Dr Rahadyan Magetsari Ph.D., Sp.OT., FICS.

1
Penanganan Trauma Muskuloskeletal
dan Imobilisasi

Yudha Mathan Sakti

Orthopaedi & Traumatologi

FK UGM / RS DR Sardjito
Jogjakarta
What should we do ??
B
= Breathing D =dissability

A = Airway

C =circulation
 Do the ATLS Procedure

A : Airway C Spine control

Musculoskeletal trauma
B
C
: Breathing
??
: Circulation
+ Oxigenation
Control bleeding
D : Dissability
E : Environment
and exposure
 Examples :

Re Check the B and C !!

A = Airway
A = Airway + C spine control
 B = Breathing + oxigenation
Assess the thoracal
condition !!
Inspection:
Jejas, luka terbuka, Ketinggalan gerak,
flail movement

Palpation :
Vokal fremitus, asimetris?

Percussion :
Sonor ?, dullness

Auscultation :
Vesicular, asimetris ?
C = Circulation + Control bleeding

Management :
Systemic, local and observation
 simultaneously
 D = Dissability

VS
AVPU system ?

E = Exposure and environment

Expose all body part but still prevent hypothermia
 ???
Betul / tidak
 Do the ATLS Procedure

A : Airway C Spine control

B
C
: Breathing
: Circulation
+ Oxigenation
Control bleeding
D : Dissability
E : Environment
and exposure

Musculoskeletal trauma ??
Management of musculoskeletal trauma

 Skeletalsystem provides
support and form
 Also provides some
protection to vital
organs against injury

 Precipitates movement
 Muscles would not be able
to perform without skeletal
support & connection
 Types of musculoskeletal injury

 Fracture
 Loss of bone discontinuity

 Dislocation
 Disruption of a joint

 Sprain
 Joint injury with tearing of ligaments

 Strain
 Stretching or tearing of a muscle
 Types of musculoskeletal injury

Hard tissue injury Soft tissue injury

Tulang / Bukan Tulang
Hubungan antar tulang
- Kutis
- Sub kutis
- Lemak
- Tendon (urat)
- Ligamen
- STRUKTUR
NEUROVASKULER
 How to DIAGNOSE

Diagnosis cedera
musculoskeletal Anamnesis

Pemeriksaan Fisik

Penunjang (X ray)

Identifikasi DIAGNOSIS dan PENYULIT

 How to DIAGNOSE
(Pemeriksaan Fisik)

Diagnosis cedera - Deformitas

musculoskeletal - Swelling
- Shortening (pemendekan)
- Luka terbuka
(keterlibatan tendon?)
Look

Feel

Move
 How to DIAGNOSE
(Pemeriksaan Fisik)

- Tenderness
Diagnosis cedera - Krepitasi
musculoskeletal - False movement
- NEUROVASKULER
disturbance (NVD) !!!

Look

Feel

Move
 How to DIAGNOSE
(Pemeriksaan Fisik)

Diagnosis cedera
musculoskeletal

Look
- Pastikan pergerakan sendi
proksimal dan distal lokasi
Feel cedera
.....

Move  Keterlibatan bagian lain

 How to DIAGNOSE
(Pemeriksaan Penunjang)

Pemeriksaan
radiologis

Two Joint = 2 sendi

Two view = 2 posisi

Rule of 2
Two side = 2 sisi

Two ocassion = 2 waktu

Fracture Types
 Kominutif Transversal

Spiral Oblique Transverse

• FRAKTUR
• DISLOKASI
• FRAKTUR – DISLOKASI

•RUPTUR TENDO
•TRAUMA PD SARAF PERIFER

24
Diskontinuitas struktur tulang

19-Sep-16 25
Fr dapat dibagi menurut :
•Menurut ltk anatomi :
ephipisis
ephypiseal plate
metaphisis
diaphisis

•Menurut ltk garis fr :

1/3 proksimal
1/3 tengah
1/3 distal
19-Sep-16 26
•Menurut jenis :
komplit
inkomplit : buckle fr
greenstick fr

•Menurut garis fr :
transver
obliqe
spiral
segmental
komunitiva
19-Sep-16 27
•Menurut hubungan dgn dunia luar :
fr tertutup
fr terbuka

