKULOSKLETAL SECARA TEPAT,CERMAT ,CEPAT, SEBELUM TINDAKAN DEFINITIF /SPESIALISTIK DILAKSANAKAN.
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TIK
• MAMPU MELAKSANAKAN TATACARA PENANGANAN TRAUMA MUSKULOSKLETAL DENGAN CEPAT,CERMAT DAN CEPAT
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POKOK BAHASAN
1. DIAGNOSA TRAUMA MUSKULOSKLETAL2. JENIS TRAUMA MUSKULOSKLETAL a. TRAUMA MSK SEDERHANA b. TRAUMA MSK MENGANCAM JIWA c. TRAUMA MSK YG MENGANCAM EKSTREMITAS3. PERTOLONGAN BEDAH AWAL PADA TRAUMA
MSK4. HAL HAL YANG MEMPERBURUK PROGNOSIS5. INDIKASI KONSULTASI
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WHAT IS THE DIFFERENCE ?????
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Biomechanics of Fractures
E ( Energy Kinetic ) = ½ MV
Vm VM
mM
2
Pelvis
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• SOFT TISSUE INJURY : skin, subcutan fat,muscle, artery,venous, nerves etc
• BONE INJURY : broken bones
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DefinitionEmergency :
A situation that involves a potential disabling or life threatening condition.
Trauma :A physical wound or injury to living tissue caused by an
extrinsic agent
Fracture : discontinuity of cortex or cartilage
Dislocation : discontinuity of joint
luxation – subluxation
Multitrauma : emergency, life threatening more than one organ requiring immediate treatment intervention
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PRIMARY SURVEYThe ABCDEs of muskuloskletal
trauma care identify life threatening condition.
A. Airway maintenance w/ cervical spine protection
B. Breathing and ventilationC. Circulation w/ hemorrhage
controlD. Disability : neurological
statusE. Exposure : completely
undress but prevent hypothermia
life threatening conditions are identified and simultaneous management is instituted
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SECONDARY SURVEY
• Done after the patient “stable”
• Head to toe !
• Every orificiums/ every tubes!!
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Early Intervention on trauma/multitrauma patient (included MSK trauma problems)
• A Airway and cervical spine protection, protec the cervical : inline imobilisation,collar brace ( head injury,
• C Circulation w/ hemorrhage control (pelvic stabilisation
• D Disability, neurological status(GCS), paraparese or paralysis…..spine fractures suspected…..inline imobilisation!!!
• Exposure : deformity of extremity….imobilisation/splinting!!!
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Early Intervention on trauma/multitrauma patient (included MSK trauma problems)
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Early Intervention on trauma/multitrauma patient (included MSK trauma problems)
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The first step toward cure is to know what the disease is (latin proverb)
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Solving the mysteri of a diagnosis is the “detective work of medicine” (Sherlock
Holmes)
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How to diagnose the muskuloskletal trauma problems?
• CLINICAL HYSTORY(not for the multitrauma patients)
• PHYSICAL EXAM : LOOK, FEEL, MOVE,MEASUREMENT
• DIAGNOSTIC IMAGING
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MUSKULOSKLETAL TRAUMA PROBLEMS
• FRACTURES : Closed, Open
• DISLOCATIONS,FRACTURE-DISLOCATION
• SOFT TISSUE INJURIES :tendon rupture,muscle rupture w/ or w/o neurovascular lesion.
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FRACTURES
Close fracture •Open fracture•Compound fracture
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FRACTURES
• FRACTURES IS NOT ONLY LESION OF THE BONE
• DOCTORS MUST THINGS : BEYOND THE PICTURES!!!
• THE BONE : LOOKLIKE THE TREE WITH THE ROOT IS THE SOFT TISSUE !!
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FRACTURES
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FRACTURES
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DIAGNOSIS
• CLINICAL HISTORY (Not for multitrauma pts)
*WHEN (time) : golden periode
*HOW ..MOI (Mechanism of injury : Low velocity/High velocity trauma/trivial) !!!
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LOOK
• Deformity – Angulation -
Rotation
- DIscrepancy
– Position– Edema– Appearance of the
distal part• Pale• Darken
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LOOK
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• FEEL
–Crepitation
–Temperature of the distal part–Pulse
–Sensory
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FEEL (neurovasc exam)
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MOVE
–Active–Passive–Power–False
movement
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MEASUREMENT
• MEASUREMENT- discrepancy– True
length,Anatomical length
– Appearance length
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CLINICAL DIAGNOSIS
• “Patognomonis sign/definite sign” of fracture: deformity,false movement,
• From Clinical History,Physical Exam ,the clinical diagnosis of fracture is established,
• Investigation ( X RAY)…important for : “fracture configuration & planning of
definitive treatment” , prognosis.
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INVESTIGATION
• X-ray (Immobilization first)– 2 VIEWS (AP-lateral)– 2 JOINTS (proximal & distal)– 2 SIDES (IF Necessary)– Special order
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INVESTIGATION (X –RAY)
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• Open fracture communication between the fracture and the external environment
• 30% pts with OF are polytrauma patients.
