Catatan bedah

CATATACATATAN N

BEDAHBEDAHdr.Syafwan Azharidr.Syafwan Azhari

Department of General SurgeryDepartment of General SurgeryZainoel Abidin HospitalZainoel Abidin Hospital

Banda AcehBanda Aceh

Glasgow Coma Glasgow Coma ScaleScale

Assesment area Assesment area ScoreScore

Motor response (M)Motor response (M) Obeys commandObeys command 66 Localizes painLocalizes pain 55 Normal flexion Normal flexion

(withdrawal to pain)(withdrawal to pain) 44 Abnormal flexion Abnormal flexion

(decorticate)(decorticate) 33 Abnormal extension Abnormal extension

(decerebrate)(decerebrate) 22 None (flaccid)None (flaccid) 1 1

Assesment area Assesment area ScoreScore

Verbal Response (V)Verbal Response (V) OrientedOriented 55 Confused conversationConfused conversation 44 Inappropriate wordsInappropriate words 33 Incomprehensible soundsIncomprehensible sounds 22 NoneNone 11

Assesment area Assesment area ScoreScore Eye opening (E)Eye opening (E) SpontaneousSpontaneous 44 To speechTo speech 33 To painTo pain 22 NoneNone 11

DecorticateDecorticate

DecerebrateDecerebrate

Figure 22-17

PosturingPosturing

Abnormal extension Abnormal extension (decerebrate (decerebrate

posturing)posturing)

Abnormal flexion Abnormal flexion (decorticate (decorticate posturing)posturing)

PERJALANAN KLINIK PERJALANAN KLINIK EDHEDH

STONESTONE

INFECTIONINFECTION OBSTRUCTIONOBSTRUCTION

PYONEPHROSISPYONEPHROSISUROSEPSISUROSEPSIS

HYDRONEPHROSISHYDRONEPHROSISHYDROURETERHYDROURETER

RENAL FAILURERENAL FAILURE(Relation with location, duration and size of stone)(Relation with location, duration and size of stone)

Grade trauma Grade trauma ginjalginjal• Grade I:Grade I:

Kontusio ginjal/hematoma perirenal.Kontusio ginjal/hematoma perirenal.

• Grade II:Grade II: Laserasi ginjal terbatas pada korteks.Laserasi ginjal terbatas pada korteks.

• Grade III:Grade III: Laserasi ginjal sampai pada medulla Laserasi ginjal sampai pada medulla ginjal, mungkin terdapat trombosis ginjal, mungkin terdapat trombosis arteri segmentalis.arteri segmentalis.

• Grade IV:Grade IV: Laserasi sampai mengenai sistem Laserasi sampai mengenai sistem kalises ginjal.kalises ginjal.

• Grade V:Grade V: – Avulsi pedikel ginjal, mungkin Avulsi pedikel ginjal, mungkin

terjadi trombosis arteria renalis.terjadi trombosis arteria renalis.– Ginjal terbelah (shatered). Ginjal terbelah (shatered).

Penilaian preoperatif & Penilaian preoperatif & diagnosisdiagnosis

Trauma Tumpul GinjalTrauma Tumpul Ginjal

HematuriaHematuriaGross / mikroskopik dengan syokGross / mikroskopik dengan syok

Stabil:Stabil: IVPIVP

Tidak stabil: Tidak stabil: LaparatomiLaparatomieksplorasieksplorasi

AbnormalAbnormal Normal Normal

E k s p l o r a s iE k s p l o r a s i ObservasiObservasi

Hematom retroperitonealHematom retroperitoneal

Meluas / berdenyutMeluas / berdenyut

ObservasiObservasiEksplorasiEksplorasi

Tidak meluasTidak meluas

HematuriaHematuriamikroskopik mikroskopik tanpa syoktanpa syok

Imajing (–) Kec: Imajing (–) Kec: Trauma penyertaTrauma penyerta Deselerasi cepatDeselerasi cepat

Tidak informatifTidak informatif

Trauma penyertaTrauma penyerta

(-)(-) (+)(+)

ObservasiObservasi

Staging Ca buli – buli Staging Ca buli – buli

Stadium Ca buli – buliStadium Ca buli – buli sistem TNM & menurut Marshallsistem TNM & menurut Marshall

TNMTNM MarshallMarshall Uraian Uraian TisTis 00 Carsinoma in situCarsinoma in situ

TaTa 00 Tumor papilari non invasifTumor papilari non invasif

T1T1 AA Invasi submukosaInvasi submukosa

T2T2 B1B1 Invasi otot superfisialInvasi otot superfisial

T3aT3a B2B2 Invasi otot profundaInvasi otot profunda

T3bT3b CC Invasi jaringan lemak prevesika Invasi jaringan lemak prevesika

T4T4 D1D1 Invasi ke organ sekitarInvasi ke organ sekitar

N1 – 3 N1 – 3 D1D1 Matestase ke limfonudi regionalMatestase ke limfonudi regional

M1M1 D2D2 Metastase hematogenMetastase hematogen

frontal views of LeFort complex fractures I - III frontal views of LeFort complex fractures I - III

lateral views of LeFort complex fractures I - IIIlateral views of LeFort complex fractures I - III

Maxillary fracture

• The LeFort IThe LeFort I, or transmaxillary fracture runs between the maxillary floor and the orbital , or transmaxillary fracture runs between the maxillary floor and the orbital floor. It may involve the medial and lateral walls of the maxillary sinuses and invariably floor. It may involve the medial and lateral walls of the maxillary sinuses and invariably involves the pterygoid processes of the sphenoid. Clinically, the floating fragment will be the involves the pterygoid processes of the sphenoid. Clinically, the floating fragment will be the lower maxilla with the maxillary teeth. lower maxilla with the maxillary teeth.

• The LeFort IIThe LeFort II occurs along yet another weak zone in the face, and is sometimes called a occurs along yet another weak zone in the face, and is sometimes called a pyramidal fracture because of its shape. A common mechanism is a downward blow to the pyramidal fracture because of its shape. A common mechanism is a downward blow to the nasal area. nasal area.

• The most severe of the classic LeFort fracture complexes is the The most severe of the classic LeFort fracture complexes is the LeFort IIILeFort III. I suppose that . I suppose that this is pretty obvious, given a three-part grading system. In this case, the large unstable this is pretty obvious, given a three-part grading system. In this case, the large unstable (floating) fragment is virtually the entire face! Thus, this fracture is also referred to as (floating) fragment is virtually the entire face! Thus, this fracture is also referred to as craniofacial disassociation. This is a very severe injury, and is often associated with craniofacial disassociation. This is a very severe injury, and is often associated with significant injury to many of the soft tissue structures along the fracture lines. Generally, significant injury to many of the soft tissue structures along the fracture lines. Generally, considerable force is necessary to produce this injury, and it is uncommon as an isolated considerable force is necessary to produce this injury, and it is uncommon as an isolated injury. It may also occur in association with severe skull and brain injuries. injury. It may also occur in association with severe skull and brain injuries.

