15 - Fractures and Joint 5.

RELATIONSHIP OF THE
FRACTURE TO THE
Injuries-General Features EXTRENAL ENVIRONTMENT
- Closed  kulit masih intact.
DEFINISI FRAKTUR - Open  ada hubungan antara
luka dengan lingkungan luar 
Fraktur adalah diskontinuitas dari tulang, dapat mengakibatkan infeksi.
epifisis plate atau tulang rawan sendi, 6. COMPLICATIONS
akibat trauma mekanik dan non mekanik - Komplikasi karena luka
yang mengakibatkan rusaknya jaringan tersebut.
lunak, arteri, saraf perifer atau tulang. - Komplikasi karena treatment
(iatrogenik).
Karena tulang dikeliling oleh soft tissue  Jenis komplikasi : sistemik &
degree of soft tissue injury. Apabila soft lokal.
tissue injury ada pada otak, spinal cord,
viscera abdominal/thoracal, arteri besar DIAGNOSIS
dan saraf perifer  clinical significance 1. Anamnesis
lebih besar disbanding dengan fraktur - Keluhan utama (Chief
tersebut. complaint)
- Nyeri (Pain): onset, lokasi,
DESKRIPSI FRAKTUR karakteristik, severitas, durasi,
1. SITE faktor yang memperingan
Sisi/lokasi yang terkena  diafisis, - Penurunan fungsing (Decrease
metafisis, epifisis, intra-artikular, in function): disability caused
fraktur-dislokasi. by muscle weakness, joint
2. EXTENT instability, joint stiffness.
Penyebaran: - Physical appearance/
- Complete deformitas: atrofi, shortening,
-Incomplete  crack/hairline rotasi.
fracture, buckle, greenstick - Riwayat jatuh, trauma, penyakit
fracture. dahulu & riwayat pengobatan.
3. CONFIGURATION - Functional Inquiry/coesixtent
-Transverse disorders: Penyakit jantung,
-Oblique DM, penyakit ginjal,
-Spiral pernafasan.
-Comminuted - Riwayat sosioekonomi
4. RELATIONSHIP OF THE - Riwayat keluarga
FRACTURE FRAGMENTS TO
EACH OTHER 2. Pemeriksaan Fisik
-Undisplaced - Perhatikan : body build
-Displaced: (habitus), ekspresi wajah
1) translated (shifted sideways) (facies), cara berjalan (gait).
2) angulated - Inspeksi:
3) rotated Skin  kemerahan, sianosis
4) distracted Bekas luka, deformitas,
5) overriding swelling, benjolan.
6) impacted. Bandingkan kanan-kiri 
shortening/atrofi.
- Palpasi:
 Kulit dingin/hangat, tenderness,
pulse, swelling, massa,
krepitasi.
- Moving  Pergerakan sendi
Active movement
Passive movement
- Auskultasi
Suara krepitasi, snapping
tendon.
3. Diagnostic Imaging
- Rontgen
- CT Scan
- MRI
NORMAL HEALING OF
FRACTURES
- Primary / direct healing by
internal remodeling
- Secondary / indirect healing by
callus formation
- Primary Bone Healing: Occurs
only with absolute stability, is a
biological process of osteonal
bone remodelling.
- Secondary Bone Healing:
◦ Inflammation
◦ Soft Callus Formation
◦ Hard Callus Formation
◦ Remodelling
1. INFLAMASI
- 1-7 hari setelah fraktur
- Pembentukan hematom
- Bone necrosis pada ujung
fraktur  mengeluarkan
sitokin yang menyebabkan
vasodilatasi dah hyperemia,
migrasi dan proliferasi
neutrophil PMN dan makrofag.
2. SOFT CALLUS FORMATION
- 2-3 minggu setelah fraktur
- Sellprogenitor pada periosteum
dan endosteum menjadi
osteoblast
- Mulai pertumbuhan tulang
intramembrane  membentuk
woven bone
- Kapiler tumbuh pada callus 
peningkatan vaskularisasi
- Progenitor mesenchymal
migrasi ke callus 
berdiferensiasi menjadi
fibroblast/chondrocyte
replacing hematoma.
-
3. HARD CALLUS FORMATION
- Setelah soft callus terbentuk
hingga 3-4 bulan
- Terjadi endochondral
ossification pada soft tissue
- Callus  rigid calcified tissue
- Formasi hard callus dimulai
dari perifer-center fraktur
4. REMODELLING
- Beberapa bulan – beberapa
tahun
- Woven bone  lamellar bone
- Sampai terbentuk morfologi
asli.
ABNORMAL HEALING OF
FRACTURES
1. MALUNION
Waktu yang diharapkan normal,
tetapi dalam posisi yang tidak
memuaskan dengan deformitas
tulang sisa.
