Aryadi Kurniawan A.Dohar A. L. Tobing - Website Staff UIstaff.ui.ac.id/system/files/users/ganti995/material/... · Aryadi Kurniawan A.Dohar A. L. Tobing Dep. of Surgery Div. Orthopaedics

Aryadi KurniawanA.Dohar A. L. Tobing

Dep. of S urgeryDiv. Orthopaedics & Traumatology, FKUI/RS CM

Kuliah MS – Des 08Kuliah MS – Des 08

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Musculoskeletal systemMusculoskeletal system

A system of organs that enables man to mobilize physically, utilizing the muscular and skeletal system.

Bones are connected one another on their articular joints, bound together by the ligaments, capsules, muscles and connective tissues around the joint.

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Basic Knowledge

Anatomy Physiology Histology Biochemistri

Kinesiology Biomechanic Kinemathics Engineering

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Comprehensive understanding on normal musculoskeletal system will ensure a better knowledge on musculoskeletal pathologies

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Musculoskeletal pathologies in general

Trauma Infection Congenital anomalies Neoplasma / tumor Degenerative (osteoporosis, osteoarthritis) Metabolic

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Musculoskeletal injury Bone:

Epiphyseal plate Cortical bone Cancellous bone

Joint: Articular cartilage Joint Capsule Ligaments

Muscles Tendon Peripheral nerve

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Forces responsible for the injury

Mechanism of injury : Direct Indirect

Orientation : Axial / compresion S hearing Twisting / rotation

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Forces responsible for the injury

Capacity of the forces : High energy Low energy

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FRACTUREFRACTURE S tructural discontinuity of bone, articular

cartilage or epiphyseal growth plate

Depending on the skin and soft tissue coverage around the fracture site

1. Closed : intact2. Open / COMPOUND : The soft tissue coverage

is breech and there is an open communication with the outer environment

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FRACTURE ETI OLOGI ESNon Pathological

1. S IN G LE TR AU M AS IN G LE TR AU M A2. Repetitive stress

Pathological1. Malignancy2. Infection3. Osteoporosis (insufficient fracture)

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Pattern of Complete Fracture

S IMPLE Transverse Oblique S piral Impacted

COMPLEX Comminutive S egmental

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Incomplete Fracture

Involve only one cortex Intact Periosteum Children/ Paediatric Greenstick #, torus #

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St r es s Fr ac t ur e / Fat i gue Fr ac t ur e Mostly on tibia/fibula Occurs frequently on athlete, dancer, new

army recruits

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Pathological fracture

Normal S tress for normal bone Deteriorated bone microstructural

Osteoporosis Malignancy Paget disease

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Sites associated with low BMD

HIP SPINE WRIST

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Paget DISEASE

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Open Fracture

Gustillo & Anderson clasification :

Grade I Grade II Grade III : III A III B III C

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Grade I

Open wound < 1 cm Clean Low energy trauma

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Grade II

Wound > 1 cm No extensive soft tissue stripping Moderate energy trauma

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Grade III

High energy trauma High velocity trauma Gun shot Grosly contaminated ( farm injury,

barnyard injury ) Associated Neurovascular injury Open fracture > 8 jam

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Grade III

III A : Adequate soft tissue coverage III B :

Bone exposed Extensive periosteal stripping Grosly comminutive

III C : With vascular injury which otherwise repaired will jeopardize the limb vitality

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FRACTURE DISPLACEMENT

o/ Trauma force o/ Muscle pull o/ Gravity

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FRACTURE DISPKACEMENT

Aposition Angulation Rotation S hortening/ Distraction

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FRACTURE HEALING

Hematoma Inflamation and cell proliferation Callus formation Consolidation Remodelling

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PHYSICAL EXAMINATION PR IM ARY S U RV E YPR IM ARY S U RV E Y Look :

S welling and edema Deformity open wound S kin colour

Feel : Tenderness Neurovascular distal

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PHYSICAL EXAMINATION

Move : Functio Laesa Mobilize the uninvolved joint to

asses the motoric scale

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X- ray

Fracture configuration Further management Follow up Medical record

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X ray

2 views : AP/Lat/Oblik

2 joints Confirm no intra articular injury

2 extremities especially in children

2 times

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I MAGI NG

Bone scanning CT scan (computerized tomography) MR I (Magnetic Resonance Imaging) MS CT (Multi S liced CT)