Common sites of Common sites of Mandibular Fractures Mandibular Fractures

Fracture Fracture TypeTypePrevalencePrevalence

BodyBody 30 - 40 %30 - 40 %

Angle Angle 25 - 31 %25 - 31 %

Condyle Condyle 15 - 17 % 15 - 17 % Symphysis Symphysis 7 - 15 % 7 - 15 %

Ramus Ramus 3 - 9 % 3 - 9 %

Alveolar Alveolar 2 - 4 % 2 - 4 % Coronoid Coronoid process process

1 - 2 % 1 - 2 %

Figure 22-11

Evaluation of the NeckEvaluation of the Neck3 zones defined by 3 zones defined by horizontal planes horizontal planes

• Zone IZone I– Injuries carry highest Injuries carry highest

mortality ratemortality rate• Zone IIZone II

– Most common injuries Most common injuries but lower mortality rate but lower mortality rate than zone I injuriesthan zone I injuries

• Zone IIIZone III– Greatest risk of injury to Greatest risk of injury to

distal carotid artery, distal carotid artery, salivary glands, and salivary glands, and pharynxpharynx

KLASIFIKASI STADIUM TNM PADA KLASIFIKASI STADIUM TNM PADA KANKER PAYUDARAKANKER PAYUDARA

TxTx Tumor primer tdk dpt dinilaiTumor primer tdk dpt dinilaiCATATAN:CATATAN:Ukuran T secara klinis, radiologis, dan mikroskopis adalah sama.Ukuran T secara klinis, radiologis, dan mikroskopis adalah sama.Nilai T dalam cm, nilai paling kecil dibulatkan ke angka 0,1 cm.Nilai T dalam cm, nilai paling kecil dibulatkan ke angka 0,1 cm.

T0T0 Tdk t’dpt tumor primerTdk t’dpt tumor primerTisTis

•Tis(DCIS)Tis(DCIS)•Tis(LCIS)Tis(LCIS)•Tis(pageTis(page

t)t)

Karsinoma in situKarsinoma in situ•Ductal carcinoma in situDuctal carcinoma in situ•Lobular carcinoma in situLobular carcinoma in situ•Penyakit Paget pd putting tanpa adanya tumorPenyakit Paget pd putting tanpa adanya tumorCATATAN:CATATAN:Penyakit Paget dgn adanya tumor dikelompokkan sesuai dgn ukuran tumornyaPenyakit Paget dgn adanya tumor dikelompokkan sesuai dgn ukuran tumornya

T1T1•T1micT1mic

•T1aT1a•T1bT1b•T1cT1c

Tumor dgn ukuran diameter Tumor dgn ukuran diameter ≤ 2 cm≤ 2 cm•Adanya micro invasi ukuran 0,1 cm at kurangAdanya micro invasi ukuran 0,1 cm at kurang•Tumor dgn ukuran lebih dari 0,1 cm sampai 0,5 cmTumor dgn ukuran lebih dari 0,1 cm sampai 0,5 cm•Tumor dgn ukuran lebih dari 0,5 cm sampai 1 cmTumor dgn ukuran lebih dari 0,5 cm sampai 1 cm•Tumor dgn ukuran lebih dari 1 cm sampai 5 cmTumor dgn ukuran lebih dari 1 cm sampai 5 cm

T2T2 Tumor dgn ukuran diameter terbesarnya lebih dari 2 cm sampai 5 cm Tumor dgn ukuran diameter terbesarnya lebih dari 2 cm sampai 5 cm T3T3 Tumor dgn ukuran diameter terbesarnya lebih dari 5 cmTumor dgn ukuran diameter terbesarnya lebih dari 5 cmT4T4

•T4aT4a•T4bT4b•T4cT4c•T4dT4d

Ukuran tumor berapapun dgn ekstensi langsung ke dinding dada atau kulit Ukuran tumor berapapun dgn ekstensi langsung ke dinding dada atau kulit •Ekstensi kedinding dada (tdk t’masuk otot pectoralis)Ekstensi kedinding dada (tdk t’masuk otot pectoralis)•Edema (t’masuk peau d’orange), ulcerasi, nodul satelit pd kulit yg t’batas pd 1 Edema (t’masuk peau d’orange), ulcerasi, nodul satelit pd kulit yg t’batas pd 1 payudarapayudara•Mencakup kedua hal diatasMencakup kedua hal diatas•Mastitis karsinomatosaMastitis karsinomatosaCATATAN:CATATAN:Dinding dada adalah t’masuk iga, otot intercostalis dan otot serratus anterior tapi Dinding dada adalah t’masuk iga, otot intercostalis dan otot serratus anterior tapi tidak t’masuk otot pectoralis tidak t’masuk otot pectoralis

NxNx KGB regional tdk dpt dinilai (telah diangkat sebelumnya)KGB regional tdk dpt dinilai (telah diangkat sebelumnya)N0N0 Tidak terdapat metastase KGBTidak terdapat metastase KGBN1N1 Metastase ke KGB axilla ipsilateral yg mobile Metastase ke KGB axilla ipsilateral yg mobile

N2 N2

•N2aN2a•N2b N2b

Metastase ke KGB axilla ipsilateral t’fiksir, b’konglomerasi at adanya pembesaran Metastase ke KGB axilla ipsilateral t’fiksir, b’konglomerasi at adanya pembesaran KGB mamaria interna ipsilateral (klinisKGB mamaria interna ipsilateral (klinis**) tanpa adanya metastase ke KGB axilla.) tanpa adanya metastase ke KGB axilla.•Metastase pd KGB axilla t’fiksir at b’konglomerasi at melekat pd struktur lainMetastase pd KGB axilla t’fiksir at b’konglomerasi at melekat pd struktur lain•Metastase hanya pd KBG mamaria interna ipsilateral secara klinisMetastase hanya pd KBG mamaria interna ipsilateral secara klinis** dan tdk t’dpt dan tdk t’dpt metastase pd KGB axilla metastase pd KGB axilla

N3N3

•N3aN3a•N3bN3b•N3cN3c

Metastase pd KGB infraklavikular ipsilateral dgn at tanpa metastase KGB axilla at Metastase pd KGB infraklavikular ipsilateral dgn at tanpa metastase KGB axilla at klinis t’dpt metastase pd KGB mamaria interna ipsilateral klinis dan metastase pd klinis t’dpt metastase pd KGB mamaria interna ipsilateral klinis dan metastase pd KGB axillaKGB axillaat metastase pd KGB supraklavikular ipsilateral dgn at tanpa metastase KGB at metastase pd KGB supraklavikular ipsilateral dgn at tanpa metastase KGB axilla/mamaria internaaxilla/mamaria interna•Metastase ke KGB infraklavikular ipsilateralMetastase ke KGB infraklavikular ipsilateral•Metastase ke KGB mamaria interna dan KGB axillaMetastase ke KGB mamaria interna dan KGB axilla•Metastase ke KGB supraklavikularMetastase ke KGB supraklavikularCATATAN:CATATAN:*t’deteksi secara klinis : t’deteksi dgn pemeriksaan fisik at secara imaging (diluar *t’deteksi secara klinis : t’deteksi dgn pemeriksaan fisik at secara imaging (diluar limfoscintigrafi)limfoscintigrafi)

