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MUSCULOSKELETAL

EMERGENICIES

Oleh : Geiska Rizqi Sona


R.S.

TYPES OF INJURIES

CONTUSION
STRAIN
SPRAIN
DISLOCATION
FRACTURE
EPIPHYSEAL TRAUMA

SPRAIN

Terengangnya atau
robeknya ligamen
( jaringan ikat yang
menghubungkan dua atau
lebih tulang dalam sebuah
sendi)

Dapat mengenai satu atau


lebih ligamen dalam waktu
yang bersamaan

Penyebab Sprain?

Jatuh
Tiba-tiba terpuntir
Tekanan pada tubuh
yang menyebabkan
tulang pada sendi
bergeser sehingga
menyebabkan
ligamen terengang
atau bahkan robek

Lokasi paling sering terkena


sprain ?

Paling sering: di
pergelangan kaki
Lokasi tersering
lainnya :
pergelangan
tangan
Sprain di jempol
biasanya pada
atlet ski

Gejala dan tanda


sprain ?

Nyeri
Bengkak
Memar
Gerak sendi
tidak stabil
Kaku sendi
Perdarahan

STRAIN

Kerusakan pada otot


atau tendon karena
penarikan otot yang
berlebihan atau
kontraksi otot yang
mendadak
Kerusakan yang terjadi
bisa penarikan
berlebihan yang simpel
di otot atau tendon,
sebagian atau
seluruhnya

Penyebab Strain?

Terpuntir atau
tertariknya otot
atau tendon
secara berlebihan
dapat bersifat
akut (beban
berat) atau kronik
(cedera berulang
kali di tempat
yang sama)

Lokasi Strain paling sering ?

Dua lokasi tersering : otot hamstring &


pinggang
Tangan lengan & siku

Tanda & Gejala Strain

khas nyeri,
keterbatasan gerak,
kram otot, otot lemah
Bengkak bersifat
lokal, kram, tanda
peradangan, bila
berat terjadi
hilangnya fungsi dari
kerja otot tersebut

DEFINISI

FRAKTUR

Fraktur atau Patah tulang ialah terputusnya jaringan

tulang, baik seluruhnya atau hanya sebagian saja.


Deformitas, nyeri, kehilangan fungsi

GEJALA DAN TANDA


1.
2.
3.
4.
5.
6.
7.

PAT
AH
TU
LAN
G

Perubahan Bentuk
Nyeri dan Kaku
Terdengar suara berderik pada daerah yang patah
Pembengkakan
Memar
Ujung tulang terlihat ( pada patah tulang terbuka )
Gangguan peredaran darah dan persarafan

JENIS PATAH TULANG

PAT
AH
TU
LAN
G

1. Patah Tulang Tertutup


Permukaan kulit utuh / tidak rusak / tidak ada luka
Bagian tulang yang patah tidak berhubungan dengan udara luar
2. Patah Tulang Terbuka
Permukaan kulit di atas / dekat bagian yang patah rusak / luka
Bagian tulang yang patah berhubungan dengan udara luar
memerlukan pertolongan yang lebih cepat, karena adanya resiko
terjadinya faktor penyulit seperti perdarahan dan infeksi.

SIMPLE MUSKULOSKLETAL
TRAUMA

LIFE THREATENING
MUSKULOSKLETAL TRAUMA

ATLS guideline
1. preparation
2. triage
3. primary survey[ABCDE]
4. resuscitation
5. adjuncts to primary survey and resuscitation
6. secondary survey
7. adjuncts to secondary survey
8. continued post resuscitation monitoring and
reevaluation
9. definitive care

1. Preparation
1.Prehospital phase [EMS]
Notify receiving hospital
Airway maintenance,
control of external
bleeding and shock,
immobilization of the
patient
2.Inhospital phase
Resuscitation area
Equipment,
monitor,warmed fluid
Trauma team
Protective communicable
disease

2. TRIAGE
19

EMERGENT
ABCs or neurovascular compromise
Fractured femur or open femur
URGENT
Deformity, loss of motion
Severe swelling or pain
NON-URGENT
Mild swelling, no neurovascular compromise

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3. Primary survey and


resuscitation

identify immediately treatable life threatening


injury with initial resuscitation
A airway maintenance with cervical spine
control
B breathing and ventilation
C circulation and bleeding control
D disability:neurologic status
E exposure/environmental control:complete
undress the patient but prevent hypothermia

A airway maintenance with cervical


spine control

Talk to the patient AVPU


Check the airway patency: secretion, blood, stridor
1.Remove of foreign material from mouth and pharynx
2.Chin lift and jaw thrust
3.Oropharyngeal or nasopharyngeal airway atau definitive airway

