Widiyatmiko
Introduction
Orthopaedics is concerned
with bones, joints,
muscles, tendons and
nerves – the skeletal
system and all that makes
it move
Introduction
Scope : Subdivision :
• Congenital & developmental • Traumatology
abnormalities
• Infection & inflammation • Orthopaedi :
• Arthritis & rheumatic disorders 1. Adult Reconstruction
• Metabolic & endocrine 2. Oncology Orthopaedic
disorders
3. Pediatric Orthopaedic
• Tumours
• Sensory disturbance & muscle 4. Spine
weakness 5. Hand & Microsurgery
• Injury & mechanical 6. Sports Injury
derangement
In Emergency Room…
• Assess all trauma patient for possibility of orthopaedic case!
• If the patient need operation prepare as soon as possible!
1. Informed consent
2. Tell to fast at least 6 hours prior to op
3. Make IV line
4. Tetanus prophilactic
5. Antibiotic & analgetic
6. Blood check (SYSMEX for < 40 y.o, complete for > 40 y.o and < 14 y.o)
7. Urine check
8. Cross match & blood reservation in blood bank
9. EKG ( for > 40 y.o)
10. Chest X-Ray, with expertise for < 14 y.o
11. Complete the medical record ! (under resident supervision)
12. IPD or paediatric consultation ( for > 40 or < 14, sometimes no
need)
13. Anesthesiology consultation
General Principles of Fracture Treatment
1. First, Do No Harm
2. Base Treatment on Accurate Diagnosis
and Prognosis
3. Select Treatment with Specific Aims
4. Cooperate with the “ Laws of Nature “
5. Make Treatment Realistic and Practical
6. Select Treatment for You as an
Individual
Aphorism of Fracture Management
Anatomic location includes the name of the bone or the bones involved.
First We LOOK
Then We FEEL
Then We MOVE
• Neurological examination
• Diagnostic imaging
• Blood Test
• Synovial fluid analysis
• Bone biopsy
• Arthroscopy
• Electro diagnosis
Adult and Children Fracture
Children Fracture
1. Fracture more common .
2. Stronger and more active periosteum .
3. More rapid fracture healing .
4. Special problems of diagnosis .
5. Spontaneous correction of certain residual
deformities .
6. Differences in complications .
7. Different emphasis on methods of treatment
8. Torn ligament and dislocation less common .
9. Less tolerance of major blood loss
Adult Fracture
1. Fracture less common but more serious .
2. Weaker and less active periosteum .
3. Less rapid fracture healing .
4. Fewer problem of diagnosis .
5. No spontaneous correction of residual fracture
deformities .
6. Differences in complication .
7. Differences emphasis on methods of treatment.
8. Torn ligament and dislocations are more
common .
9. Better tolerance of major blood loss .
CLOSED FRACTURE
The fracture is not exposed to the
external environment.
Goals
• Prevention of infection
• Restoration of function
Steps in management
The 3 S’s
Stop the bleeding!
Splint the extremity
Stabilize the pelvis
Primary Survey & Resuscitation
• Hemorrhage control
• Pain relief
• Prevent further soft tissue injury
Apply splint early, but avoid delay in resuscitation.
Be careful in dislocation
Primary Survey & Resuscitation
Adjuncts : X-Rays
Determinited by patient’s condition
Look
Feel
Listen
For What?
For What?
Look Feel
Deformity Crepitus
Pain Skin flaps
Tenderness Neurologic
Wound(s) deficit
Pulses
Listen
Doppler signals
Bruit
Life- Threatening Injuries
Major pelvic disruption with hemorrhage
Major arterial hemorrhage
Crush syndrome (rhabdomyolysis)
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
• Posterior pelvic structures disrupted
• Pelvis open : vessels, nerves,rectum, skin
• Mechanism of injury
– Motorcycle
– Pedestrian
– Crush
– Falls > 12 feet (3.6 meters)
Life Threatening Musculoskeletal
Trauma
Pelvic Trauma with Massive Bleeding
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
Pelvic Wrapping
Life Threatening Musculoskeletal
Trauma
Main Arterial Rupture
1. Trauma
- sharp, blunt
2 Examination
- Artery pulse, Doppler
- Ankle / brachial index
3. Management
- Pneumatic tourniquet
- Vascular clamp?
- Traction, Splint
Life Threatening Musculoskeletal
Trauma
Crush Syndrome
Myoglobinuria
Metabolic acidosis, ↑K,
↓Ca and coagulopathy
Compartment syndrome
IV fluids, alkalization of
urine
Limb- Threatening Injuries
Open fracture and joint injuries
Vascular injuries
Compartment syndrome
Neurologic injury
What are my early concerns?
Vascular compromise
Open fractures
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Reduce fracture(s)
Splint fracture(s)
Assess by Doppler
Obtain consult (time
is critical)
Consider
angiography
Limb Threatening Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation
Limb Threatening Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation
Management
• Muscle necrosis : 6 h
• Warm & Cold Ischemic
• Reimplatantation &
Revascularization
• Proper amputee
management!
Limb Threatening
Musculoskeletal Trauma Compartement
Syndrome
• Fractures of the arm or leg ischemia
• Infarcted muscles fibrous tissue
(Volkmann’s ischemic contracture)
Limb Threatening
Musculoskeletal Trauma Compartement
Syndrome
Clinical features
• Elbow, forearm bones, 1/3 prox.
of tibiae, multiple fractures of
the foot or hand, crush injuries &
circumferential burns
• Five Ps
• The presence of a pulse does not
exclude the diagnosis
• Be careful in unconscious patient
!
Limb Threatening
Musculoskeletal Trauma Compartement
Syndrome
Treatment
• Decompression
• Open fasciotomi
Limb Threatening
Musculoskeletal Trauma Dislocations
• Displacement of bone from normal joint
Occult injuries
Occult blood loss
Compartment syndrome
Case 1 : Male, 40 y.o
ICD 9-CM 79.63, 93.44
Summary
Primary Survey : Identify life-threatening
Injuries
Secondary Survey : Identify limb-
threatening injuries
Mechanism of Injuries : History important
Orthopaedic consult
Early immobilization