MUSCULOSKELETAL TRAUMADr. Nur Rachmat Lubis, SpOT

FRACTURE & DISLOCATIONFRACTUREDefinition :A fracture, whether of a bone, an epiphyseal plate or a cartilaginous joint surface, is simply a structural break in its continuity.

must be consider : surrounding soft tissue around the fracture site

Physical factors in the Production of FracturesCortical Bone: can withstand compression and shearing forces better that it can withstand tension forces

2. Cancellous Bone/ spongious:Cant withstand compression. Can produced: Crush # / compression # Impacted #

Descriptive Terms Pertaining to FracturesFracture site :DiaphysealMetaphysealEpiphyseal

2. Extent of Fracture:completeIncomplete

3. Configuration of #:1. Transverse2. Oblique3. Spiral4. Comminuted1234

4. Relationship of the Fracture Fragments to Each Other :UndisplacedDisplaced :1. Overriding2. Angulated3. Rotated4. Distracted5. Impacted6. Shifted sideways

Relationship of the fracture fragments to each other caused by : Effects of Gravity Effects of muscle pull on the fragments

5. Relationship of the Fracture to the External Environment: Closed # Open #:Fracture fragment has penetrated the skin ( from within)Sharp object has penetrated the skin to # the bone (from without)6. Complication : Uncomplicated Complicated:Local : InfectionSystemic : Emboli, Sepsis

THE DIAGNOSIS OF FRACTURESHISTORY :Fall, Direct Trauma.Mechanism of injury.Common symptom of # :Localized pain.Decreased function of the involved part.

THE DIAGNOSIS OF FRACTURESPHYSICAL EXAMINATION:INSPECTION ( LOOKING ):Swelling ( edema )Deformity( angulations, rotation, shortening )Abnormal movementEchymosis( subcutaneous extravasations of blood )PALPATION ( FEELING ) :Localized tenderness at the # site.Crepitus (not necessary)RANGE OF MOVEMENT (ROM):Limitation.

THE DIAGNOSIS OF FRACTURES!!!! CAREFULL ASSESSMENTPatients General ConditionSearch for associated injuries:BrainSpinal CordPeripheral NervesMajor vesselsThoracesAbdominal viscera

THE DIAGNOSIS OF FRACTURESRADIOGRAPHIC EXAMINATION:# : PHYSICAL EXAMINATIONConfirmation by X-Ray Accurate DiagnosisTo determine extent and configuration of the fracture.Include entire length of the bone and the joints at each end.2 Projection : AP / Lat, particularly obliqueSpine and pelvis : (+) CT

THE NORMAL HEALING OF FRACTURESCortical bone (diaphyseal bone/ tubular bone)# torn of blood vessels, canaliculi, Haversian canal on the # site Osteocyte in the lacunae A vascularBleeding from periosteum 1. Fracture Hematoma Localized on the end of fragment #Osteogenic cells from periosteum formedExternal callus

From endosteum Internal callusCartilage callus change in to bone by Endochondral Ossification2 Clinical Union ( fracture line still apparent)3 Consolidation ( Radiographic Union )4 Remodeling

THE NORMAL HEALING OF FRACTURES2. CANCELLOUS BONEInternal Fracture Hematomaosteogenic cells from trabeculaeInternal callusClinical UnionConsolidation

THE TIME REQUIRED FOR UNCOMPLICATED # HEALINGFACTOR INFLUENCE:Age of the patientYounger age, the healing rate faster.Example : femur # after birth union 3 weeksfemur # on the age 8 year union 8 weeks femur # on the age 12 year union 12 weeks femur # on the age 20 th/> union 20 weeks

HEALING TIME UNCOMPLICATED #2. # Site and Configuration # through bones that are surrounded by muscle >union faster cancellous bone # > union faster than cortical bone long oblique / spiral # > union faster than transverse #

WAKTU PENYEMBUHAN # UNCOMPLICATED3. Initial Displacement of the Fracture :undisplaced #, intact periosteum heal twice as rapidly as displaced #