2. DELAYED UNION
Membutuhkan waktu lebih lama
dari seharusnya.
3. NON UNION
Fail to heal completely  9 bulan
COMPLICATION
1. IMMEDIATE
- Lokal
Skin injuries:
Dari luar: abrasi, laserasi, kulit
hilang
Dari dalam: penetrasi kulit oleh
fragmen
- Vaskular
Arteri: division, contusion,
spasme
Vena: division, contusion
Perdarahan local
- Muskular: division
 - Neurogis: braim, sci, nervus
perifer
- Viscreal injuries
- Thorax: jantung, pembuluh
besar, paru, trakea, brongkus
- Intraabdominal: GI, liver,
spleen, TU
2. EARLY/Hitungan Jam
Nekrosis kulit, gangrene,
compartment syndrome, gas
gangrene, septic arthritis, infeksi
(osteomyelitis), avascular necrosis.
3. LATE/2 Minggu-Berbulan-bulan
Kekakuan, post traumatic
degenerative arthritis, abnormal
healing, gangguang pertumbuhan,
osteomyelitis kronis, post traimatik
osteoporosis, refraktur, nerve palsy.
GENERAL PRINCIPLES OF
FRACTURE TREATMENT
1. First, Do NO Harm
2. Treatment awal sesuai dengan Dx
dan prognosis
3. Pilih treatment yang sesuai
4. Laws of nature
5. Realistis dan praktis
6. Cegah infeksi
EMERGENCY
Primay Survery: ABCDE
Secondary Survey: AMPLE
SPECIFIED METHODS OF
TREATMENT FOR CLOSED
FRACTURE
1. Proteksi (tanpa imobilisasi/reduksi)
 simple sling, crutches
Indikasi : undisplaced, clinical
union
2. Imobilisasi dengan External
Splinting (tanpa reduksi)
Plaster of Paris, metallic/plastic
splint
Indikasi: undisplaced & unstable
3. Closed reduction (dengan
imobilisasi)-
Indikasi: unstable oblique, spiral,
comminuted #tulang Panjang
Unstable spinal
Fraktur dengan kerusakan vaskuler
4. Closed Reduction by Continuous
Traction Followed by
Immobilization
- Skin traction or skeletal traction
; fixed traction (end of bed) or
balanced traction (cords with
weights / pulleys)
- Overcoming muscle pull and
gravity
5. Close reduction Followed by
Functional Fracture-bracing
Cast for 3-4 weeks. THEN, hinged
cast-brace/plastic brace is aClosed
reduction / continuous traction for
few days, followed by
immobilization by plaster pplied to
allow motion in the joints above
and below the fractured bone.
6. Closed Reduction by Manipulation
Followed by External Skeletal
Fixation
Two or three metal pins are
inserted percutaneously through the
bone above and below the fracture
site, and held together by external
bars to provide firm (but not rigid)
fixation of the fracture “at a
distance”
Indications:
- Severely comminuted and
unstable tibia/femur shaft
fracture
- Unstable fracture of pelvis,
humerus, radius, metacarpals
 7. Closed Reduction by Manipulation
Followed by Internal Skeletal
Fixation
Accurate manipulative reduction
 percutaneous insertion of
metallic nails or IM rods across the
fracture site
8. Open Reduction Followed by
Internal Skeletal Fixation
Internal fixation is achieved by
metallic device, the technique is
called osteosynthesis – beware of
soft tissue damage
Mechanical devices include screws,
onlay plates held by screws, IM
nails and rods, smooth and
threaded pins, encircling bands,
and wire sutures.
Indications:
- Failed / impossible closed
reduction e.g. displaced
avulsion #, intraarticular #,
displaced epiphyseal # in
children, soft tissue
interposition.
- Grossly unstable fracture 
needs internal fixation. E.g.
intertrochanteric femur #, # of
both bones of the forearm in
adults, displaced phalanges #
- Associated vascular injury
requiring exploration and
repair.
9. Excision of a Fracture Fragment
and Replacement by an
Endoprosthesis
ASPECTS OF TREATMENT
FOR OPEN FRACTURES
1. Cleansing the wound
◦ Extensive pulsating
irrigation with sterile water
or isotonic saline
2. Excision of devitalized tissue
(Debridement)
◦ May prevent wound healing
and enhance infection
3. Treatment of the Fracture
◦ In general, internal fixation
may be used unless its mere
insertion would tend to
traumatize and devitalize
more tissue and increase the
risk of infection.
4. Closure of the wound
◦ After 4-7 days, provided no
infection has developed,
delayed primary closure is
indicated. STSG may be
applied; suction drainage
may be used
5. Antibacterial Drugs
6. Prevention of tetanus
CLASSIFICATION OF OPEN
FRACTURES