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FRAKTUR UMUM
DR. WAHYU EKO W, SPOT ORTHOPAEDI DAN TULANG BELAKANG RS BINA HUSADA

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FRAKTUR
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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
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I.

Berdasarkan hub dengan dunia luar :

1.Fraktur tertutup

2. Fraktur terbuka

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KLASIFIKASI
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I. II. III.

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

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KLASIFIKASI
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Gustillo Anderson :

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Fractures due to a traumatic incident


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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


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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
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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


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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 2.Inkomplet

1.Komplet

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III.

Jumlah garis patah

1. Simple

2. Komunitif
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3. Segmental

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IV.

Arah garis patah

1. Transversal 2. Oblique 3. Spiral


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4. Kompresi

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V.

Lokasi 1. Tulang Panjang 1/3 proksimal 1/3 tengah 1/3 distal 2. Tulang Melintang 1/4 medial 1/4 lateral

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KLASIFIKASI
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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


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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


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Fractures of cancellous bone Fractures treated by rigid internal fixation

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The time factor


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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)
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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
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12 - 16 weeks

Fractures that fail to unite


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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
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The fracture is not always at the site of the injury

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ANAMNESIS
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Umur, jenis kelamin - Pekerjaan Pendidikan - Lingkungan rumah Riwayat trauma:


Arah Jenis

- Lokalisasi nyeri

- Gangguan fungsi

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Examination
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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
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Swelling, bruising, Deformity Skin intact ?

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

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Move
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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
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Move :
Nyeri

gerak Sensorik Motorik

aktif pasif

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Bekas dukun
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Bekas dukun
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Xray
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Special imaging
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Tomography CT- scan MRI Radioisotope scanning

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RADIOLOGI
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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
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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
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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
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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
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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
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Keberhasilan dinilai dari : Alignment Contact > 50 % Rotation (-) Discrepancy (-) Sudut < 15

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

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HOLD REDUCTION
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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
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# 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
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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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Fr Collim Femur
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OREF ; Complication
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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
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EMERGENCY GOLDEN PERIOD 6 8 HO

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OPEN FRACTURE; assesment


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

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Fraktur Terbuka
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Perbaiki KU Debridement, kultur/resistensi ATS-Toxoid, Antibiotik Tutup luka dengan kasa bersih Reposisi Imobilisasi

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ANTIBACTERIAL
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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
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To cleanse the wound of foreign material Remove devitalized tissue (debridement) 4C: 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


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Infection Delayed union and non union Malunion Growth disturbance Avascular necrosis

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Complication involving soft tissue


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

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Compartement syndrome
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Arterial

ischaemia

reduced

painful

Damage

blood flow

pale
pulseless paresthetic paralysed

Direct Injury

oedema fasciotomy incr comp pressure

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Complication involving joints


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Joint stiffness Osteoarthritis Sudecks atrophy

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TERIMA KASIH

Created by : Tepeng

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