4. Blood supply to the Fragments :If both fracture fragments have a good blood supply healing faster

ABNORMAL HEALING OF FRACTURESMALUNION Heal normally expected time but in unsatisfactory position with residual bone deformity DELAYED UNIONunion time longer than normalNON UNIONfractures fail to heal by bone :Fibrous UnionFalse joint (Pseudoarthrosis)

PRELIMINARY CARE FOR PATIENTS WITH #PRIORITYAirwayBreathingShock# and dislocationComplete PESplinting Extr # : To minimize painPrevent further injury to the soft tissueINITIAL

SPESIFIC METHODS OF TREATMENT FOR CLOSED FRACTURES1. Protection alone(without reduction/immobilization)Indication : # costa stable, # undisplaced # stable2. Immobilization by external splinting (without reduction)3.Closed Reduction by manipulation followed by immobilization4Closed reduction bt continuous traction followed by immobilization

SPESIFIC METHODS OF TREATMENT FOR CLOSED FRACTURES5. Closed Reduction followed by Functional Fracture Bracing6. Closed Reduction by manipulation followed by External Skeletal Fixation7. Closed Reduction by manipulation followed by Internal Skeletal Fixation8. Open Reduction followed by Internal Skeletal Fixation9. Excision of a # fragment and replacement by an Endoprosthesis

CLASSIFICATION OF OPEN #TYPE IWound < 1 cmClean woundBone penetrated skin with minimal injury to the muscle (usually from within)Simple #, transverse, short oblique

CLASSIFICATION OF OPEN #TYPE II:Wound > 1 cmWithout extensive soft tissue damage, skin flaps or avulsionsimple # transverse, short oblique,mild comminuted

CLASSIFICATION OF OPEN #TYPE III:Extensive soft tissue damage ; skin, muscle, nerve injuries and major arterial injuryOften caused by high speed injuryExample :Traffic accident, farm accidentsGunshot wound> 8 hours

CLASSIFICATION OF OPEN #TYPE III A :High speed injury, soft tissue can coverage the woundSegmental # or severe cominuttedTYPE III B :High speed injury> soft tissue lossAvulsion of periosteumWound with severe contaminationTYPE III C :Major arterial injury need to repair

SPECIAL TYPES OF # Stress # (fatigue #) :March # metatarsal II-III #Prox. Tibia # jumpers and ballet dancersPathological # :Occur in abnormal boneWithout major trauma

DISLOCATIONStructural loss of its stability3 structure that prevent normal ROM & also prevent joint stability

Joint shape ( joint surface )

Capsule and ligament

Muscle that prevent joint stability

DISLOCATION3 DEGREES OF JOINT INSTABILITY :1st Degree : Occult Joint instability ( apparent only when joint is stressed)2nd Degree : Subluxation ( less than luxation) 3rd Degree : Dislocation (Luxation) ( joint surfaces have completely lost contact)

DISLOCATIONJoint most susceptible to traumatic dislocation:ShoulderElbowHipInter phalangealAnkle

DIAGNOSISPhysical Examination :Swelling (edema)Deformity ( angulation, rotation, loss of normal contour, shortening)Abnormal movementLocal tendernessRadiographic Examination :Typical features of a subluxationAP / LAT projection

SPECIFIC TYPES OF JOINT INJURIES CONTUSION:Hemarthrosis (rupture of synovial vessels)Normal X-rayLIGAMENTOUS SPRAIN:Acute sprain, strain sudden stretching of the ligament withincomplete tears local hemorrhage local swelling tenderness, pain aggravated by movementRadiographic examination : normalTreatment : strapping / splinting DISLOCATION :Anatomical reductionimmobilization

SPECIFIC FRACTURES AND JOINT INJURIES IN ADULTSFracture less common, but more seriousWeaker and less active Periosteum Less rapid fracture healingFewer problems of DiagnosisNo spontaneous correction of residual fracture deformitiesDifferences in complication:Open fracture > common in adultMajor arterial trauma Fat embolism

SPECIFIC FRACTURES AND JOINT INJURIES IN ADULTSTorn ligaments and Dislocations more commonBecause > rigid, child > elasticIf in children make separation in adult dislocation / # dislocationBetter tolerance of major blood lossDifferent emphasis on methods of treatment> frequently require ORIFIf undisplaced # , adult tend to be more cooperative during treatment, # can be treated by protection alone