MxMx Metastase jauh belum dapat dinilaiMetastase jauh belum dapat dinilai

M0M0 Tidak terdapat metastase jauhTidak terdapat metastase jauh

M1M1 Terdapat metastase jauhTerdapat metastase jauh

GROUP STADIUM KANKER PAYUDARA GROUP STADIUM KANKER PAYUDARA STADIUM 0STADIUM 0 TisTis N0N0 M0M0

STADIUM ISTADIUM I T1*T1* N0N0 M0M0

STADIUM IIASTADIUM IIA T0T0T1*T1*T2T2

N1N1N1N1N0N0

M0M0M0M0M0M0

STADIUM IIBSTADIUM IIB T2T2T3T3

N1N1N0N0

M0M0M0M0

STADIUM IIIASTADIUM IIIA T0T0T1T1T2T2T3T3T3T3

N2N2N2N2N2N2N1N1N2N2

M0M0M0M0M0M0M0M0M0M0

STADIUM IIIBSTADIUM IIIB T4T4T4T4T4T4

N0N0N1N1N2N2

M0M0M0M0M0M0

STADIUM IIICSTADIUM IIIC Tiap TTiap T N3N3 M0M0

STADIUM IVSTADIUM IV Tiap TTiap T Tiap NTiap N M1M1

Mammogram normalMammogram normal

Usia lanjut <------------------- usia muda

MechanismMechanism of of

InjuryInjury

KLASIFIKASI STADIUM TNM PADA KANKER KELENJAR LIUR KLASIFIKASI STADIUM TNM PADA KANKER KELENJAR LIUR (AJCC 2002)(AJCC 2002)

TxTx Tumor primer tdk dpt dinilaiTumor primer tdk dpt dinilai

T0T0 Tdk t’dpt tumor primerTdk t’dpt tumor primer

T1T1 Tumor dgn ukuran diameter Tumor dgn ukuran diameter ≤ 2 ≤ 2 cmcmTidak ada ekstensi Tidak ada ekstensi ekstraparenkimekstraparenkim

T2T2 Tumor dgn ukuran diameter > 2 Tumor dgn ukuran diameter > 2 cm sampai 4 cmcm sampai 4 cm Tidak ada ekstensi Tidak ada ekstensi ekstraparenkimekstraparenkim

T3T3 Tumor dgn ukuran diameter > 4 Tumor dgn ukuran diameter > 4 cm sampai 6 cmcm sampai 6 cmAtau ada Atau ada ekstensi ekstraparenkim ekstensi ekstraparenkim tanpa terlibat n.VIItanpa terlibat n.VII

T4T4 Tumor dgn ukuran diameter > 6 Tumor dgn ukuran diameter > 6 cmcmAtau ada invasi ke n.VII / dasar Atau ada invasi ke n.VII / dasar tengkoraktengkorak

NxNx KGB regional tdk dpt dinilaiKGB regional tdk dpt dinilai

N0N0 Tidak terdapat metastase KGBTidak terdapat metastase KGBN1N1 Metastase ke KGB tunggal < 3 cmMetastase ke KGB tunggal < 3 cm

IpsilateralIpsilateralN2 N2

•N2aN2a

•N2b N2b

•N2c N2c

Metastase ke KGB tunggal / Metastase ke KGB tunggal / multiple >3 cm – 6 cmmultiple >3 cm – 6 cmIpsilateral / bilateral / Ipsilateral / bilateral / kontralateralkontralateral

Metastase ke KGB tunggal >3 cm Metastase ke KGB tunggal >3 cm – 6 cm– 6 cmIpsilateralIpsilateralMetastase ke KGB multiple Metastase ke KGB multiple ≥ ≥ 6 6 cmcmipsilateralipsilateralMetastase ke KGB Metastase ke KGB ≥ ≥ 6 cm6 cmbilateral / kontralateralbilateral / kontralateral

N3N3 Metastase ke KGB Metastase ke KGB > > 6 cm6 cmMxMx Metastase jauh belum dapat Metastase jauh belum dapat dinilaidinilai

M0M0 Tidak terdapat metastase jauhTidak terdapat metastase jauh

M1M1 Terdapat metastase jauhTerdapat metastase jauh

GROUP STADIUM KANKER KELENJAR LIURGROUP STADIUM KANKER KELENJAR LIUR

STADIUM ISTADIUM I T1T1T2T2

N0N0N0N0

M0M0M0M0

STADIUM IISTADIUM II T3T3 N0N0 M0M0

STADIUM IIISTADIUM III T1T1T2T2

N1N1N1N1

M0M0M0M0

STADIUM IVSTADIUM IV T4T4T3T3T4T4

Tiap TTiap TTiap TTiap TTiap TTiap T

N0N0N1N1N1N1N2N2N3N3

Tiap NTiap N

M0M0M0M0M0M0M0M0M0M0M1M1

Lymph node stationsLymph node stations

1 = jugular chain1 = jugular chain2 = spinal chain2 = spinal chain3 = supraclavicular chain3 = supraclavicular chain4 = occipital lymph nodes4 = occipital lymph nodes5 = mastoid lymph nodes5 = mastoid lymph nodes6 = parotid lymph nodes6 = parotid lymph nodes7 = submandibular lymph nodes7 = submandibular lymph nodes8 = submental lymph nodes8 = submental lymph nodes9 = retropharyngeal lymph 9 = retropharyngeal lymph

nodesnodes10 = recurrent lymph nodes10 = recurrent lymph nodes11 = pretracheal lymph nodes11 = pretracheal lymph nodes12 = prethyroidean lymph 12 = prethyroidean lymph

nodesnodes

Superficial surgical trianglesSuperficial surgical triangles

m = mandiblem = mandiblec = claviclec = claviclei = hyoid bonei = hyoid bone

1 = angle of mandible1 = angle of mandible2 = posterior belly of digastric muscle2 = posterior belly of digastric muscle3 = hyoglossus muscle3 = hyoglossus muscle4 = mylohyoid muscle4 = mylohyoid muscle5 = anterior belly of digastric muscle5 = anterior belly of digastric muscle6 = sternocleidomastoid muscle6 = sternocleidomastoid muscle7 = superior belly of omohyoid muscle7 = superior belly of omohyoid muscle8 = sternohyoid muscle8 = sternohyoid muscle9 = trapezius muscle9 = trapezius muscle10 = inferior belly of omohyoid muscle10 = inferior belly of omohyoid muscle

Pembagian Pembagian Zona Zona

RetroperitoneRetroperitonealal

Clasification de Kuds y Sheldon

1982. Zona I (central) Zona II (lateral) Zona III (pelvic)

Schematic lateral Schematic lateral view of the cervical spineview of the cervical spine

Note the odontoid (dens),Note the odontoid (dens),the predental space and thethe predental space and thespinal canal.spinal canal.

A=anterior spinal line.A=anterior spinal line. B=posterior spinal line.B=posterior spinal line. C=spinolaminar line.C=spinolaminar line. D=clivus base line. D=clivus base line.

Retroperitoneal Retroperitoneal hematomahematoma

• Zone 1:Zone 1:Explore regardless of Explore regardless of mechanism.mechanism.

• Zone 2:Zone 2:Explore penetrating Explore penetrating trauma.trauma.Observe blunt trauma: Observe blunt trauma:

non expanding non expanding non pulsatile non pulsatile no urologic no urologic

indicationsindications

•Zone 3:Zone 3:Explore penetrating.Explore penetrating.Observe blunt.Observe blunt.

