FRAKTUR

Veronica Maslina Simanjuntak (0710130)

Dewi Yuniar (0710083)
Stephanie Viola Warokko (0710064)
Noverio Michael S. Tarukallo (0710023)
Florence Fedora (0710004)

Supervisor: dr. Daniel Pratikno, Sp.OT

DEPARTMENT OF SURGERY
Maranatha Christian University
IMMANUEL HOSPITAL
BANDUNG
2011
BONE HEALING
I. Pendahuluan
Bila tlg fracture tjd serangkaian proses mulai
mobilisasi sel radang sampai kembalinya btk tlg ke
keadaan sblm fracture ( Rockwood,1991)
Bone healing = proses regenerasi : tlg yg rusak diganti
dgn tlg yg baru tanpa jar.parut (sikatrik)
Bone healing melibatkan peran sel mesenkim & sel
hematopoetik
II. Tahapan bone healing
Rockwood (1991):
- inflammatory phase
- reparative phase
- remodeling phase
Gambar 1. Tahapan penyembuhan fraktur dan perkiraan
waktu yang dibutuhkan mulai fase hematoma sampai fase
remodeling (Yeo Li, 1994).
1. Fase inflamasi
Jejas pembuluh darah rusak vasokonstriksi
clotting & agregasi trombosit
Clotting mengandung sel inflamasi (neutropil &
makrofag) sekresi sitokin (IL-1 & IL-6) reaksi
inflamasi
Trombosit yg teragregasi sekresi mediator sitokin &
growth factors (PDGF,IGF-1,EGF,TGF-)
Growth factors yg terbentuk mengakibatkan endotel &
fibroblas bergerak ke tempat jejas terbentuk jaringan
granulasi yg kaya pembuluh darah (provisional matrix)
suplai O
2
& nutrisi lancar
2. Fase reparasi
Dimulai dgn terbentuknya hematom yg banyak
mengandung pembuluh darah
Sel inflamasi mensekresi growth factor :
sel mesenkim bergerak ke tempat jejas
sel mesenkim berproliferasi & diferensiasi mjd
fibroblas dan osteoblas
Fibroblas dan osteoblas akan mensintesa jaringan
fibrous,kartilago dan woven bone (fracture callus)
Kalus yg terbentuk pd periosteum : hard callus
Kalus yg terbentuk pd medulla : soft callus

Kalus akan dimineralisasi oleh osteoblast dan kondrosit
menjadi matriks tlg yg mengandung serat kolagen.
Kondrosit membantu stabilisasi kadar glikosaminoglikan
dgn cara mensekresi enzim proteoglikenase
3. Fase remodeling
Remodeling ttd 2 proses :
- bone formation yg dilakukan oleh osteoblas
- bone resorption yg dilakukan oleh osteoklas
Kerjasama antara osteoblas dan osteoklas dlm bone
remodeling coupling phenomenon
Aktivitas penyerapan dan pembentukan tlg dipengaruhi
oleh elektronegatifitas daerah fraktur

Gambar 2. Aktivitas penyerapan tulang yang dilakukan sel osteoklas dikontrol
osteoblas melalui jalur OPG/RANK/RANK-L. Diferensiasi osteoklas precursor
menjadi osteoklas dapat terjadi bila reseptor RANK yang terdapat pada
osteoklas precursor berikatan dengan ligan yang disekresi oleh osteoblas. Di
samping itu osteoblas juga mensekresikan osteoprotegerin yang bersifat
inhibisi terhadap RANKL. Anak panah yang berada di sisi kiri osteoblas
meningkatkan aktivitas penyerapan tulang melalui rangsangan osteoblas
untuk mensekresi RANKL, sementara anak panah yang terputus-putus
mengurangi aktivitas penyerapan tulang dengan menghambat jalur RANKL.
Osteoklas menempel pada permukaan tulang melalui integrin (V3) yang
kemudian akan mensekresikan ion H+ dan enzim cathepsin untuk
mendegradasi kolagen (Joseph T. Dipiro).
TREATMENT OF FRACTURE
I. Treatment of closed fractures
II. Treatment of open fractures and
gunshot wounds
TREATMENT OF CLOSED
FRACTURES
General treatment is the first consideration