• Require emergency treatment
• Significant morbidity
OPEN FRACTURES
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OPEN FRACTURES
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Grade I open fracture
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Grade II open fracture
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Grade III A open fracture
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GRADE IIIb open fract
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Grade III C open fracture
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AO Principles of Fracture Management, 2000, pp 671
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Gustilo, Burgess, Tscherne, the AO-ASIF group, recommended the following steps for open injuries: – Treat OF as emergencies – Initial evaluation to diagnose life & limb-threatening
injuries – Appropriate antibiotic tx in the emergency OR and
continue treatment for 2 to 3 days only – Immediately debride the wound of contaminated and
devitalized tissue, copiously irrigate, repeat debridement within 24 to 72 hours
– Stabilize the fracture with the method determined at initial evaluation
– Leave the wound open – Rehabilitate the involved extremity aggressively
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Principles of Management
• Prevention of infection• Soft tissue healing and bone
union• Restoration of anatomy• Functional recovery
AO Principles of Fracture Management, 2000,
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• Prevention of infection• Soft tissue healing and bone union• Restoration of anatomy• Functional recovery
• Golden 6 hours - Bacterial colonization and subsequent wound infection
• Once the skin barrier is disrupted, bacteria enter from the local environment and attempt to attach and grow
• Assess contamination - appropriate antibiotics• Radical Debridement - dead tissue is culture
media( can’t be replaced /prolonged GP by anykind of AB)
• Copious lavage > 10 litres - decrease bacterial load
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ORTHOPAEDIC INFECTION:Diagnosis and treatment,1989 pp8
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Debridement
• Radical• Wound extended
adequately for visual• Decompress tight
compartments• Copious lavage
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• Avoid further soft tissue damage reduce and splint fractures
• Zones of Injury - Repeated Debridement
• Gentle handling• Bony stability• Early coverage < 1 week• Delay closure
• Prevention of infection• Soft tissue healing and bone union• Restoration of anatomy• Functional recovery
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• Prevention of infection• Soft tissue healing and bone union• Restoration of anatomy• Functional recovery
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• Prevention of infection• Soft tissue healing and bone union• Restoration of anatomy• Functional recovery
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FRACTURES OF THE SPINEFRACTURES OF THE SPINE
Cervical Dislocation Thorax Dislocation
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Lumbar Fracture
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How to decide the level of injury? (based on clinical exam)
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SENSORY
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MOTOR
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REFLEX (PHYSIOLOGIC)
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REFLEX (PATOLOGIC)
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DISLOCATIONS
• All joint s are surrounded by a joint capsule and ligaments, a dislocation to occur, at least a part of capsule and its ligaments must be torn
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DISLOCATION
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COMPLICATION OF MUSKULOSKLETAL TRAUMA
1.DAMAGED OF NERVE OR SPINAL CORD
2. DAMAGED OF THE VASCULAR
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COMPLICATION OF MUSKULOSKLETAL TRAUMA
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COMPARTEMENT SYNDROME
• Compression of nerve & bloodvessels
• Within enclosed anatomic space (osteofacial)
• Leading to impaired bloodflow
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Pathophysiology
2 main pathways*
– Increasing fluid content within the
compartment (ex : haemorrhage,
oedema)
– Decreasing the compartment size
(ex : external compression)
* Whitesides, Acute compartment syndr, J Am Acad Orthop Surg 1996;4
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How to Diagnosed ?
• Mainly by clinical examination!!!
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Sign & Symptoms
Classic signs 5 P
– Pain
Severe extremity pain out of proportion to
injury
Early sign, worse with passively stretching
involved muscle
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– Paresthesia or anesthesia to light touch
– Paralysis
– Pulselessness
Not present in early cases
• Pallor
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LATE COMPLICATION OF FRACTURES
INFECTION IN OPEN FRACT
• Grade I less than 1%
• Grade II 1-10 %
• Grade III 10-50%
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SIMPLE MUSKULOSKLETAL TRAUMA
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LIFE THREATENING MUSKULOSKLETAL TRAUMA
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LIMB THREATENING MUSKULOSKLETAL TRAUMA
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FACTORS THAT MAKE THE PROGNOSIS BECOME WORSE
• Bad pre hospital management
* no imobilisation/splint
* improper transfer of patients (ex : to transfer spine fract w/o inline imobilisation)
*delayed transfer (over golden periode,under diagnosis of vascular injury)
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Pre Hospital
– Control :
Airway
Circulation
Immobilization
Transportation
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INDICATION OF CONSULTATION
• ALL FRACTURES & DISLOCATION ARE PATOLOGIC CONDITION.
• IMOBILISATION /SPLINT FIRST
• STRICTLY NO DELAY OF TRANSFERING PATIENTS W/ FRACT + NEUROVASCULAR INJURY, OPEN FRACTURES , DISLOCATION.
• DO NOT DO HARM
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SUMMARY
• 30% of OF ARE POLYTRAUMA PATIENTS.• FRACTURES IS NOT ONLY LESION ON THE
BONE.• EARLY INTERVENTION OF MSK TRAUMA
SHOULD BE DONE PROPERLY, FOR BETTER PROGNOSIS.
• TO KNOW THE BASIC KNOWLEDGE FOR MAKING DIAGNOSIS OF MSK TRAUMA IS MANDATORY BEFORE TREATING PATIENTS.
• DO NOT DO HARM
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REFERENCE
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