Systemic inflammatory respose Systemic inflammatory respose syndromesyndrome

SIRSSIRS

Two or more ofTwo or more of1.Temperature >38 C or <36 C1.Temperature >38 C or <36 C2.Tachycardia >90/min2.Tachycardia >90/min3.RR >20/min or PaCO2 ,4.3kPa3.RR >20/min or PaCO2 ,4.3kPa4.WBC>12X10 or < 4X10 or 10% immature 4.WBC>12X10 or < 4X10 or 10% immature formform

SepsisSepsis SIRS due to infectionSIRS due to infection

Severe sepsisSevere sepsis Sepsis with evidence of organ hypoperfusionSepsis with evidence of organ hypoperfusion

Septic shockSeptic shockSevere sepsis with hypotension (SBP,90) Severe sepsis with hypotension (SBP,90) despite adequate fluid resuscitation or the despite adequate fluid resuscitation or the requirement for vasopressors/inotropes to requirement for vasopressors/inotropes to maintain blood pressuremaintain blood pressure

Metabolisme pigmen empedu Metabolisme pigmen empedu dan proses eksresinyadan proses eksresinyaHaemoglobin Haemoglobin

Ferum Ferum Cincin porfirin Cincin porfirin

Bilirubin – GlobinBilirubin – Globin(larut lemak/nonkonyugasi)(larut lemak/nonkonyugasi)

Bilirubin Bilirubin (larut air/terkonyugasi)(larut air/terkonyugasi)

Urobilinogen Urobilinogen

Starkobilin Starkobilin

Feces Feces

Bilirubin Bilirubin (sistemik)(sistemik)

BilirubinBilirubin(urin)(urin)

Urobilinogen Urobilinogen (sistemik)(sistemik)

UrobilinUrobilin(urin)(urin)

Hepar Hepar (faal?)(faal?)

EmpeduEmpedu(obstruksi?)(obstruksi?)

Limpa Limpa

Usus Usus

An anterior view of segmental anatomy.An anterior view of segmental anatomy.HV, hepatic vein; IVC, inferior vena cava; PV, portal vein.HV, hepatic vein; IVC, inferior vena cava; PV, portal vein.

Segmental anatomy viewed from the inferior surface.Segmental anatomy viewed from the inferior surface.

Grading of Liver Grading of Liver InjuriesInjuries

Grading of Splenic Grading of Splenic InjuriesInjuries

Clasifikasi fraktur pelvisClasifikasi fraktur pelvis

Clasifikasi menurut Tile

Tipe AStable

Tipe B Rotationally unstable

Vertically stable(open book type)

Tipe CRotationally and

Vertically Unstable

Tile ClassificationTile Classification• Type A: StableType A: Stable

– Type A1: Fractures of the pelvis not involving the ring; avulsion Type A1: Fractures of the pelvis not involving the ring; avulsion injuries. injuries.

– Type A2: Stable, minimally displaced fractures of the ring.Type A2: Stable, minimally displaced fractures of the ring.

• Type B: Rotationally unstable, vertically stable.Type B: Rotationally unstable, vertically stable.– Type B1: Open-book.Type B1: Open-book.– Type B2: Lateral compression; ipsilateral.Type B2: Lateral compression; ipsilateral.– Type B3: Lateral compression; contralateral (bucket handle).Type B3: Lateral compression; contralateral (bucket handle).

• Type C: Rotationally and vertically unstable.Type C: Rotationally and vertically unstable.– Type C1: Unilateral. Type C1: Unilateral. – Type C2: Bilateral; one side rotationally unstable, with Type C2: Bilateral; one side rotationally unstable, with

contralateral contralateral side vertically Unstable. side vertically Unstable.– Type C3: Associated acetabular fracture.Type C3: Associated acetabular fracture.

Pelvic C clamp

Pathophysiology compartment syndromaPathophysiology compartment syndroma

InjuryInjury

Arterial injury Arterial injury

TraumaticTraumaticInflammatoryInflammatoryResponseResponse

HemorrhageHemorrhage

““Vicious Vicious cycle”cycle”

IschemiaIschemia

ICPICP

PerfusionPerfusionEdemaEdema

Classification of open fractureClassification of open fractureby Gustilo - Andersonby Gustilo - Anderson

Gustilo and Anderson Classification Gustilo and Anderson Classification of All Open Fracturesof All Open Fractures

Type IType I• Wound less than 1cm longWound less than 1cm long• Moderately clean puncture, Moderately clean puncture,

where spike of bone has piercedwhere spike of bone has piercedthe skinthe skin

• Little soft tissue damageLittle soft tissue damage• No crushingNo crushing• Fracture usually simple Fracture usually simple

transverse or oblique with littletransverse or oblique with littlecomminutioncomminution

Type IIType II• Laceration more than 1cm longLaceration more than 1cm long• No extensive soft tissue No extensive soft tissue

damage, flap or contusiondamage, flap or contusion• Slight to moderate crushing Slight to moderate crushing

injuryinjury• Moderate comminutionModerate comminution• Moderate contaminationModerate contamination

Type IIIType III• Extensive damage to soft Extensive damage to soft

tissuestissues• High degree of contaminationHigh degree of contamination• Fracture caused by high Fracture caused by high

velocity traumavelocity trauma

IIIA: Adequate soft tissue coverIIIA: Adequate soft tissue cover

IIIB: Inadequate soft tissue IIIB: Inadequate soft tissue cover,a local or free flap is cover,a local or free flap is requiredrequired

IIIC: Any fracture with an arterial IIIC: Any fracture with an arterial injury which requiresinjury which requiresrepairrepair

MM angled angled EE xtremity xtremity SS everity everity SS corecore

Applying Skeletal TractionApplying Skeletal Traction

Fracture DeformitiesFracture Deformities

A: Angulation is A: Angulation is described by the described by the direction in which the direction in which the apex of the fracture is apex of the fracture is pointing.pointing. B: Displacement is B: Displacement is defined as the position defined as the position of thedistal fragment in of thedistal fragment in relation to the proximal relation to the proximal fragment. fragment.

(Netter images reprinted with permission (Netter images reprinted with permission from Elsevier. All rights reserved.)from Elsevier. All rights reserved.)

Valgus angulationValgus angulationVarus angulationVarus angulation Anterior angulationAnterior angulation Posterior angulationPosterior angulation

ShorteningShortening TranslationTranslation

Fracture patternsFracture patterns

Transverse Transverse fracturefracture

Oblique Oblique fracturefracture

Comminuted Comminuted fracturefracture

Butterfly Butterfly fragmentfragment

Segmental Segmental fracturefracture

Spiral fractureSpiral fracture

Descriptive terms for Descriptive terms for typical fracture patterns.typical fracture patterns.

Avulsion (greater Avulsion (greater tuberosity of humerus tuberosity of humerus avulsed byavulsed bysupraspinatus m.)supraspinatus m.)

Greenstick Greenstick fracturefracture Torus (buckle) Torus (buckle)

fracturefracturePathologic fracturePathologic fracture(tumor or bone (tumor or bone disease)disease)

Compression fractureCompression fracture

impresion fractureimpresion fractureSegmental fractureSegmental fracture

Three Columns Three Columns of the of the

Thoracolumbar Thoracolumbar SpineSpine

Schatzker classification of tibial Schatzker classification of tibial plateau fractures.plateau fractures.

Schatzker Classification:Schatzker Classification:Type I: Lateral plateau, split Type I: Lateral plateau, split fracture.fracture.

Type II: Lateral plateau, Type II: Lateral plateau, split depression fracture.split depression fracture.