Beberapa istilah :

fr compresi
fr impacted
fr patologis
fr intraarticular
fr avulsi
fr dislokasi
fr dengan komplikasi
19-Sep-16 28
Kominutif Transversal

Spiral Oblik
19-Sep-16 29
Segmental Impacted

Kompresi Avulsi
19-Sep-16 30
Fraktur intraartikuler

Fraktur - dislokasi Fraktur komplikasi

19-Sep-16 31
 PENYEBAB FRAKTUR

TRAUMA FATIQUE PATOLOGIS

• Direct
• Indirect

Bone Cyst

19-Sep-16 32
 DIAGNOSIS FRAKTUR

RIWAYAT GBR. KLINIS RADIOLOGIS

• TRAUMA • UMUM
• P. LAIN • LOKAL
- LOOK
- FEEL
- MOVE
19-Sep-16 33
PENGUKURAN

19-Sep-16 34
PEMBACAAN FOTO RADIOLOGI

SECARA UMUM :
hari dan tanggal
posisi penglihatan
perbedaan jar keras dan lunak
mulai dari luar ke dalam
nilai kelainan ortopedinya

19-Sep-16 35
Pada fr yang dinilai :
aposisi dan panjang
angulasi
displacement
rotasi

Pada dislokasi :
jauhnya terlepas :
subluksasi
luksasi
adanya fraktur ?

19-Sep-16 36
 Pembacaan setelah reposisi dan fiksasi

Perubahan pada posisi :

angulasi < tidak lebih dari 5 –10 derajat>
rotasi < 0 derajat >
aposisi < llebih dari 50 derajat >
pemendekan tidak ada < kec pada anak>

Posisi dari ostoesynthesis : K wire,K nail,plate &

srew dll

Tanda-tanda penyembuhan fr atau komplikasinya:

callus
mal union atau non 19-Sep-16
union 37
 PERGESERAN FRAGMEN

Aposisi Angulasi

1. Lokasi fraktur
2. Fragmen distal

Rotasi
19-Sep-16 38
 PENYEMBUHAN FRAKTUR

1. Std. Destruksi / Hematom

2. Std. Inflamasi & Proliferasi sel
3. Std. Pembentukan kalus
4. Std. Konsolidasi
5. Std. Remodelling 1 2 3 4 5
Union Remodelling

Fraktur Konsolidasi
19-Sep-16 39
19-Sep-16 40
UNION
•Klinis
• Radiologis MALUNION

Komplikasi penyembuhan fr :

delayed union
malunion
non union : atropi
hypertropi

19-Sep-16 41
NON UNION

19-Sep-16 42
 PENATALAKSANAAN

1. Imobilisasi
2. Manipulasi / reposisi
a. Reposisi tertutup
b. Traksi •Thomas splint
• Bryant
• Hamilton Russel
3. Fiksasi :
- Dalam: osteosynthesis
- Luar : POP, external fixasi
4. Rehabilitasi
19-Sep-16 43
MANIPULASI PADA ANAK-ANAK

FRAKTUR RADIUS DISTALIS

(Distal Radial Fracture)

19-Sep-16 44
19-Sep-16 45
 CARA GIP

Stockingette Padding

PLESTER 19-Sep-16
SLAB 46
 Bryant ‘s / Gallow’s
traction

Buck Extension

19-Sep-16 47
 RUSSEL TRACTION

TRAKSI BERIMBANG
( SUSPENDED OR
FLOATING TRACTION )

19-Sep-16 48
Plate - screw

Fixasi External
Modifikasi
Luque

ORIF (OPEN REDUCTION AND INTERNAL FIXATION)

19-Sep-16 49
Gb klinis ex Fix Fixasi External

19-Sep-16 50
Compartment syndrome:
Gejala klinis :
5P
- Pain (nyeri)
- Pale (pucat)
- Pulseless
Compartment Syndrome
- Paresthesia pada fraktur supracondyler humerus
- Paralyzed

Penatalaksanaan :
- Pasca pemasangan gips
 Lepas gips
-Menurunkan tekanan intakompartemen :
 Fasciotomy

19-Sep-16 51
19-Sep-16 52
19-Sep-16 53
BATASAN FRAKTUR TERBUKA

a. Diskontinuitas jaringan tulang

b. Diskontinuitas jaringan lunak dan kulit
c. Berhubungan dengan dunia luar
 CLASIFICATION OF OPEN FRACTURE
According to Gustilo and Anderson 1976
Revision Gustilo et. al.1984