SPECIFIC FRACTURES AND DISLOCATIONSTHE HANDGeneral features:CommonTreatment should always deference prevent disabilityEdema >> disturbance function elevation to# digits immobilized as short as possible never more than 3 weeksfinger Immobilized in the flexed position

SPECIFIC FRACTURES AND DISLOCATIONSTHE HAND1. DISTAL PHALANX :Mallet Finger ( baseball finger, cricket finger )Caused by:Passive flexion distal of the interphalangeal joint with the extensor tendon under tension may avulse a fragment of bone from the base of the distal phalanx into which the tendon is inserted.Treatment:Acute : Splinting the finger with DIP joint extended & the PIP joint flexed 3 weeks. ORIF with wire fixation.

SPECIFIC FRACTURES AND DISLOCATIONSTHE HAND2. MIDDLE & PROXIMAL PHALANGES# as result of crushing / hyperextension injuryUndisplaced # : Treatment: strapping to adjacent finger, Allow movement of the fingers joint(+)Usually stabledisplaced # :Frequently anterior angulation Treatment : ORIF if unstable3. DISLOCATION OF THE MP. JOINTSSevere hyperextention injuryTreatment : closed reduction

SPESIFIC FRACTURES AND DISLOCATIONSTHE HAND4. METACARPAL S:Boxer Fracture ( Street Fighter # ):# neck metacarpal VStreet fighters #Treatment :ReductionImmobilized in cast not more than 2 weeksORIF with K-wire fixation if # unstable

SPESIFIC FRACTURES AND DISLOCATIONSTHE HAND

Bennets Fracture :# dislocation of the 1st carpo metacarpal jointLongitudinal force along the axis of the 1st metacarpal with the thumb in flexed Serious intraarticular fracture dislocation of the CMC jointTreatment:Closed reductionORIF K-wire

SPESIFIC FRACTURES AND DISLOCATIONSTHE HANDRolando # :# base 1st metacarpal with intrarticular T or Y #

SPESIFIC FRACTURES AND DISLOCATIONSTHE HAND5. # SCAPHOIDRelative common in young adults, particularly in malesFall on the open hand with the wrist dorsiflexed and radially deviatedClinical features:Pain on the radial side of the wrist, particularly on dorsoflexion and radial deviationRadigraphical features:Not clearly outlined in AP projection, requires special oblique projections ( scaphoid view)

SPESIFIC FRACTURES AND DISLOCATIONSTHE HANDTreatment :Undisplaced immobilized in scaphoid castComplication :Avascular necrosisDelayed unionNon unionPost traumatic degenerative joint disease

SPESIFIC FRACTURES AND DISLOCATIONSTHE WRIST AND FOREARM 1. Distal end of the Radius ( Colles # ) Colles # : # radius, 2,5 cm / 1 inch from wrist jointCommonest # in adults, > 50 th > Fracture occur through bone that has became markedly weakened by combination senile & post menopausal osteoporosisMechanism of injury : fall with lands on outstretched hand positionClinical features:Dinner fork deformity : posterior displacement or posterior tilt of the distal radial fragment

COLLES FRACTURECLINICAL FEATURES : DINNERS FORK DEFORMITY

COLLES FRACTURERadiographic features :Stable type : There is 1 main transverse # line with little cortical comminutionUnstable type :Gross comminution, particularly of the dorsal cortex, and also marked crushing of the cancellous bone

COLLES FRACTURE TREATMENT :Undisplaced # : immobilization with Below Elbow Cast for 4 weeksDisplaced # : Closed Reduction + BE cast Closed Reduction+ External FixationCOMPLICATION :Usually Colles # had clinical union in acceptable position within 6 weeksPreventable complication:Finger Stiffness, Shoulder stiffness, malunionRare complication: Sudecks Reflex Symphatetic DystrophyLate rupture EPL

2. Reverse Colles # / Smiths # Predominantly in young menOccurs young adults Fall on the back of the flexed wrist and hence is a pronation injury Distal fragment dislocated to the anterior side

