Professional Documents
Culture Documents
Management
Widiyatmiko
Introduction
Orthopaedics is
concerned with
bones, joints,
muscles, tendons and
nerves the skeletal
system and all that
makes it move
Introduction
Scope :
Congenital &
developmental
abnormalities
Tumours
Subdivision :
Traumatology
Orthopaedi :
1. Adult Reconstruction
2. Oncology
Orthopaedic
3. Pediatric Orthopaedic
4. Spine
5. Hand & Microsurgery
6. Sports Injury
In Emergency Room
Assess all trauma patient for possibility of orthopaedic case!
If the patient need operation prepare as soon as possible!
1. Informed consent
2. Tell to fast at least 6 hours prior to op
3. Make IV line
4. Tetanus prophilactic
5. Antibiotic & analgetic
6. Blood check (SYSMEX for < 40 y.o, complete for > 40 y.o and < 14
y.o)
7. Urine check
8. Cross match & blood reservation in blood bank
9. EKG ( for > 40 y.o)
10. Chest X-Ray, with expertise for < 14 y.o
11. Complete the medical record ! (under resident supervision)
12. IPD or paediatric consultation ( for > 40 or < 14, sometimes no
need)
13. Anesthesiology consultation
Aphorism of Fracture
Management
1. Think before you start. Are you
treating the patient? Or merely the x
ray?
2. Think before you reduce. Have you
worked out how to do it? And how to
hold your reduction?
3. Think before you hold. Is your splint
necessary? Is it harmful?
4. Think before you operate. Are you
good enough? Are your facilities good
enough?
What is fracture ?
Fracture is a break or disruption in
the continuity of a bone.
Fracture divide in 2 types :
Closed fracture
Open fracture
Fracture Description
Anatomic location includes the name of the bone or the bones
involved.
Regional location diaphysis ,metaphysis ,epiphysis;
intraarticular or extraarticular and physis.
Directions of the fracture lines transverse ,oblique and
spiral.
Conditions of the bone comminution # ,pathological #
,incomplete # ,segmental # ,fracture with bone loss ,fracture with
butterfly fragment ,stress # and avulsion #
Extent Fracture may complete or incomplete
Relationship of the fracture fragments to each other
undisplaced or displaced
eg:translated,angulated,rotated,distracted,overriding and
impacted.
Neurological examination
Diagnostic imaging
Blood Test
Synovial fluid analysis
Bone biopsy
Arthroscopy
Electro diagnosis
Children Fracture
1.
2.
3.
4.
5.
6.
7.
8.
9.
Adult Fracture
1.
2.
3.
4.
5.
6.
7.
8.
9.
CLOSED FRACTURE
The fracture is not exposed to
the
external environment.
TREATMENT
Protection Alone without
reduction or immobilization
Immobilization by External
Splinting without reduction
Closed Reduction by Manipulation
Followed by Immobilization
Closed Reduction by Continuous
Traction Followed by
Immobilization
Closed Reduction Followed by
Functional Fracture Bracing
TREATMENT
Closed Reduction by manipulation
Followed by External Skeletal
Fixation
Closed reduction by Manipulation
Followed by Internal Fixation
Open Reduction Followed by
Internal Skeletal Fixation
Excision of a Fracture Fragment
and Replacement by an
Endoprosthesis
OPEN FRACTURE
The fracture is exposed to the
external environment.
The amount of soft tissue
destruction is related to the
level of energy imparted to the
limb during the traumatic
episode.
Describe with GustilloAnderson grading system.
OPEN (COMPOUND)
FRACTURES
Goals
Prevention of infection
Healing of the fracture
Restoration of function
Steps in management
ABC included resucitation and
immobilisation
Assess neurovascular status of
the limb
Swab wound
Photograph & Cover wound
Tetanus prophylaxis
Give IV antibiotics
WHAT IS POLYTRAUMA ?
Objectives
Establish the principles for assessing
the patient with musculoskeletal
injuries.
Establish treatment priorities.
Identify the importance of
musculoskeletal injuries in the
multiply injured patient.
Emergency in Orthopaedic
Emergency : trauma cases
- Life threatening
- Limb treatening
85 % of blunt trauma
affect musculoskeletal
system
Life saving before limb
saving
Key Questions
How do musculoskeletal injuries
impact on the primary survey?
What are my priorities?
What are my management
principles?
Primary survey
management
The 3 Ss
Stop the bleeding!
Splint the extremity
Stabilize the pelvis
Secondary Survey
History
AMPLE
Secondary
Survey
Look
Feel
Listen
For What?
For What?
Look
Deformity
Pain
Tenderness
Wound(s)
Feel
Crepitus
Skin flaps
Neurologic
deficit
Pulses
Listen
Doppler signals
Bruit
Life- Threatening
Injuries
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
Posterior pelvic structures disrupted
Pelvis open : vessels, nerves,rectum,
skin
Mechanism of injury
Motorcycle
Pedestrian
Crush
Falls > 12 feet (3.6 meters)
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive
Bleeding
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive
Bleeding
Pelvic
Wrapping
Life Threatening
Musculoskeletal Trauma
Main Arterial Rupture
1. Trauma
- sharp, blunt
2 Examination
- Artery pulse, Doppler
- Ankle / brachial index
3. Management
- Pneumatic tourniquet
- Vascular clamp?
- Traction, Splint
Life Threatening
Musculoskeletal Trauma
Crush Syndrome
Myoglobinuria
Metabolic acidosis, K,
Ca and coagulopathy
Compartment syndrome
IV fluids, alkalization of
urine
Limb- Threatening
Injuries
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Classifying the injury
Gustilos classification (Gustilo et al,
1990)
Open Fracture
grade 3C
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Principles of treatment
Objectives :
- Prevention of infection
(sepsis/osteomyelitis)
- Promote bone healing
- Restoration of function
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Principles of treatment
4 essentials are :
1. Wound irrigation & debridement
2. Antibiotic prophylaxis
3. Stabilization of the fractures
4. Early wound coverage
Open Fracture
Complicated
case
Not proper initial management
Limb Threatening
Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation
Reduce fracture(s)
Splint fracture(s)
Assess by Doppler
Obtain consult (time
is critical)
Consider
angiography
Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Fractures of the arm or leg
ischemia
Infarcted muscles fibrous tissue
(Volkmanns ischemic contracture)
Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Clinical features
Elbow, forearm bones, 1/3
prox. of tibiae, multiple
fractures of the foot or hand,
crush injuries &
circumferential burns
Five Ps
The presence of a pulse does
not exclude the diagnosis
Be careful in unconscious
patient !
Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Treatment
Decompression
Open fasciotomi
Limb Threatening
Musculoskeletal Trauma
Dislocations
Neurologic Injury
Limb Threatening
Musculoskeletal Trauma
Massive skin avulsion
Abdominal flap
following skin avulsion
of the hand
Kelirumologi in Fracture
Management
Pitfalls
Occult injuries
Occult blood loss
Compartment syndrome
Question
Summary