Type Description
I Low energy injury with minimal soft tissue damage and a small wound ( less than one
centimeter) ; The fracture typically occurs as an inside -to out puncture from underlying spike
of bone. Typically, there is slight comminution of the bone.
II A Transition between the low-energy type I and the high - energy type III fracture. This
type may have associated soft tissue lacerations one to ten long, slight or moderate
comminution, and no or slight periosteal stripping of bone fragments.
IIIA The most severe pattern of open fracture. But it’s having adequate covarage with soft tissue
despite extensive soft tissue lacerations or flaps or injury reflecting high energy trauma, such
as extensive osseous comminution, segmental fracture pattern, or extensive soft tissue injury
(irrespective of the size of the wound) or combination of any these. Open fracture that occur
in an environment that predispo to extensive bacterial contamination, such as a baryard setting
or a public waterway
III B The most severe pattern of open fractures with extensive soft tissue injury, periosteal stripping
and expose bone. The problem is periosteal stripping with adequate muscle covarage of the
bone (it should be classified III A or III B) our decision it should if we need local or distant
flap covarage of areas of exposed bone.
III C The fracture is associated with a vascular injury that require repair for the limb-salvage.
A tibial fracture with only an isolated injury of the anterior or posterior tibial artery should not
be considered type III C
19-Sep-16
(Description revision 1998) 55
DIAGNOSIS
I. RIWAYAT

II. PEMERIKSAAN FISIK

LOOK
FEEL
MOVE
III. PEMERIKSAAN RADIOLOGIS
PNEUMATISASI

19-Sep-16 56
PENATALAKSANAAN Golden Periode

1. LIVE SAVING & LIVE LIMB

2. PRELIMINARY ASSESSMENT
3. ANTIBIOTIK
IRIGASI
DEBRIDEMEN
• PRIMARY REPAIR / DELAYED
• AMPUTASI ?
TIPE I / II = FRAKTUR TERTUTUP
III = FIKSASI LUAR

19-Sep-16 57
19-Sep-16 58
19-Sep-16 59
Gb klinis ex Fix Fixasi External

19-Sep-16 60
FRAKTUR PADA ANAK-ANAK

19-Sep-16 61
ANATOMI TULANG ANAK

• Ephiphyseal plate

• Epiphysis

• Periosteum

19-Sep-16 62
BIOMEKANIK
1.Traumatik Bowing
2. Fraktur Buckle
3. Fraktur Grinstik
4. Fraktur komplit

Bengkok F. Buckle

F. Grinstik F. Komplit
19-Sep-16 63
 FRAKTUR KOMPLIT

Spiral Oblik

Transversal Butterfly

19-Sep-16 64
EPIFISIOLISIS
( Salter - Haris 1963)

Tipe I Tipe II Tipe III

Tipe IV

Tipe V

19-Sep-16 65
TYPE DESCRIPTION CHARACTERISTICS

I Transverse fractures throught younger children

physis
II Fractures through physis with Children > 10 years
with metaphyseal fragment
III Fractures through phyis Intra-articular
and epiphysis
IV Fractures through epiphysis, physis Migration/growth arrest
and metaphysis
V Crush injury of physis Growth arrest late
VI Injury to perichondrial ring Bridging / angular
deformity

19-Sep-16 66
KLASIFIKASI PETERSON
Metafisis
Fisis
Metafisis Fisis Epifisis
I II III IV V VI

Metafisis Epifisis Fisis Missing

fisis Fisis

19-Sep-16 67
TRAUMA CINCIN PERIKHONDRAL

Osteochondroma

Angulasi

SH Tipe VI

19-Sep-16 68
FRAKTUR EPIFISIS

AVULSI FR. KOMPRESI

FR. OSTEOKHONDRAL

19-Sep-16 69
FISIOLOGIS

HUKUM WOLF

19-Sep-16 70
PENATALAKSANAAN

Diagnosis

Terapi

19-Sep-16 71
KONSERVATIF

19-Sep-16 72
TRAKSI

19-Sep-16 73
U-SLAB AND VELPAUE BANDAGE

19-Sep-16 74
 OPERATIF
INDIKASI
1.Tindakan manipulasi reposisi tertutup gagal

2. Fraktur antebrakhii anak muda

3. Fraktur tibial spine (tuberositas tibie)

4. Fraktur radial neck (kolum radial)

19-Sep-16 75
 FRAKTUR PADA MANULA

FRAKTUR COLLES
OSTEOPOROSIS
FRAKTUR KOLUM FEMORIS

19-Sep-16 76
 VERTEBRAE

HIP

COLLES

AGE GROUP (YEARS)