TREAT THE PATIENT, NOT SIMPLY THE
INJURED PART
Sequence in treating patients with
fractures:
I. First aid
II. Transport
III. Treatment of shock, haemorrhage, and
associated injuries
Pre-hospital scene
Wooden splint for pre-hospital immobilization
PRINCIPLES OF TREATMENT OF
FRACTURES
1. Manipulation to improve the position of
fragments (REDUCE)
2. Followed by splintage to hold the fragments
together until they unite (HOLD)
3. Meanwhile, joint movement and function must
be preserved (EXERCISE)
Remember:
Treatment determined not only by the TYPE
OF FRACTURE, but also by the condition
of the SOFT TISSUES
Conflicts
In treating fractures a surgeon will meet
some conflicts:
1. How to hold a fracture adequately and yet
use the limb sufficiently


2. How to resolve as rapidly as possible, yet to
avoid unnecessary risks
HOLD vs MOVE
SPEED vs SAFETY
These dual conflicts epitomizes the FOUR
FACTORS THAT DOMINATE fracture
management
Term FRACTURE QUARTET used to
represent these factors (HOLD, MOVE,
SPEED, SAFETY)
THE FRACTURE
QUARTET
MOVE
HOLD
SAFETY
SPEED
REDUCE
NO UNDUE DELAY

Swelling of the soft parts during the first 12
hours makes reduction is increasingly
difficult

Reduction is UNNECESSARY if:
1. Little / no displacement
2. Displacement does not matter (like in
the fractures of the clavicle)
3. Reduction is unlikely to succeed (eg.
compression fractures of the vertebrae)
ALIGNMENT IS MORE IMPORTANT THAN APPOSITION
Fractures involving articular surface:
Should be reduced as near to perfection
as possible because any irregularity will
predispose to degenerative arthritis
Methods of reduction:
1. Closed reduction
2. Open reduction
CLOSED REDUCTION
Done under appropriate anesthesia and
muscle relaxation
Most effective when the periosteum and
muscle on one side of the fracture remain
intact
Soft tissue strap prevents over-reduction
and stabilizes the fracture after reduction
Some fractures (e.g. of the femoral shaft)
are difficult to reduce by manipulation
because of powerful muscle pull and may
need prolonged traction
Indications:
1. All minimally displaced fractures
2. Most fractures in children
3. Fractures that are not unstable after
reduction
Contraindications:
1. Fractures with severe soft tissue damage
2. Inherently unstable fractures
3. Multiple fractures
4. Fractures in confused or uncooperative
patients
Cervical Collar
Devices used for protection
Mitela
Devices used for protection
Arm Sling
Devices used for protection
Shoulder Immobilizer
Devices used for protection
Clavicle Brace
Devices used for protection
OPEN REDUCTION
Reduction under direct vision
Indications:
1. When closed reduction fails
2. There is a large articular fragment that
needs accurate positioning
3. For traction fractures in which the
fragments are held apart
HOLD REDUCTION
The word immobilization should
deliberately AVOIDED because the
objective is seldom complete immobility,
usually it is the prevention of displacement
Nevertheless, some restriction of
movement is needed to promote soft
tissue healing and to allow free movement
of the unaffected parts
Methods of holding reduction:
1. Continuous traction
2. Cast splintage
3. Functional bracing
4. Internal fixation
5. External fixation
CONTINUOUS TRACTION
Traction is applied to the limb distal to the
fracture, so as to exert a continuous pull
in the long axis of the bone
Indications:
Particularly useful for shaft fractures which
are oblique and spiral and easily displaced
by muscle contraction
Disadvantages:
Traction cannot HOLD a fracture still,
maintain accurate reduction is sometimes
difficult
SPEED is slow because traction keeps the
patient in hospital