SPESIFIC FRACTURES AND DISLOCATIONSTHE WRIST AND FOREARM

SMITHS # Treatment : Closed reduction requires strong supination of the wristAbove Elbow Cast, for 6 weeks, maintain the position in supination

3.Bartons #Other form of smith # Intra articular #SPESIFIC FRACTURES AND DISLOCATIONSTHE WRIST AND FOREARM

FRACTURE OF THE SHAFT OF THE RADIUS AND ULNARADIUS ULNA :

1. GALEAZZI # :# of the shaft of the radius and dislocation of the distal radio-ulnar joint.displaced # of distal third of the radial shaft associated with complete disruption & dislokation of the distal radioulnar joint.Usually sustained by young adultsDistal fragment tilted posteriorly

FRACTURE OF THE SHAFT OF THE RADIUS AND ULNATreatment :Open Reduction & Internal fixation of the radius, the dislocatiwill be on reduced.

FRACTURE OF THE SHAFT OF THE RADIUS AND ULNA2. PROXIMAL RADIUS # :Tend to rotateTreatment : ORIFComplication:Delayed unionNon union

FRACTURE OF THE SHAFT OF THE RADIUS AND ULNA3. RADIUS ULNA # :> difficult to treatTreatment : ORIF for both boneComplication :Delayed unionNon unionCross union (must avoided)

FRACTURE OF THE SHAFT OF THE RADIUS AND ULNAMONTEGGIA # :

# of the Prox half of the ulna accompanied by anterior dislocation of the prox radioulnar jointDislocation post / antCommon type, hyperextension & pronation injury. Can also produced by direct trauma over the ulnar border of the forearm.

FRACTURE OF THE SHAFT OF THE RADIUS AND ULNATreatment :Adult ORIF

ELBOW AND ARM# OLECRANONCommonest type is due to a fall with passive flexion of the elbow combined with powerful contraction of the triceps muscle.Treatment : ORIF using TBW (Tension Band Wire)

ELBOW AND ARM2. # OF THE RADIAL HEADRelative commonYoung adultsCaused by a severe valgus abduction force applied to the extended elbowRadiographic Examination:# radial head

ELBOW AND ARMTreatment :Depends upon the severity of the damage to the radial headundisplaced # : only protection, immobilized with sling for 2 weeksDepressed & comminuted # : excision of the entire head of the radiusComplication :Post traumatic degenerative joint disease of the elbow

POSTERIOR DISLOCATION OF THE ELBOWMECHANISM OF INJURY : Fall on the hand with the elbow slightly flexed Severe Hyperextension injury of the elbowCLINICAL FINDING : Swollen elbow is held in a position of semi flexion Olecranon is readily palpable posteriorlyRADIOGRAHIC EXAMINATION : Dislocation.

POSTERIOR DISLOCATION OF THE ELBOWTREATMENT: Closed Reduction Immobilization by cast for at least 3 weeksCOMPLICATION :Elbow stiffnessMedian nerve injury

FRACTURE DISLOCATION OF THE ELBOWSide swipe injury :Occurs when a driver has his elbow out the open window of a car at the moment the car is struck from the side by another vehicle.Usually :Elbow dislocationMultiple comminuted # of the humerus, radius & ulnaTreatment :Wait until soft tissue healedORIF

FRACTURES OF THE SHAFT OF THE HUMERUS > adults Direct trauma # transverse / comminuted Indirect trauma fall on the hand # spiral Clinical Examination :Flail armPatient tries to support with the opposite hand, Radial Nerve lesion should always be sought and its presence or absence recorded at the time of the initial examination

FRACTURES OF THE SHAFT OF THE HUMERUS Treatment :Closed treatmentIndication for ORIF if injury of Brachial artery which necessitates arterial repairTRANSVERSE # OF THE HUMERAL SHAFT:Anaesthesia reduction U Slab (Sugar Tong Splint) / Hanging CastClinical union achieved within 6 weeks

FRACTURES OF THE SHAFT OF THE HUMERUS # SPIRAL & COMMINUTED FRACTURES :Do not require reduction / anaesthesiaGravity alone is adequate to provide alignment of the fracture fragment immobilized in U shaped plaster slab