19-Sep-16 77
BATASAN OSTEOPOROSIS

Decreased Bone Deasity Mass

1. Osteoporosis primer
Tipe 1.
Tipe 2.
2. Osteoporosis sekunder
3. Osteoporosis idiopatik

19-Sep-16 78
PERMASALAHAN

1. CONFUSION & DISORIENTATION

2. REHABILITASI

3. REST

4. OBESITAS

5. SOCIAL WORKERS

19-Sep-16 79
PENATALAKSANAAN

• STABILISASI FRAKTUR

•MENCEGAH KOMPLIKASI

• REHABILITASI

19-Sep-16 80
PENCEGAHAN

1. OSSEOUS OSTEOPOROSIS

2. EXTRA OSSEOUS
Umum
Khusus
Lingkungan

19-Sep-16 81
TRAUMA SENDI/ DISLOKASI

19-Sep-16 82
 • Jenis Sendi
STABILITAS • Otot
SENDI
• Ligamen

19-Sep-16 83
TERMINOLOGI TRAUMA SENDI

1. Kontusi
2. Sprain
3. Occult joint instability
4. Subluksasi / dislokasi

19-Sep-16 84
TERMINOLOGI TRAUMA SENDI

5. Fraktur - dislokasi
6. Dislokasi -
8. Dislokasi buttonhole
9. Subluksasi residual

19-Sep-16 85
 DIAGNOSIS TRAUMA SENDI

1. Riwayat : terlepasnya sendi

2. Pemeriksaan fisik
LOOK
FEEL
MOVE
3. Pemeriksaan radiologis

19-Sep-16 86
Dislokasi Posterior Hip Joint

19-Sep-16 87
Penatalaksanaan

Stimson (gravity)

Allis technique
Dislokasi Anterior Hip Joint

19-Sep-16 89
Dislokasi Anterior ShoulderJoint

19-Sep-16 90
Penatalaksanaan

Traction and counter traction

Stimson (gravity)

Kocher method
Immobilization on
Velpeau bandage 19-Sep-16
Dislokasi : merupakan kasus emergensi!!
Komplikasi akut :
- Pendesakan pada struktur neurovaskuler
- Mencegah terjadinya komplikasi kronik

Komplikasi kronis :
- Ireducible dislocation
- Cedera vaskuler  amputasi
- Kerusakan permanen pada syaraf

19-Sep-16 92
TRAUMA NERVUS PERIFER

19-Sep-16 93
KLASIFIKASI TRAUMA PERIFER

1. Iskhemi
2. Neuropraksia
3. Aksonotmesis
4. Neurotmesis

Penyebab :
trauma tajam
trauma tumpul
taruma tarikan

19-Sep-16 94
DIAGNOSIS
1. Gejala klinis
• Paralisis flasid
• Sensation
• Temperatur
2. Pemeriksaan tambahan
• Tes elektris
• Nerve conduction test
• Strength duration curve
• electromyography
19-Sep-16 95
PENATALAKSANAAN

1. Trauma terbuka
2. Trauma tertutup
3. Sisa paralisis

19-Sep-16 96
19-Sep-16 97
 NERVUS RADIALIS

19-Sep-16 98
NERVUS MEDIANUS

19-Sep-16 99
NERVUS ULNARIS

19-Sep-16 100
19-Sep-16 101
TRAUMA PADA TENDON

PENYEBABNYA : TRAUMA TAJAM

PENATALAKSANAAN :
REPAIR PRIMER
REPAIR SEKUNDER
DELAYED REPAIR
TENDON GRAFT

19-Sep-16 102
19-Sep-16 103
TRAUMA PADA PEMBULUH DARAH

TRAUMA TAJAM
TRAUMA LEDAKAN

HARUS SEGERA DI REPAIR

19-Sep-16 104