C-spine protection

unconscious
GCS 8
Neck pain
Quadriplegia, paraplegia, hemiplegia

B breathing and ventilation

Respiration
Chest movement
RR
Tracheal position
Breath sound
Subcutaneous emphysema
Inspection of neck vein and wound

C circulation and bleeding control

BP, PR, LOC


Skin color, capillary refill
External bleeding site
Internal bleeding site: thorax, abdomen,
pelvis, extremities

D disability:neurologic status

GCS
Pupils size and light
reaction

E exposure/environmental
control

Undressed
Exam back region
All entry and exit wound
Prevent hypothermia( warming light, warm
blankets, warm resuscitation fluid, warm
inspired air)
Patients right, closed area

adjuncts to primary survey and


resuscitation

Vital signs monitor


ECG trolley ECG
O2 sat,pulse oximeter monitor, AGD
Urinary and gastric catheter pasang kateter
urin, pasang NGT
Urine out put hitung balans cairan
Trauma film : lateral c-spine,CXR,pelvis
Blood Test

Primary survey and resuscitation


Protect and secure airway
Ventilate and oxygenate
Stop the bleeding!
Vigorous shock therapy
Protect from hypothermia

secondary survey
The complete
history and
physical
examination

Secondary survey

History AMPLE

Physical exam: head to toe

Chief Complaint
Mechanism of injury
Onset of symptoms
Observation
Inspection
Palpation
5 Ps

tubes and fingers in every orifice


Complete neurological exam
Special diagnosis tests
reevaluation

Secondary survey

Mechanism of injury

Detailed Exam: DCAP-BLS-TIC


Deformities

Burns

Contusions

Lacerations Instability

Abrasions

Swelling

Penetrations

Tenderness
Crepitus

Look: for deformity, discoloration, wounds, swelling,


shortening.
Feel: for abnormal movement, crepitus, pulses,
temperature, sensation.
Move: assess the ranges of active and passive
movement as well as joint stability.

LOOK

Deformity Angulation
- Rotation
- DIscrepancy
Position
Edema
Appearance of the
distal part

Pale
Darken

FEEL (neurovasc exam)

37

INSPECTION/PALPATION
FIVE PS
PAIN
PULSE
PALLOR
PARASTHESIA
PARALYSIS

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MOVE
38

Flexion and extension


Rotation

internal
external

Abduction and adduction

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MEASUREMENT

MEASUREMENTdiscrepancy

True
length,Anatomical
length
Appearance length

How to diagnose the muskuloskletal


trauma problems?

CLINICAL HYSTORY(not for the multitrauma


patients)
PHYSICAL EXAM : LOOK, FEEL,
MOVE,MEASUREMENT
DIAGNOSTIC IMAGING
X-ray (Immobilization first)

2 VIEWS (AP-lateral)
2 JOINTS (proximal & distal)
2 SIDES (IF Necessary)
Special order

MUSKULOSKLETAL TRAUMA
PROBLEMS

FRACTURES : Closed, Open

SOFT TISSUE INJURIES :tendon


rupture,muscle rupture w/ or w/o neurovascular
lesion.

SPRAIN & STRAIN

Anamnesis

Definisi Sprain
(cedera sendi) &
Strain (cedera
otot)
Mekanisme
trauma
(penyebab,
kapan, apa saja
yang sudah
dilakukan
Lokasi cedera
(ingat
lokasipaling
sering strain &
sprain)

Pemeriksaan Fisik
Primary Survey : A,B,
C clear
Secondary Survey

Sprain
Inspeksi : memar,
bengkak
Palpasi : rasakan tanda
deformitas, nyeri tekan

Strain
Inspeksi : deformitas,
memar, bengkak
Palpasi : rasakan tanda
deformitas, nyeri tekan

Tatalaksana Awal ?
RICE Therapy

Rest
Ice
Compression
Elevation

Derajat sprain & strain


berat : RICE
Spesialis untuk
dilakukan operasi
penyambungan
ligamen, otot, atau
tendon
Bila ragu, tatalaksana
setiap cedera
muskuloskeletal
sebagai fraktur

RICE

REST
Istirahat sambil melindungi daerah yang
cedera
Tujuan : memberi kesempatan regenerasi
ICE
Imobilisasi selama 3-6 minggu

Tujuan :
vasokonstriksi
Kantong berisi
kumpulan es batu
dikompres di area
cedera
Lakukan 3 kali
sehari, selama 10-20
menit, 2-3 kali sehari
selama 24 jam

Compression

Memberi tekanan
dengan menggunakan
perban khusus
Mengikatkan kantong
es di tempatnya dan
tetap di lanjutkan
setelah terapi dingin
Menghindari
pembengkakan.
Tidak terlalu ketat
(jangan lupa cek nadi
& CRT setiap 10-20
menit)

Elevate

Tujuan :
memudahkan
kembalinya darah &
mengurangi
pembekakan
memudahkan
kembalinya darah
dan untuk
mengurangi
pembengkakan
Dilakukan selama
24-36 jam

PRINCIPLE OF MANAGEMENT
FRACTURE

ALL FRACTURES & DISLOCATION ARE PATOLOGIC


CONDITION.