COMPLICATION :Radial Nerve InjuryDelayed UnionNon Union

FRACTURES OF THE NECK OF THE HUMERUSIn elderly persons, especially Impacted # relatively commonTreatment : only protection from further injury by a sling during 6 weeks required for union

SHOULDER JOINTShoulder Joint DislocationAnterior Dislocation of the ShoulderPredominantly of young adultsCaused by forced external rotation and extension of the shoulderRadiographic examination : confirm the diagnosisTreatment :Reduce as soon as possible, methods :Kocher MethodGravitationHipocratesAfter reduce must immobilized by Velpeau Bandage

SHOULDER JOINT2. Recurrent Anterior Dislocation of The Shoulder :The stability of the shoulder depend on the integrity of the joint capsule capsule, capsule & anterior labrum are nearly always avulsed caused the dislocation may recur more and more frequently with less and less violence.Treatment :Surgical repair with Putti Platt operation capsule as well as the Subscapularis muscle are divided and then refeed (overlapped) limiting external rotation.

SHOULDER JOINT3. Posterior Dislocation of the ShoulderLess common than anterior dislocationPosterior dislocation can occur : Fall on the front of the shoulder, with shoulder adducted and internally rotatedClinical Finding :The patients arm seems locked in a position of adduction and internal rotattedRadiographic finding:Not readily detected in an AP projection, need special examination :Superoinferior (axillary) projection with the shoulder abducted, is necessary to confirm that the humeral head is in fact lying posteriorlyTreatment :Closed reduction

SHOULDER JOINT4. Acromioclavicular Joint Dislocation (AC Joint)Complains of severe pain over the shoulderLocal tenderness (+) overthe AC jointRadiolographic examination: Patient standing and holding a weight in each hand.

SHOULDER JOINTTreatment :Non operatif : Kenny-Howard Sling, depress the clavicle and elevate the acromionIf failed ORIF, capsult repair, insertion of a K-wireK-wire removed after 6 weeks

SHOULDER JOINT5. FRACTURE OF CLAVICLECommon site is the middle third of the clavicleLateral fragment pulled inferiorly and medially by the weight of the shoulder and upper limbTreatment :Figure of 8 padded bandageClinical united in 3 weeksComplicationMalunionDelayed unionNonunion relative rare

FOOT1.# OF THE METATARSAL>>common #Drop by heavy objectsRun over injury with a metal wheelImportant: impairment of circulation to the forefootTreatment :multiple # K-wire fixation4 weeks NWB walking cast worn for additional 4 weeks

FOOT2.CALCANEAL #Fall from a considerable height onto one or both heels.High incidence of associated compression # of the spineTreatmentextra-artikular # :Under anaesthesia the two major fragments should manually compressed from side to side walking cast for 6 weeksintra-artikular # :ORIF

FOOT3. FRACTURES OF THE NECK OF THE TALUS No muscle attached to talus> covered by articular cartilageBlood supply not to good# neck talus correlate with incidence of avascular necrosis (the body) and non union

FOOTMechanism of trauma Severe dorsoflexion injury as may be incurred when the driver has his foot hard on the brake pedal at the moment of a head-on collisionTreatment :Closed reduction BK cast for at least 8 weeksComplication:Avascular necrosisDegenerative joint diseaseNonunion

THE ANKLE# & # DISLOCATIONS OF THE ANKLE1. Isolated # of the Medial MaleolusAbduction injury avulse medial maleolus below the joint line

Adduction injury shear off the medial maleolus above the joint line

Treatment :Undisplaced : BK cast for 8 weeksDisplaced : ORIF

ANKLE2. Isolated # of the Lateral MaleolusAbduction / external rotation injuryMost common injury of the ankleTreatment :Closed reduction stable immobilized in BK Cast for 6 weeksNWB 3 weeks

ANKLE3. Bimalleolar # (# of both medial & lateral malleolus)Severe injuries of the abduction or external rotationTreatment : closed reduction unstable ORIF4. Trimalleolar #Treatment :ORIF

ANKLEComplication :Joint stiffnessnon-union rare>> malunion sbg hsl dari loss of correction dari fragmen #Degenerative joint disease