CONTINUOUS TRACTION

Speed is the weak member
of the quartet
MOVE
HOLD
SAFETY
SPEED
As soon as the fracture is STICKY
(deformable but not displaceable) traction
should be replaced by bracing
Methods of Traction
1. Traction by gravity
2. Skin traction
3. Skeletal traction
TRACTION BY GRAVITY
Only for upper limb injuries
Weight of the arm provides continuous
traction to the humerus
For the patients comfort and stability of
the fragments, a U-slab or a removable
plastic sleeve may be applied from the
axilla to just above the elbow
SKIN TRACTION
Also called Bucks traction
Can sustain a pull of no more than 4 to 5
kg
Skin traction (Ankle traction)
Skin traction
Skin Traction
SKELETAL TRACTION
Traction/weight applied through a
Kirschner, Steinmann pin or Denham pin
that inserted through the bone
Skeletal traction
Place of pin insertion:
1. Behind the tibial tubercle for hip, thigh
and knee injuries
2. Lower in the tibia, or through the
calcaneum for tibial fractures
Steinmann Pin for Skeletal Traction
Traction must always be apposed by
counter traction; that is, the pull must be
exerted against something, or it merely
drags the patient down the bed
Fixed Traction
The pull is exerted against a fixed point

Balanced Traction
The pull is exerted against an opposing
force provided by the weight of the body
when the foot of the bed raised
Combined Traction
A Thomas splint is used
Complications:
In children: traction tapes and circular
bandages may constrict the
circulation
In older people: leg traction may
predispose to peroneal nerve
injury
Compartment syndrome following
excessive traction through a calcaneal pin
Thomas Splint with Pearson Attachment
90 90 traction
CAST SPLINTAGE
Plaster of Paris is still widely used as a
splint, especially for distal limb fractures
and for most childrens fractures
Disadvantages:
Joints in plaster are liable to stiffen
Cartilage defects heal slower
CAST SPLINTAGE
Move is the weak member
of the quartet
MOVE
HOLD
SAFETY
SPEED
Application of Plaster of Paris for forearm fracture
Below knee cast
Complications:
1. Tight cast
2. Pressure sooner
3. Skin abrasion or laceration
FUNCTIONAL BRACING
Segments of a cast are applied only over
the shafts of the bones, leaving the joints
free
Using Plaster of Paris or lighter materials
Cast segments are connected by metal or
plastic hinged which allow movements in
one plane