Type III: Lateral plateau, Type III: Lateral plateau, depression fracture.depression fracture.

Type IV: Medial plateau Type IV: Medial plateau fracture.fracture.

Type V: Bicondylar plateau Type V: Bicondylar plateau fracture.fracture.

Type VI: Plateau fracture Type VI: Plateau fracture with metaphyseal-with metaphyseal-diaphysealdiaphysealdissociation.dissociation.

Type IType I Type IIType II Type IIIType III

Type IVType IV Type VType V Type VIType VI

classification of classification of distal femur distal femur fractures.fractures.

AO Classification:AO Classification:Type A: Extra articularType A: Extra articular• Type A1: Simple, two-part Type A1: Simple, two-part

supracondylar fracturesupracondylar fracture• Type A2: Metaphyseal wedgeType A2: Metaphyseal wedge• Type A3: Comminuted supracondylar Type A3: Comminuted supracondylar

fracturefracture

Type B: UnicondylarType B: Unicondylar• Type B1: Lateral condyle, sagittalType B1: Lateral condyle, sagittal• Type B2: Medial condyle, sagittalType B2: Medial condyle, sagittal• Type B3: CoronalType B3: Coronal

Type C: BicondylarType C: Bicondylar• Type C1: Noncomminuted Type C1: Noncomminuted

supracondylar “T” or “Y”supracondylar “T” or “Y”• fracturefracture• Type C2: Comminuted supracondylar Type C2: Comminuted supracondylar

fracturefracture• Type C3: Comminuted supracondylar Type C3: Comminuted supracondylar

and intercondylarand intercondylar• fracturefracture

The deformity of the The deformity of the humeral shaft fracture is humeral shaft fracture is

dependent on the muscles dependent on the muscles that insert above and that insert above and

below the fracturebelow the fracture

Fractures of the Radius with Distal Radioulnar Subluxation

(Galeazzi)

Anteroposterior and lateral Anteroposterior and lateral radiographs of a fracture of the radiographs of a fracture of the radius with a distal radioulnar radius with a distal radioulnar subluxation.subluxation.

Note the small intra-articular Note the small intra-articular fracture from the distal ulna fracture from the distal ulna (arrow)(arrow)..

Open reduction and internal fixation Open reduction and internal fixation of this fracture are essentialof this fracture are essential

Fracture of the ulna with dislocation of the Fracture of the ulna with dislocation of the proximal radioulnar joint (Monteggia fracture)proximal radioulnar joint (Monteggia fracture)

Radiograph showing a displaced fracture of the ulna Radiograph showing a displaced fracture of the ulna with a dislocated radial head.with a dislocated radial head.

Bado ClassificationBado Classification

• Type I: Anterior dislocation of the radial Type I: Anterior dislocation of the radial head with fracture of the ulnar head with fracture of the ulnar diaphysis at any level with diaphysis at any level with

anterior anterior angulation.angulation.

• Type II: Posterior/posterolateral Type II: Posterior/posterolateral dislocation of the radial head dislocation of the radial head

with with fracture of the ulnar diaphysis fracture of the ulnar diaphysis with with posterior angulation. posterior angulation.

• Type III: Pateral/anterolateral dislocation Type III: Pateral/anterolateral dislocation of the radial head with fracture of the radial head with fracture of the ulnar metaphysic. of the ulnar metaphysic.

• Type IV: Anterior dislocation of the radial Type IV: Anterior dislocation of the radial head with fractures of both the head with fractures of both the radius and ulna within proximal radius and ulna within proximal third at the same level. third at the same level.

Hirschsprung’s DiseaseHirschsprung’s DiseaseDefinisiDefinisi

SSuatu kelainan bawaan yang ditandai dengan tidak uatu kelainan bawaan yang ditandai dengan tidak ditemukannya ditemukannya sel-sel ganglion (syaraf simpatis dan para sel-sel ganglion (syaraf simpatis dan para simpatis) simpatis) di di kedua lapisan yaitu lapisan otot kedua lapisan yaitu lapisan otot (Auerbach’s) dan submukosa (meissner’s)(Auerbach’s) dan submukosa (meissner’s) pada kolon pada kolon sehingga sehingga menyebabkan hilangnya peristaltic pada menyebabkan hilangnya peristaltic pada segmen tersebutsegmen tersebut yang berakibat terjadinya obstruksi yang berakibat terjadinya obstruksi fungsionalfungsional.. → → Paling sering di rectosigmoid.Paling sering di rectosigmoid.

Differensial diagnosis:Differensial diagnosis:– Atresia Ileum.Atresia Ileum.– Meconeum Plug Syndroma (MPS).Meconeum Plug Syndroma (MPS).– Stenosis/Atresia Recti.Stenosis/Atresia Recti.– N E C stadium Awal (Stadium 1 – 2a ).N E C stadium Awal (Stadium 1 – 2a ).

Tipe-tipe Hirschsprung’s DiseaseTipe-tipe Hirschsprung’s Disease

SUBCLASSIFIED ACCORDING SUBCLASSIFIED ACCORDING TO THE RELATIVE LENGTH TO THE RELATIVE LENGTH OF THE AGANGLIONIC OF THE AGANGLIONIC REGION : REGION :

• SHORT –SEGMENT DISEASE SHORT –SEGMENT DISEASE (RECTO-SIGMOID ) : 75 –80 %.(RECTO-SIGMOID ) : 75 –80 %.

• LONG – SEGMENT DISEASE LONG – SEGMENT DISEASE (SPLENIC FLEXURE): 10 %.(SPLENIC FLEXURE): 10 %.

• TOTAL COLONIC – AGANGLIONIC : TOTAL COLONIC – AGANGLIONIC : LESS 5 %.LESS 5 %.

• ULTRA SHORT – SEGMENT IS A ULTRA SHORT – SEGMENT IS A CONTROVERSIAL ENTITY CONTROVERSIAL ENTITY (Achalasia Recti )(Achalasia Recti )

Pullthrough(swenson’96 ; Leappe,96 ; Aschraft’00 ; fitgerald’05 ; Orvas’05)

Swenson 1

DuhamelSwenson

2

Soave Rehbein

SOAVE

3 zones of the neck3 zones of the neckZone IZone I

From the clavicles to the From the clavicles to the cricoidcricoid

Zone IIZone IIFrom cricoid to angle of From cricoid to angle of

mandiblemandible

Zone IIIZone IIIAngle of mandible to base Angle of mandible to base

of skullof skull• Trachea.Trachea.• Lungs.Lungs.• Proximal carotid and Proximal carotid and vertebral arteries.vertebral arteries.• Jugular veins.Jugular veins.• Thoracic Vessels.Thoracic Vessels.• Esophagus.Esophagus.• Superior Mediastinum.Superior Mediastinum.• Thoracic Duct.Thoracic Duct.• Spinal Cord. Spinal Cord. • Brachial Plexus.Brachial Plexus.

• Trachea.Trachea.• Larynx.Larynx.• Carotid and vertebral Carotid and vertebral arteries.arteries.• Jugular Vein.Jugular Vein.• Esophagus.Esophagus.• Spinal Corda.Spinal Corda.

• Distal carotid and Distal carotid and vertebral arteries.vertebral arteries.• Pharynx.Pharynx. • Spinal cord.Spinal cord.