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BONE SCAN

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3D CT SCAN

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CT SCAN

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PRINCIPLE OF MANAGEMENT

Recognize Reduce Retain Rehabilitation

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REDUCTION

Reduce = reposition reduction closed manipulation open surgery reduksi a vue

( direct vision)

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CLOSED REDUCTION

General anaesthesia Muscle relaxant 3 Manouvre manipulation

Apply taction on the distal fragment along its longitudinal axis (disengagement)

Reduce to anatomical position Realign on 2 dimension

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OPEN REDUCTION

Debridemen open fracture Closed frakture

Failed closed reduction Intra articular fracture Avulsion fraktur

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OPEN FRACTURE

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RETAINMENT / IMOBILIZATION

S plint S kin traction Circular cast Internal fixation Exeternal fixation

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GIPS

= Plaster = POP = Plaster of Paris S plint Circular cast

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OPEN FRACTURE

Contamination higher risk of infection Principles of management eradicate

infection S tart with primary survey Therapeutic IV antibiotic (not prophylactic) Tetanus Prophylactic : Toxoid, ATS

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OPEN FRACTURE

Emergency Debridement

Decontamination from dirt, foreign body (The best solution for pollution is dilution)

Excision of non vital tissue Open reduction

General anaesthesia

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EPIPHYSEAL PLATE INJURY

Paediatric If managed unproperly may lead to growth

disturbance or even cessation

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FRACTURE COMPLICATION

Early : Viseral injury Vaskuler injury Compartment syndrome

( Volkmann’s ischemia) Nerve injury Infection

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COMPARTMENT SYNDROME

An increased pressure in closed osseofasial compartment that compromise the intrinsic vascularization and jeopardize the vitality of the involved limb

The plaster is too tight Vascular injury Haemophillia

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COMPARTMENT SYNDROME

High risk elbow fracture, forearm, tibia proksimal

5 P S IGN: Pain Paraesthesia Pallor Paralis is Pulselessness

Tx : fasiotomi

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FRACTURE COMPLICATION

Late : Delayed union Non-union Malunion Joint stifness Muscle Hypotrofi/atrofi M iositis osifikans Avascular Necrosis Algodystrophy (S udeck’s atrophy) Osteoarthritis

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Del ayed Uni on

At the time of estimated union such fracture healing is not attained yet

Cause : S evere soft tissue injury Infection Inadequate stabilization

TX : bone graft

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Non- union

Fracture site is filled with fibrosis Pseudoarthrosis No sign of fracture healing process at all X ray : obvious fracture line

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Malunion

Fracture united in malposition leading to impairment of fucntion

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Avascular Necrosis Dislokation Bone ischemic avascular

necrosis Occurs frequently : feoral head, proximal

scafoid, lunate, talus

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Fr ac t ur e di s eas e

Prolonged immobilization Muscle hypotrofi/atrofi Disuse osteoporosis Joint stifness

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Sprain ligament

Ligamentous injury without any structural discontinuity

i.e. sprain ankle Clinical sign : tenderness, swelling,

blueish

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Sprain ankle

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Strain ligament

Ligamentous injury with partial structural discontinuity which doesn’t affect the joint stability

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LIGAMENTOUS RUPTURE

Partial or total structural discontinuity May be associated with aulsion fracture Knee, ankle, Haematoma, severe tenderness and

swelling

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DISLOCATION Total loss of joint contact S evere pain, deformity, limited range of

motion

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Dislokasi posteriorkaput femur

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Dislokasi

Dislok CMC 1 Dislok TMJ

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SUBLUXATION

Partial joint contact is maintained

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St r ai n mus c l e

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Strain Muscle

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Tendon

Tendonitis : inflamation on the tendon sheath

example : tendonitis achilles (heel cord ) tendonitis supraspinnatus dll

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SPONTANEOUS RUPTURE OF ACHILLES TENDON

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Rupture of long head of biceps

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