LOWER EXTREMITY# OF THE SHAFTS TIBIA & FIBULA> fractured more frequentlyPeriosteum is thin in adultFrequency open #Rate of union slowMechanism of injury :Direct trauma bumper, Traffic accidentClinical features :Swelling, deformity, TendernessRadiographic : AP / Lateral

LOWER EXTREMITYTreatmentReduction of the tibiaOblique & transverse # closed reductionClinical Union after 3-4 weeksUnstable oblique # & spiral # ORIFComplicationAnkle stiffnessNerve injuryDelayed unionNon-unionmalunion

KNEE JOINT# of the proximal end of theTibia ( Bumper #)Mechanism of injury :Usually in elderlyA severe abduction injury, usually a direct blow on the lateral aspect of the limb with the foot fixed on the ground.Treatment:Closed reduction for elderly If the patient young ORIF

KNEE JOINT2. Traumatic Dislocation of the knee jointTorn of 4 major ligaments :CMLCLLACLPCLComplication:Trauma of the Popliteal Artery risk of gangren in the distal partTreatment:Reduced as soon as possible Complete Dislocation of the knee joint

KNEE JOINT3. FRACTURES OF THE PATELLAIndirect : Tears of the Quadriceps expansion at the level of the patella produce transverse avulsion fracture of the patellaDirect :Direct trauma comminuttedClinical finding :Patient cant extent the lower extremityTreatment :TBW

KNEE JOINT4.INTERCONDYLAR FEMUR #Patient fall (knee in flexion position) from height.Clinical finding : swelling >>Radiolographic :Treatment :ORIF

FEMURFRACTURES OF THE FEMORAL SHAFTClinical features:swelling >>deformityRadiographic examination :Done after ABC stabile

FEMURTreatment:1. Nonoperative treatment :Longer period in the hospitalLonger period of weight bearingContinuous traction (12 weeks )Clinical union active exercise, non weight bearingRadiological unionWeight bearing2. Operative treatment : ORIF with intramedullary nail

FRACTURES OF THE FEMORAL SHAFTIndication for intramedullary nail # of the femur :Fail in Closed reductionMultiple trauma (head trauma)Femoral Artery injury need to repair.Elderly, prolonged bed rest is deleteriousPathological #Complication :ShockFat embolismKnee stiffnessNon-union

PELVIS1. TROCHANTERIC # OF THE FEMURInclude: Intertrochanter # ( # between the lesser and greater trochanters)# through the trochanter pertrochanteric #> common in adults over the age of 60 years > Clinical featuresLower limb complete external rotationExtremity appears shortUpper part of thigh is swollen

PELVISRadiolographic examination: extent of the #Treatment :ORIF NonoperatifComplication:Malunion nonoperatif

NECK FEMORAL FRACTURE1. Subcapital2. Transcervical3. BasilarGarden classification :4 type (intracapsular)Type 1: incompleteType 2: complete, undisplacedType 3: partially displacedType 4: complete displaced

NECK FEMORAL FRACTURETreatment :Operative : Hemiarthroplasty for the elderly patientComplication:Avascular necrosis femoral headNon-union > 30%

TRAUMATIC DISLOCATION DISLOCATION OF THE HIPPOSTERIOR DISLOCATIONPosition:Flexion & adduction, internal rotationUsually caused by dashboard injuryExtremity became shortens

TRAUMATIC DISLOCATION DISLOCATION OF THE HIPTreatment:Closed ReductionMethodsComplication :Avascular necrosis femoral headSciatic nerve lesionPost traumatic degenerative joint disease

TRAUMATIC DISLOCATION DISLOCATION OF THE HIP2. ANTERIOR DISLOCATIONLess commonCaused by a violent injury which forces the hip into extension, abduction and external rotation.Radiographical finding: head femur below the acetabulum

TRAUMATIC DISLOCATION DISLOCATION OF THE HIPTreatment :Closed reduction as soon as possible Applying traction on the flexed thigh and then internally rotating and adducting the hip.After reduction, the patient hip should be immobilized in a Hip Spica Cast in its most stable position ( flexion, adduktion, internal rotation)

TRAUMATIC DISLOCATION DISLOCATION OF THE HIPFull flexionAdduction of the hipInternal rotationExtensionNeutral position

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