Motor Function of spinal Motor Function of spinal rootsroots

Upper Upper ExtremitExtremit

yy

Nerve RootNerve Root MuscleMuscle Motor Motor ExaminationExamination

C5C5 DeltoidDeltoid Shoulder abductionShoulder abduction

C6C6 BicepsBiceps Elbow flexionElbow flexion

C7C7 TricepsTriceps Elbow extensionElbow extension

C8C8 Flexor carpi ulnarisFlexor carpi ulnaris Wrist flexionWrist flexion

T1T1 LumbricalesLumbricales Finger abductionFinger abduction

Lower Lower ExtremitExtremit

yy

L2L2 IliopsoasIliopsoas Hip flexionHip flexion

L3L3 QuadricepsQuadriceps Knee extensionKnee extension

L4L4 Tibialis anteriorTibialis anterior Ankle dorsiflexionAnkle dorsiflexion

L5-S1L5-S1 Extensor hallucis longusExtensor hallucis longus Great toe extensionGreat toe extension

S1S1 GastrocnemiusGastrocnemius Ankle plantarflexionAnkle plantarflexion

ScoreScore Functional AbilityFunctional Ability00 No contraction of muscleNo contraction of muscle

11 Palpable muscle contraction, no limb movementPalpable muscle contraction, no limb movement

22 Able to move in gravity-neutral planeAble to move in gravity-neutral plane

33 Able to move against gravityAble to move against gravity

44 Diminished strengthDiminished strength

55 Normal strengthNormal strength

BacteremiaBacteremia

FungemiaFungemia

ParasitemiaParasitemia

ViremiaViremia

OtherOther

BurnsBurns

PancreatitisPancreatitis

SIRSSIRSSEPSISSEPSISINFECTIONINFECTIONOtherOther

TraumaTrauma

Beal et al, JAMA, 1994;271;226-233

The Lethal Triad of DeathThe Lethal Triad of Death

Severe Trauma Prolonged hypotensionSevere Trauma Prolonged hypotension

CoagulopathyCoagulopathy

Metabolic AcidosisMetabolic Acidosis

HypothermiaHypothermia

DEATDEATHH

The Lethal Triad of DeathThe Lethal Triad of Death

Rotondo MF, Zonies DH. Surg Clin North Am 1997; 77(4): 761-777Rotondo MF, Zonies DH. Surg Clin North Am 1997; 77(4): 761-777

SIRSSIRS Systemic Inflammatory Response Systemic Inflammatory Response

SyndromeSyndrome

MODSMODS Multiple Organ Dysfunction SyndromeMultiple Organ Dysfunction Syndrome

MOFMOF Multiple Organ FailureMultiple Organ Failure

MSOFMSOF Multiple-Sytem Organ FailureMultiple-Sytem Organ Failure

ARDSARDS Acute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome

DICDIC Disseminated Intravascular CoagulationDisseminated Intravascular Coagulation

Microcirculatory SystemMicrocirculatory System

AA LL II (Acute (Acute LLung ung IInjury)njury)

AA RR DD SS((AAcute cute RRespiratory espiratory DDistress istress SSyndrome)yndrome)

ALIALI

ARDSARDS

SIRS /SIRS /SEPSISSEPSIS

Penetrating abdominal InjuryPenetrating abdominal InjuryExplore woundExplore woundunder localunder localanesthesiaanesthesia

LaparotomyLaparotomy

NONO

DPLDPL

Debride sutureDebride sutureConsider dischargeConsider discharge

NegativeNegative

Admit, observeAdmit, observe

Is Is peritoneumperitoneum intact ? intact ?

PositivePositive

Gun shot?Gun shot?Evisceration?Evisceration?Rigid silent abdomen?Rigid silent abdomen?Free gas on radiography?Free gas on radiography?

NONO YESYESYESYES

Trauma of the kidneyTrauma of the kidney

Stab wound of the Stab wound of the kidneykidney

BluntBlunt

HematuriaHematuria

StableStable UnstableUnstable

Explore Retroperitoneal hematomeExplore Retroperitoneal hematome

Expand (+)Expand (+)

Bulging (+)Bulging (+)

Expand (-)Expand (-)

Bulging (-)Bulging (-)

KUB - IVPKUB - IVP

NormalNormal

ObserveObserve

Non VisualNon Visual

AbnormalAbnormal

ExploreExplore ObserveObserveFurther ExploreFurther ExploreCT scanCT scan

Blunt Trauma Of The KidneyBlunt Trauma Of The Kidney

HematuriaHematuria

Microscopic, shock (+)Microscopic, shock (+)

MacroscopicMacroscopic

Microscopic, Shock (-)Microscopic, Shock (-)

StableStable UnstableUnstable

KUB - IVPKUB - IVP

ExploreExplore

Retro-hematomaRetro-hematoma Retro-hematomaRetro-hematomaBulging (-)Bulging (-) Bulging (+)Bulging (+)Expanding (-)Expanding (-) Expanding (+)Expanding (+)

ObserveObserve Explore furtherExplore further

AbnormalAbnormal NormalNormal

Explore Explore ObserveObserve

Not InformativeNot Informative

Concomitant Concomitant Concomitant Concomitant Trauma (-)Trauma (-)TraumaTrauma (+) (+)

Explore Explore ObserveObserve

Where is CT Scan functionWhere is CT Scan function

Imaging exam not necessaryImaging exam not necessaryExcept: Except:

• Concomitant traumaConcomitant trauma• DecelerationDeceleration

Trauma of the kidneyTrauma of the kidney

Stab wound Stab wound

Approach to Traumatic Approach to Traumatic Retroperitoneal HematomaRetroperitoneal Hematoma

Type - Type - HematomaHematoma

Penetrating Penetrating InjuryInjury

Blunt InjuryBlunt Injury

Central (Zone I)Central (Zone I) ExploreExplore ExploreExploreLateral (Zone II)Lateral (Zone II) Usually exploreUsually explore Usually do not Usually do not

exploreexplorePelvic (Zone III)Pelvic (Zone III) ExploreExplore Do not exploreDo not explore

Mosche Schein : Common Sense Emergency Abdominal Surgery, Thieme 2000Mosche Schein : Common Sense Emergency Abdominal Surgery, Thieme 2000

CATATAN:CATATAN:Blunt injury pada Zona II biasanya akan dieksplorasi bila:Blunt injury pada Zona II biasanya akan dieksplorasi bila:

– Ukuran sangat luas.Ukuran sangat luas.– Pulsating.Pulsating.– Expanding.Expanding.

Exposure Zone IExposure Zone I Exposure Zone IIExposure Zone II

Manuver KocherManuver Kocher

Trauma vena retrohepatik.Trauma vena retrohepatik. Manuver Pringle Manuver Pringle + klem oklusi + klem oklusi

parsialparsial

Manuver Mattox Manuver Mattox untuk mengekspos aorta untuk mengekspos aorta

abdominalabdominal

Manuver CattellManuver Cattelluntuk mengekspos v.cava untuk mengekspos v.cava

dan duodenumdan duodenum

PRINCIPLES OF MANAGEMENT OF PRINCIPLES OF MANAGEMENT OF KIDNEY INJURIESKIDNEY INJURIES

• HISTORY.HISTORY.• PHYSICAL EXAMINATION.PHYSICAL EXAMINATION.• LABORATORY EXAMINATION.LABORATORY EXAMINATION.• IMAGING.IMAGING.

