Dr.iswahyudi SpB Trauma : mechanical damage to the body caused by an external force WHO : tahun 2020 kematian akibat trauma 8,4 juta (9,4%) > KLL ( Indonesia : 70% sepeda motor) : ◦ Peningkatan jumlah kendaraan ◦ Perilaku pengemudi ◦ Rendahnya pemakaian APD Trauma pada jaringan lunak : vulnus, perdarahan, kontusio, sprain, avulsi, gg pembuluh darah dan saraf Cedera pada tulang : ◦ Fraktur ◦ Dislokasi ◦ Fraktur dislokasi Prinsip penanganan : 1. Rekognisi 2. Reduksi /reposisi 3. Retaining (fiksasi/imobilisasi) 4. Rehabilitasi : mengembalikan kemampuan anggota yg sakit agar dapat berfungsi kembali Gejala klinis : riwayat trauma, nyeri dan bengkak di daerah yg patah, deformitas, nyeri tekan (look, Feel, Movement) X ray : ◦ 2 view (AP Lat) ◦ 2 Joints (sendi proksimal dan distal #) ◦ 2 sides (pembanding) Klasifikasi # ◦ Terbuka /tertutup ◦ Anak2 : lempeng pertumbuhan (epifise) > klasifikasi Shalter-Harris Fracture : structural break in bone continuity Description : ◦ Pattern : transverse, oblique, spiral ◦ Morphology : simple (2 parts)or comminuted(3 more parts), fragmented ◦ Location : proximal, middle, or distal; extra articular or intra articular ◦ Radiographic parameters : displacement, angulation, rotation, shortening, apposition. Pediatric fractures are classified according to their physical (growth plate) involvement ( Salter-Harris clasification) ◦ Type I : displaced or non displaced through growth plate ◦ Type II : small metaphyseal fragment ◦ Type III : intraarticular through epiphysis ◦ Type IV : through metaphysis and epiphysis ◦ Type V : severe crush to growth plate Management ◦ Physical examination : Look (L): inspect for soft tissue abnormality, deformity or asymmetry of the extremities. Turn the patients to the side (log roll) Fell (F): palpate bone and soft tissue to evaluate tenderness, crepitus, and firmness of compartment Movement (M) : test active and passive range of movement (ROM) to detect bony injury, ligamentous injury, or weakness Neuro vascular distal (NVD) : a neurovascular examination record quality of peripheral pulse, sensation ( pin prick, light touch) and motor function Emergent treatment of fracture or dislocation 1. Reduce the fracture or dislocation 2. Splint/ stabilize the extremity 3. Irrigate open fracture with saline and cover with sterile saline-soaked gauze 4. Administer parenteral antibiotics for open fracture or perioperatively in patient who requires orif 5. Administer tetanus prophylaksis if > 5 years since last dose for patient with open # or who require ORIF Definitive treatment of fracture or dislocations : the goal is to restore normal anatomy and function and relive pain as quickly as possible. The early reduction and internal fixation in the multiply injuried patient has reduced morbidity and mortality 1. Reduction : can be accomplished by either closed (external realignment) or open ( direct operative approach) 2. Immobilization of the extremity by splint, cast, traction, orthosis, external or internal fixation The most important measure in the care of open fracture are delivery antibiotic, extensive and appropriate debridement followed by skeletal stabilization. Prevention of infection is of paramount importance. Osteomyelitis is a devastating complication > loss function of limb. Antibiotic are not a substitute for effective debridement of necrotic and contaminated tissue Classification of open fracture (Gustilo and Andersen) 1. Type I : low energy, < 1 cm wound caused by protrusion of the bone through the skin, or a low velosity bullet 2. Type II : moderate energy, > 1 cm with flap or avulsion wound in the skin with minimal devitalized soft tissue and minimal contaminaiton Classification of open fracture ◦ Type III : high energy, extensive soft tissue injury (> 10 cm) “ barnyard injury” 1. III a : adequate soft tissue coverage, no vascular injury necessitating repair 2. III b : significant soft tissue loss with exposed bone that require tissue transfer for coverage 3. III c : vascular injury requiring repair for limb preservations. Amputation rates 25-50% Management after initial evaluation ◦ Open # require urgent operative debridement and irrigation, with the orthopedic standard within 6 hours if the patient is physiologically stable ◦ Wounds require repeated irrigation and debridement in the operating room (OR) every 48 to 72 hours until definitive stabilization and soft tissue coverage can be achieved (within 7 days of injury). Minimize multiple inspection of the wound out side the OR except by the surgeon making critical management of decisions. Continue antibiotics until 48 hours after definitive coverage ◦ A staged, planned redebridement may be necessary in open # with severe soft-tissue damaged Komplikasi patah tulang ◦ Segera Lokal Kulit dan otot : vulnus, kontusio, avulsi Vaskular : terputus, kontusio, perdarahan Organ dalam Nerologis : otak, medula spinalis, saraf perifer Umum : trauma multipel, syok ◦ Dini Lokal : nekrosis kulit, sindroma kompartment, osteomielitis ◦ Umum : ARDS, emboli paru, tetanus Komplikasi patah tulang ◦ Komplikasi lama Lokal Tulang : mal union, non union, delayed union. Osteomielitis, gg pertumbuhan, patah tulang rekuren Sendi : ankilosis, penyakit degeneratif sendi paska trauma Miositis osifikans Dsitrofi refleks Kerusakan saraf Umum : batu ginjal (immobilasi lama dan hiperkalsemi). Neurosis paska trauma Tanda dan gejala sindrome kompartement 1. Nyeri pada keadaan istirahat (pain) 2. Parestesia 3. Pucat (pale) 4. Paresis atau paralisis 5. Denyut nadi hilang (pulselessness) 6. Jari di posisi fleksi 7. Gangguan diskriminasi 2 titik (two points discrimination test) 8. Tekanan tinggi di dalam kompartement (pressure) Dislokasi sendi/luksasio : tergesernya permukaan tulang yg membentuk persendian terhadap tulang lainnya ◦ Lepas komplet (cerai sendi) ◦ Partial (dislokasi inkomplete, keseleo) Bila ligament / kapsul sendi tak sembuh dg baik > luksasio mudah terulang kembali : luksasio habitualis Dislokasi harus ditangani segera > nekrosis avaskular dan kekakuan sendi Dalam fase syok lokal (5-20 ‘) terjadi relaksasi otot sekitar sendi dan rasa baal (hipestesia) > bisa reposisi tanpa narkosis Reposisi tertutup dg anestesia : lakukan gerakan yg berlawanan dg gaya trauma, kontraksi atau tonus otot Mobilisasi setelah penyembuhan jaringan lunak (2-3 minggu paska cedera)