Pengayaan Koass Ortho - Update 4 Version

8/12/2019 Pengayaan Koass Ortho - Update 4 Version

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Introduction

Orthopaedics is

concerned with bones,

joints, muscles, tendonsand nervesthe

skeletal system and all

that makes it move


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Introduction

Scope :

Congenital & developmentalabnormalities

Infection & inflammation

Arthritis & rheumaticdisorders

Metabolic & endocrinedisorders

Tumours

Sensory disturbance &

muscle weakness

Injury & mechanicalderangement

Subdivision :

Traumatology

Orthopaedi :

1. Adult Reconstruction

2. Oncology Orthopaedic

3. Pediatric Orthopaedic

4. Spine

5. Hand & Microsurgery


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Introduction

Steps in orthopaedic diagnosis:

1. History taking

2. Physical Examination

* Posture

* Gait1. Inspection

2. Palpation

3. Examination of movements

4. Conduction of special tests3. Further investigations

1. Examination of radiographs

2. Examination of blood, sinovial fluid, etc


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Inspection

Is there swelling?

Is there bruising?

Is there any discoloration, or edema? Is there muscle wasting?

Is there any alteration in shape or posture,

or is there evidence of shortening?


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Inspection


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Palpation

Is the joint warm?

Is there tenderness?

How is the artery

pulse?


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Movements

Active ROM

Passive ROM

Fixed deformities

Restriction of ROM

Movements in abnormal plane

Crepitus

Strength of muscle contraction

Gait


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Movements


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Conduction of Special Test

Integrity of certain

joint ligaments

Examination of

structures associatedwith the joint

Appropriate

neurological

examination


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Examination of Radiographs

Soft tissue

Bone : shape, size, contour

Alignment


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Examination of Radiographs

Comparison films

Oblique projections

Localized views Stress films


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Arranging Further Investigations

ESR, CRP

Full blood count with differential

Estimation of RF Serum calcium, phosphate & AP

Serum Uric Acid

Chest X-Ray


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Equipment Requirements

A tape measure

A goniometer

A tendon hammer A disposable sharp point


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WHAT IS POLYTRAUMA ?


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ObjectivesEstablish the principles for assessing the

patient with musculoskeletal injuries.

Establish treatment priorities.

Identify the importance of musculoskeletal

injuries in the multiply injured patient.


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Emergency in Orthopaedic

Emergency : trauma cases

- Life threatening

- Limb treatening 85 % of blunt trauma affect

musculoskeletal system

Life savingbefore limbsaving


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How do musculoskeletal injuries

impact on the primary survey?

What are my priorities?

What are my management principles?

Key Questions


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Assessment of the Polytrauma Patient

Primary Survey

Airway with cervical spine control

B reathing

Circulation with control of hemorrage

D isability (neurological state)

Exposure (take the patient clothes off)


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Primary survey management

The 3 Ss

Stop the bleeding!

Splint the extremity

Stabilize the pelvis


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Primary Survey & Resuscitation

Recognize and control hemorrhage

Direct pressure

Splint fractures

Fluid resuscitation

BE AWARE OF REPERFUSION

INJURY!


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Adjuncts : Fracture immobilization

Goals

Hemorrhage control

Pain relief

Prevent further soft tissue injury

Apply splint early, but avoid delay in

resuscitation.

Be careful in dislocation


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Adjuncts : X-Rays Determinited by patients condition

Obtain AP pelvis early if hemodynamicallyabnormal and no obvious source of

bleeding



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Secondary Survey

History

A M P L E

From Head to toe examination

Every orifice must be examined

Dont forget the back!


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Secondary Survey

Look

FeelListen

For What?


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Life- Threatening Injuries

Major pelvic disruption with hemorrhage

Major arterial hemorrhage

Crush syndrome (rhabdomyolysis)


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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)


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Life Threatening




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Life Threatening




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PelvicWrapping


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Life Threatening

Musculoskeletal TraumaMain Arterial Rupture1. Trauma

- sharp, blunt

2 Examination- Artery pulse, Doppler

- Ankle / brachial index

3. Management

- Pneumatic tourniquet- Vascular clamp?

- Traction, Splint


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Life Threatening


Myoglobinuria

Metabolic acidosis, K,Ca and coagulopathy

Compartment syndrome

IV fluids,alkalization of

urine

Crush Syndrome


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Vascular compromise

Open fractures

What are my early concerns?


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Limb Threatening

Musculoskeletal TraumaOpen Fractures

Apply appropriate splint

Cleanse / debride (now or later)

Consider time factor

Obtain orthopaedic consult


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Limb Threatening


Classifying the injuryGustilos classification (Gustilo et al, 1990)


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Open Fracture grade 1


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Open Fracture grade 2


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Open Fracture grade 3A


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Open Fracture grade 3B


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Open Fracture

grade 3C

Li b Th i


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Limb Threatening


Principles of treatment

Objectives :- Prevention of infection

(sepsis/osteomyelitis)

- Promote bone healing- Restoration of function

Li b Th t i


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Limb Threatening

Musculoskeletal TraumaOpen FracturesPrinciples of treatment

4 essentials are :

1. Wound irrigation & debridement

2. Antibiotic prophylaxis

3. Stabilization of the fractures4. Early wound coverage

O F


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Open Fracture

Complicated case

Not proper initial management


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Limb Threatening

Musculoskeletal TraumaVascular Trauma & Traumatic Amputation

Reduce fracture(s)

Splint fracture(s)Assess by Doppler

Obtain consult (time

is critical)

Consider

angiography

Li b Th t i M l k l t l T


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Limb Threatening Musculoskeletal Trauma

Vascular Trauma & Traumatic Amputation



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Management

Muscle necrosis : 6 h

Warm & Cold Ischemic

Reimplatantation &

Revascularization

Proper amputee

management!


Vascular Trauma & Traumatic Amputation

Li b Th t i


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Limb Threatening

Musculoskeletal TraumaCompartement Syndrome

Fractures of the arm or legischemia

Infarcted musclesfibrous tissue(Volkmanns ischemic contracture)

Li b Th t i


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Limb Threatening


Clinical features Elbow, forearm bones, 1/3

prox. of tibiae, multiplefractures of the foot orhand, crush injuries &circumferential burns

Five Ps

The presence of a pulsedoes not exclude thediagnosis

Be careful in unconscious

patient !

Li b Th t i


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Limb Threatening


Treatment

Decompression

Open fasciotomi

Li b Th t i


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Limb Threatening

Musculoskeletal TraumaDislocations

Displacement of bone from normal joint

Location : hip, shoulder, elbow, finger,patella, knee, ankle, acromioclavicular

Sign : loss of normal shape &

loss of movement


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Posterior Hip Dislocation


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Neurologic Injury

Due to fracture /dislocation

Posterior shoulder : Axillary nerve

Posterior hip : Sciatic nerve Recognize injury and immobilize

Early orthopaedic consult

Careful reduction, if possible reassess and splint

Limb Threatening


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Limb Threatening


Massive skin avulsion


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Abdominal flap following

skin avulsion of the hand


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Kelirumologi in Fracture


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Kelirumologi in Fracture

Management


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Pitfalls

Occult injuries

Occult blood loss

Compartment syndrome


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Case 1 : Male, 40 y.o


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ICD 9-CM 79.63, 93.44


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Question


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Summary

Primary Survey :Identify life-threatening

Injuries

Secondary Survey :Identify limb-

threatening injuries

Mechanism of Injuries :History important

Orthopaedic consult

Early immobilization

Pengayaan Koass Ortho - Update 4 Version

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