DIAGNOSISDIAGNOSIS

MANAGEMENTMANAGEMENTSUSPICION OF INJURY OF THE SUSPICION OF INJURY OF THE

KIDNEYKIDNEY1.1. Trauma, pain, lacerations on the flank area.Trauma, pain, lacerations on the flank area.2.2. Fractures of T8 - T12 rib, a mass in the retroperitoneal area.Fractures of T8 - T12 rib, a mass in the retroperitoneal area.3.3. Hematuria (bloody urine).Hematuria (bloody urine).4.4. Shock.Shock.

IMAGING EXAMINATIONIMAGING EXAMINATIONIN KIDNEY TRAUMAIN KIDNEY TRAUMA

• KUB – IVP.KUB – IVP.• CT – Scan.CT – Scan.• Arteriography.Arteriography.

Very helpful in determining whether to do exploration or not.Very helpful in determining whether to do exploration or not.

• Done almost everywhere in Indonesia.Done almost everywhere in Indonesia.• Relatively inexpensive.Relatively inexpensive.• Double dose (2 cc/kg BW).Double dose (2 cc/kg BW).• How to interpret:How to interpret:

• Psoas line or kidney shape in KUB is (-).Psoas line or kidney shape in KUB is (-).• Decrease of the excretion of contrast.Decrease of the excretion of contrast.• Scoliosis due to psoas muscle contraction.Scoliosis due to psoas muscle contraction.• Contrast extravasation.Contrast extravasation.

Indication to do kidney explorationIndication to do kidney exploration• Persistent hemorrhage believed from renal injury.Persistent hemorrhage believed from renal injury.

• Reccurent Shock.Reccurent Shock.

• During Laparotomy, there is expanding and bulging of During Laparotomy, there is expanding and bulging of retroperitoneal hematome.retroperitoneal hematome.

• IVP :IVP :• Contrast extravasation.Contrast extravasation.• Non visualized part of the kidney (ideally Non visualized part of the kidney (ideally

continue with a CT Scan exam).continue with a CT Scan exam).

• Arteriography :Arteriography :• Part of the kidney avascular.Part of the kidney avascular.• Total obstruction of renal artery.Total obstruction of renal artery.• Large extravasation.Large extravasation.

Isolasi pembuluh darah ginjal (prosedur Mc Anninch)Isolasi pembuluh darah ginjal (prosedur Mc Anninch)

Insisi retroperitoneal diatas aorta Insisi retroperitoneal diatas aorta medial dari v. mesenterika inferiormedial dari v. mesenterika inferior

VENA VENA MESENTERICA INFERIORMESENTERICA INFERIOR

AORTAAORTA

INSISIINSISI

• Hubungan anatomi dari Hubungan anatomi dari pembuluh darah ginjalpembuluh darah ginjal

• Insisi retroperitoneal Insisi retroperitoneal lateral dari kolon lateral dari kolon memperlihatkan ginjalmemperlihatkan ginjal

Teknik Renorafi:Teknik Renorafi:A.A. Cidera khas pada ginjal tengah.Cidera khas pada ginjal tengah.B.B. Debridement, hemostasis dan penutupan sistem pengumpul.Debridement, hemostasis dan penutupan sistem pengumpul.C.C. Aproksimasi tepi parenkim.Aproksimasi tepi parenkim.D.D. Penjahitan dengan gelfoam.Penjahitan dengan gelfoam.

Cedera pembuluh darah: Cedera pembuluh darah: KiriKiri : Cedera pada pembuluh darah utama / cabang segmental.: Cedera pada pembuluh darah utama / cabang segmental.TengahTengah : Perbaikan pada vena utama ginjal.: Perbaikan pada vena utama ginjal.Kanan Kanan : Dilakukan ligasi pada cabang vena.: Dilakukan ligasi pada cabang vena.

Pemotongan Pemotongan secara tajam untuk secara tajam untuk jaringan yang non jaringan yang non viabelviabel

M – I – S – T M – I – S – T

•MMechanism of injuryechanism of injury•IInjury sustainednjury sustained•SSignsigns•TTreatmentreatment

BEBERAPA JENIS IRISAN KULIT BEBERAPA JENIS IRISAN KULIT PADA OPERASI LEHERPADA OPERASI LEHER

MARTIN 1951MARTIN 1951 SCHOBINGER 1957SCHOBINGER 1957 LAMEY 1940LAMEY 1940

LATYSHEVSKY LATYSHEVSKY FREUND 1960FREUND 1960

MAC FEE 1960MAC FEE 1960 CONLEY 1966CONLEY 1966

SLAUGHTER 1955SLAUGHTER 1955

SCHWEITZER 1965SCHWEITZER 1965

EDGERTON 1957EDGERTON 1957FARR 1969FARR 1969

INDIKASI PEMBEDAHAN INDIKASI PEMBEDAHAN EKSPLORASI LEHER :EKSPLORASI LEHER :

1. Active bleeding.1. Active bleeding. 8. Hoarseness.8. Hoarseness.

2. Hematoma.2. Hematoma. 9. Stridor.9. Stridor.

3. Shock.3. Shock. 10.Dysphonia or voice change.10.Dysphonia or voice change.

4. Pulse defisit.4. Pulse defisit. 11. Hemoptysis.11. Hemoptysis.

5. Bruit.5. Bruit. 12. Subcutaneous emphysema.12. Subcutaneous emphysema.

6. Neurologic defisit. 6. Neurologic defisit. 13. Dysphagia or odynaphagia.13. Dysphagia or odynaphagia.

7. Dispnea.7. Dispnea. 14. Hematemesis.14. Hematemesis.

PATOFISIOLOGI :PATOFISIOLOGI : Gagal ventilasi, Gagal difusi, Gagal sirkulasiGagal ventilasi, Gagal difusi, Gagal sirkulasi

HIPOKSIA SELULERHIPOKSIA SELULER

CYTOKINESCYTOKINES

ARDS, SIRS, MOD/MOF, SEPSISARDS, SIRS, MOD/MOF, SEPSIS

Fraktur Iga Fraktur Iga FLAIL CHESTFLAIL CHEST

FLAIL CHEST FLAIL CHEST → PARADOXAL RESPIRATION→ PARADOXAL RESPIRATION

RUPTUR DIAFRAGMARUPTUR DIAFRAGMA

• Trauma tumpul kerasTrauma tumpul keras• Sisi kiri terbanyakSisi kiri terbanyak• !!! Cedera organ abdomen!!! Cedera organ abdomen• Terapi : Terapi :

Operasi (cegah hernia)Operasi (cegah hernia)• Ragu : Ragu :

Torakoskopi / Laparoskopi.Torakoskopi / Laparoskopi.

Compartment : Compartment : Closed anatomic space bound by Closed anatomic space bound by relatively relatively rigid wallsrigid walls of bone and fascia of bone and fascia

DefinitionDefinitionCondition which is both limb and life Condition which is both limb and life threatening threatening need prompt emergency need prompt emergency actionaction

Acute Compartment Syndrome (ACS)Acute Compartment Syndrome (ACS)

Intra Compartment Pressure (ICP) Intra Compartment Pressure (ICP) tissue perfusion tissue perfusion compromise of circulation and function of tissues compromise of circulation and function of tissues

EtiologyEtiology-FracturesFractures

- Arterial injuryArterial injury

- BurnBurn

- Soft tissue injurySoft tissue injury

- Exertional sport injuryExertional sport injury

-Prolong limb compressionProlong limb compression

Symptom → 5 PSymptom → 5 P EarlyEarly Pain, severe, pain out of proportion to severity Pain, severe, pain out of proportion to severity injury. injury. Paresthesia Paresthesia LateLate ParesisParesis PallorPallor Pulselessness, last occur. Pulselessness, last occur.