IMOBILISATION /SPLINT FIRST

STRICTLY NO DELAY OF TRANSFERING PATIENTS W/ FRACT


+ NEUROVASCULAR INJURY, OPEN FRACTURES ,
DISLOCATION.

DO NOT DO HARM

Immediate treatment
Orthopaedic consultation (evaluation of stable versus
unstable injury pattern)
Temporary splintage (Mast trousers, binding feet
together, pelvic wrapping)
Skeletal stabilization (pelvic Ex-fix, clamp)
Assessment of related injuries (visceral, rectal,
urological)

Major limb haemorrhage


Immediate treatment
Direct pressure on sites of compressible haemorrhage
Dressings and compression applied to wounds
Splintage of limbs

Large/contaminated open wound

Immediate treatment
Sterile wound dressing
Splintage
Irrigation if appropriate
Attention to tetanus immune status

Splintage
Splintage helping to:
reduce haemorrhage
prevent further tissue damage
aid analgesia
reduce the incidence of fat embolism.

Splinting General Rules


Immobilization of the limb, including the joint above
and below the fractured segment.
Realignment of the limb.
Application so as not to compromise arterial supply or
venous return.
Application to allow examination and re-assessment
of distal neurovascular status.

IMMOBILIZATION/SPLINTING
KEY POINTS

Immobilize joint above


and below injury
Assess neurovascular
status distal to injury
prior to splint
application and again
right after splint
application
If angulation at fracture
site without
neurovascular
compromise, immobilize
as presented

Minimize
movement of
extremity during
splinting
Secure splint to
provide support
and compression
Reassess/monitor
neurovascular
status every 5-10
minutes
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54

55

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Types of Splints

Long-Bone Splinting
Stabilize extremity manually.

Assess distal PMS.

Make sure splint extends several inches


beyond joints above/below injury.

Apply splint. Immobilize joints


above/below injury.

Secure extremity to splint.

Secure foot or hand in the position


of function.

Reassess distal PMS.

Pelvic Wrap
Prepare backboard.

Pelvic Wrap
Logroll patient & bring sheets around patient.

Pelvic Wrap
Secure sheets without over-compressing.

Sling should be
triangular

Form sling.

Assess PMS; position sling.

Secure corner of sling.

Leave fingertips exposed. Check distal


PMS.

Splint for Injured Finger

Types of injury

Pelvic fracture

Pelvic Fracture Stabilization

Leg Splint

Fast Splinting

OPEN FRACTURES
75

Usually associated with the long bones

Femur
Tibia
Fibula

Lacerated blood vessels can cause moderate to


severe hemorrhage into the tissue which may not
be evident
Any open fracture is considered urgent due to
the likelihood of bacterial infection or other
contamination of the wound.
If neurovascular compromise exists, then it
becomes an emergent condition.
Illinois EMSC

OPEN FRACTURES

Open
fracture

communication
between the fracture
and
the
external
environment
30% pts with OF are
polytrauma patients.
Require emergency
treatment
Significant morbidity

Gustilo, Burgess, Tscherne, the AO-ASIF group,


recommended the following steps for open injuries:

Treat OF as emergencies
Initial evaluation to diagnose life & limb-threatening
injuries
Appropriate antibiotic tx in the emergency OR and
continue treatment for 2 to 3 days only
Immediately debride the wound of contaminated and
devitalized tissue, copiously irrigate, repeat debridement
within 24 to 72 hours
Stabilize the fracture with the method determined at initial
evaluation
Leave the wound open
Rehabilitate the involved extremity aggressively

Principles of Management

Prevention of infection
Soft tissue healing and bone
union
Restoration of anatomy
Functional recovery

AO Principles of Fracture Management, 2000,

Some DO NOT's when applying first aid


for fractures
DO NOT Massage the affected area
DO NOT Straighten the broken bone
DO NOT Move without support to broken
bone
DO NOT Move joints above or below the
fracture
DO NOT Give oral liquids or food

THANK YOU
FOR YOUR
ATTENTION!