Indications:
Most widely used for fractures of the
femur or tibia
Brace is NOT VERY RIGID
Apply only when the fracture is beginning to
unite, i.e. after 3-6 weeks of traction or
conventional plaster
Advantages:
Fracture can be held reasonably well
Joints can be moved
Fracture joints heal at normal speed
without keeping the patient in hospital
Method safe
Disadvantage:
Greater risk of malunion
Simple Arm
Brace
Functional Braces for Lower Extremity
Functional Brace for the Hip
INTERNAL FIXATION
Bone fragments may be fixed using:
- Screws
- Transfixing pins or nails
- A metal plate held by screws
- Intramedullary nails (with or without locking
screws)
- Circumferential bands
- Or combinations of these methods
Wires used for Internal Fixation
Plates for Internal Fixation
Protheses for hemiarthroplasty of the hip
Rod for Internal
Fixation
Advantages:
Internal fixation holds a fracture securely
so that movements can begin at once
Good speed outcome, the patient can
leave the hospital as soon as the wound
healed
Disadvantages:
Risk of operation complications
Risk of infection
INTERNAL FIXATION
Safety is the weak member
of the quartet
MOVE
HOLD
SAFETY
SPEED
Indications:
1. Fractures that cannot be reduced except
by operation
2. Fractures that are inherently unstable
and prone to redisplacement after
reduction, and those liable to be pulled
apart by muscle action
3. Fractures that unite poorly and slowly,
principally fractures of the femoral neck
4. Pathological fractures, in which bone
disease may prevent healing
5. Multiple fractures
6. Fractures in patients who present
nursing difficulties
Complications:
1. Infection
2. Non-union
3. Metal failure
4. Refracture
Most of the complications of internal fixation are
due to POOR TECHNIQUE, POOR EQUIPMENT,
or POOR OPERATING CONDITIONS
Non-union resulting from poor technique
Non-union resulting from poor technique
EXTERNAL FIXATION
A fracture may be held by transfixing
screws or tensioned wire which pass
through the bone above and below the
fracture and are attached to an external
frame
Indications:
1. Fractures associated with severe soft
tissue damage
2. Fractures with nerve or vessel damage
3. Severely comminuted and unstable
fractures
4. Ununited fractures
5. Fractures of the pelvis, which often
cannot be controlled by any other
method
6. Infected fractures
7. Severe multiple injuries
Complications:
1. Overdistraction of the fragments, which
are then held rigidly apart
2. Reduced load transmission through the
bone, which delays fracture healing and
causes osteoporosis
3. Pin-track infection
External fixators should be DYNAMIZED or
REMOVED after 6-8 weeks, and REPLACED
by some alternative form of splintage
which will allow bone loading
External Fixation for
Metacarpal Fracture
External Fixation
External fixation
Ilizarov device
EXERCISE
Restore function is a more correctly term
Applied not only to the injured parts but
also to the patient as a whole
Objectives:
1. To reduce oedema
2. To preserve joint movement
3. To restore muscle power
4. To guide the patient back to normal
activity
Methods:
1. Prevention of oedema
2. Elevation
3. Active exercise
4. Assisted movement
5. Functional activity
Prevention of Oedema
persistent oedema is an important cause
of joint stiffness, especially in the hand
Reduce / prevent oedema by:
1. Elevate the injured parts
2. Exercise Active exercise
Elevation
Elevate the limb after reduction
Do not dangle the injures limb
Elevate the limb even after the plaster
removed until circulatory control is fully
restored

Active Exercise
Active movement helps to pump away
oedema fluid, stimulates the circulation,
prevents soft-tissue adhesion, promotes
fracture healing
For limbs those encased in plaster static
muscle contraction
Start muscle-building exercises after
splintage is removed
Remember:
Exercise unaffected joints also
Assisted Movement
Gentle assistance during active exercises
may help to retain function or regain
movement after fractures involving the
articular surfaces
Nowadays this is done with machines that
can be set to provide a specified range
and rate of movement (Continuous
passive motion)
Functional Activity
As the patients mobility improves, an
increasing amount of directed activity is
included in the programme
The patient may need to be taught to do
his daily activity
Encourage the patient to use the injured
limb as much as possible
TREATMENT OF OPEN FRACTURES
General Considerations
Many patients with open fractures have
multiple injuries and severe shock


Appropriate treatment at the scene of the
accident is essential

Cover the wound with a sterile dressing or
clean material and left undisturbed until
the patient reaches the accident
department
In the hospital a rapid general assessment
is the first step, any life-threatening
conditions are addressed

Inspect the wound after initial assessment
Ideally the wound should be
photographed with a Polaroid/digital
camera so that it can again be covered
and left undisturbed until the patient in
the operating theatre
Important points in wound assessment:
1. What is the nature of the wound?
2. What is the state of the skin around the
wound?
3. Is the circulation satisfactory?
4. Are the nerves intact?
All open fractures, no matter how trivial
they may seem, MUST BE ASSUMED TO
BE CONTAMINATED
PRINCIPLES OF OPEN FRACTURE
MANAGEMENT
1. Immediate wound cover
2. Antibiotic prophylaxis
3. Early wound debridement
4. Stabilization of the fracture
Early Management
The wound should be kept covered until
the patient reaches the operating theatre
Antibiotics are given as soon as possible,
no matter how small the lacerations are
Continue antibiotic therapy until the
danger of infection has passed
Give tetanus prophylaxis
Debridement
Objective:

To render the wound devoid of foreign
material and of dead tissue, leaving a good
blood supply throughout
Irrigate the wound thoroughly with
cupious amounts of physiological saline
Final irrigation may be with an
antibacterial agent
Do not use torniquet because it would
endanger the circulation still further and
make it difficult to recognize wiche
structures are devitalized
Intra-operative tissue management
How to manage:
1. Skin?
2. Fascia?
3. Muscle?
4. Blood vessels?
5. Nerves?
6. Tendons?
7. Bone?
8. Joints ?
SKIN: spare as much skin as possible

FASCIA: devide fascia extensively so that
the circulation is not impeded

MUSCLE: excise all dead and doubtfully
viable muscle

BLOOD VESSELS: tied or clamped
bleeding vessels
NERVES:
- Usually best to leave cut nerves undisturbed
for later repair
- The sheath can be sutured if the wound is
clean and the nerve ends need no dissection

TENDONS:
- Best to leave cut tendons undisturbed for
later repair
- Tendons can be sutured if the wound is clean
and need no dissection
BONE:
- Fracture surfaces are gently cleaned and
replaced in the correct position
- Spare bone as much as possible
- Remove fragments only if they are small and
totally detached
JOINTS:
- Open joint injuries are best treated by wound
toilet, closure of synovium and capsule, and
systemic antibiotics
- Drainage or suction irrigation is used only if
contamination is severe
Wound Closure
To close or not to close the skin can be a
difficult decision
A small uncontaminated wound can be
sutured without tension, or skin grafted
after early debridement
All other wound MUST BE LEFT OPEN until
the dangers of tension and infection have
passed
Pack the wound with sterile gauze, inspect
for 5 days. If it is clean, the wound
sutured or skin grafted (DELAYED
PRIMARY CLOSURE)
Stabilization of the Fracture
Stability of the fracture is important in
reducing the likelihood of infection
For a type I or small type II wound with a
stable fracture a widely split plaster, or
traction can be used
More severe wounds demand a more
secure fixation
External fixation is THE SAFEST
method of fixation for open fractures
Other implants can be used only by experienced
surgeon and the circumstances are ideal
Aftercare
Shock may still require treatment
Elevate the limb in the ward
Carefully watch the circulation
Continue antibiotic therapy
Culture and sensitivity test
Wound closure using delayed primary closure or skin
graft
If toxaemia or septicaemia persists in spite of
chemotherapy the wound is drained
GUNSHOT INJURIES
General Considerations
Missile wounds are looked upon as a
special type of open injury
Tissue damage produced by:
1. Direct injury in the immediate path of the missile
2. Contusion of muscles around the missile track
3. Bruising and congestion of soft tissues at a
greater distance from the primary track

Fractures caused by gunshot injury
Low-velocity missile High-velocity missile
In all gunshot injuries debris is sucked into the
wound, which is therefore CONTAMINATED from
the outset
Early Management
Bleeding control and general resuscitation
is the first priority
Examine the wounds for artery or nerve
damage
Cover the wounds using sterile dressings
Antibiotics should be given immediately
Definitive Treatment
All missile injuries are treated as severe
open injuries
Perform exploration of missile track and
debridement
Low-velocity wounds with relatively clean
entry and exit wounds can be treated as
Gustilo type I injuries
High-velocity injuries demand thorough
cleansing and debridement, ischaemia
prevention, the wounds should left open
The SAFEST PLAN, if the contamination is
considerable, and if anatomical considerations
permit, is to JOIN THE ENTRY AND EXIT
WOUNDS and LEAVE THE ENTIRE TRACK OPEN
Delayed primary closure after 7 days
If there are comminuted fractures, these are
best managed by EXTERNAL FIXATION
Post-mortem specimen of an
osteomyelitic bone following
gunshot injury
references
Apleys System of Orthopaedics and Fractures
A. Graham Apley, Louis Solomon
Pengantar Ilmu Bedah Ortopedi
Chairuddin Rasjad
Textbook of Disorders and Injuries of the
Musculoskeletal System
Robert Bruce Salter
Traction and Orthopaedic Appliances
John D.M. Stewart, Jeffrey P. Hallet


Thank You