SignsSigns

Decreased sensation of the involved nervesDecreased sensation of the involved nerves

Pain increases with passively streching the involved Pain increases with passively streching the involved musclesmuscles

palpation : tense, palpation : tense, wooden wooden signsign

1872 : Richard van Volkmann 1872 : Richard van Volkmann

Contracture of forearm and hand following Contracture of forearm and hand following Supracondylar fracture of humerus.Supracondylar fracture of humerus.

Volkmann Ischemic Volkmann Ischemic contracturecontracture

Anterior compartmentAnterior compartment - Muscles- Muscles : Tib. Ant, Extensors (Dig & Hallucis): Tib. Ant, Extensors (Dig & Hallucis) - Artery- Artery : Tib. Ant. : Tib. Ant. - Nerve- Nerve : Deep Peroneal : sensation first dorsal web : Deep Peroneal : sensation first dorsal web

of foot of foot

Lateral CompartmentLateral Compartment - Muscle- Muscle : Peroneals (Longus et Brevis): Peroneals (Longus et Brevis) - Nerve- Nerve : Superficial Peroneal : sensation dorsum foot: Superficial Peroneal : sensation dorsum foot

Deep Posterior compartment Deep Posterior compartment - Muscle- Muscle : Tib. Post, Flexors (Dig & Hallucis): Tib. Post, Flexors (Dig & Hallucis) - Artery- Artery : Tib. Post. : Tib. Post. - Nerve- Nerve : Tib Post. : Tib Post. sensation sole of foot sensation sole of foot

Superficial Posterior CompartmentSuperficial Posterior Compartment - Muscle- Muscle : Gastroc, Soleus, Plantaris: Gastroc, Soleus, Plantaris - Nerve- Nerve : Sural : Sural sensation lateral aspect of foot and sensation lateral aspect of foot and

distal calf distal calf

Treatment of choice for ACS in the Treatment of choice for ACS in the lower leg lower leg FasciotomyFasciotomy - Dermotomy - Dermotomy

Incision : the WHOLE length of compartment. Incision : the WHOLE length of compartment.

ACS in the lower legACS in the lower leg

Mubarak : Mubarak : Two / Double incisions technique anterolateral & posteromedial Two / Double incisions technique anterolateral & posteromedial incisionsincisions

Safer access to all 4 compartment with good visualization of Safer access to all 4 compartment with good visualization of important superficial and deep structuresimportant superficial and deep structures

Anterolateral IncisionAnterolateral Incision Posteromedial IncisionPosteromedial Incision

TIMETIME factor very important : factor very important : -- Consensus : 12 hoursConsensus : 12 hours > 12 hours : catastrophic clinical result> 12 hours : catastrophic clinical result

- Full recovery if within 6 hours- Full recovery if within 6 hours

- Exact time of onset : difficult- Exact time of onset : difficult

ACS in the ThighACS in the Thigh

ForearmForearm

ContraindicationContraindication : If ACS in late diagnosed : If ACS in late diagnosed fasciotomy little benefit – probablyfasciotomy little benefit – probably

contraindicated after 3 – 4 days. contraindicated after 3 – 4 days. If performed late severe infection may develops in the If performed late severe infection may develops in the

necrotic muscle, even death. necrotic muscle, even death. Painlessness / Paralysis (+) no use of fasciotomy.Painlessness / Paralysis (+) no use of fasciotomy.

Post fasciotomyPost fasciotomy -- Leave the wound Leave the wound OPENOPEN

-- Skin graft performed after 1 – 3 weeksSkin graft performed after 1 – 3 weeks

-- Avoid skin graft : silicone sheet coverageAvoid skin graft : silicone sheet coverage

-- Do not elevate the limb elevate the limb arterial flow arterial flow av. av. Pressure Pressure gradient gradient ischemia ischemia

Sepsis

Morfologi TV

LOKASI TREPANASI

LOKASI TREPANASI

LOKASI TREPANASI

DiagnosiDiagnosiss

•Pada setiap trauma abdomen bawah dan tungkai selalu pikirkan Pada setiap trauma abdomen bawah dan tungkai selalu pikirkan kemungkinan fraktur pelvis.kemungkinan fraktur pelvis.

•Perhatikan mekanisme cedera.Perhatikan mekanisme cedera.

•Pemeriksaan klinis :Pemeriksaan klinis :–Jejas pada pelvis/abdomen bagian bawah.Jejas pada pelvis/abdomen bagian bawah.–Nyeri tekan pada pelvis.Nyeri tekan pada pelvis.–Ketidakstabilan pada perabaan.Ketidakstabilan pada perabaan.–Perbedaan panjang kedua tungkai.Perbedaan panjang kedua tungkai.–Rectal examination & darah pada MUE.Rectal examination & darah pada MUE.–Hipotensi & tachycardia (bila disertai gangguan hemodinamik).Hipotensi & tachycardia (bila disertai gangguan hemodinamik).

•Radiologis : foto pelvis AP, CT scanRadiologis : foto pelvis AP, CT scan

Physical Physical examinationexamination

Pemeriksaan fraktur pelvisPemeriksaan fraktur pelvis

•Tekan kearah posterior Tekan kearah posterior dan anterior pada krista dan anterior pada krista iliaka (stabilitas iliaka (stabilitas anteroposterior).anteroposterior).

•Lakukan traksi pada salah Lakukan traksi pada salah satu tungkai dengan satu tungkai dengan memfiksasi pelvis memfiksasi pelvis (stabilitas vertikal).(stabilitas vertikal).

Outlet and inlet Outlet and inlet viewview

I

O

Fraktur Fraktur PelvisPelvisPelvic ring

Cedera pada urethra

Cedera vaskuler

Klasifikasi fraktur Klasifikasi fraktur pelvispelvis

Klasifikasi TileKlasifikasi Tile

Tipe ATipe AStableStable

Tipe B Tipe B Rotationally unstableRotationally unstable

Vertically stableVertically stable(open book type)(open book type)

Tipe CTipe CRotationally andRotationally and

Vertically UnstableVertically Unstable

Pelvic Pelvic ligamentsligaments

Pelvic Ring Pelvic Ring AnatomyAnatomy

Stabilisasi Stabilisasi pelvispelvis

•Mengecilkan Mengecilkan rongga pelvis : rongga pelvis : berfungsi berfungsi sebagai tampon.sebagai tampon.

•Pelvic sling, Pelvic sling, stagen.stagen.

•Fiksasi eksterna.Fiksasi eksterna.

•Fiksasi interna.Fiksasi interna.

ARTICULATIO GENUARTICULATIO GENU

ARTICULATIO ARTICULATIO GENUGENU

Fraktur pelvisFraktur pelvis

Fraktur pelvisFraktur pelvis

Fraktur pelvisFraktur pelvis

Blunt abdominal trauma

Penetrating abdominal Penetrating abdominal traumatrauma..