FRACTURE AND DISLOCATION

Nucki N Hidajat, dr, MS, SpBO (K), FICSDepartment Orthopaedi & Traumatology

Faculty of Medicine, Padjadjaran UniversityDr Hasan Sadikin Hospital - Bandung

Orthopaedic tree

orthospaedos

introduction 1741, Nicolas Andry

“Orthopaedia, the Art of Preventing and Correcting Deformities in Children”

The present scope of orthopaedics: Include all ages Consist of art and science of prevention, investigation,

diagnosis, and treatment of disorders and injuries of the musculoskeletal system by medical, surgical, and physical means

Orthopedist Surveys in North America – at least 15% of the total

patients 80% of the blunt trauma in ER.

introduction The musculoskeletal system

Organ system include bones, cartilage, muscles, tendons, ligaments, neurovascular in upper and lower extremities, joints, and vertebrae

Congenital deformities, infections and inflammation, Neoplasms, fracture and associated trauma, degenerative.

fracture

DefinitionA fracture is a break in the

structural continuity of bone, or cartilage, or epiphyseal plate

Must constantly think soft tissue surrounding the bone Physical factors in the

production of fracture

How fractures happen?

Fracture due to a traumatic incident Caused by sudden and

excessive force Direct or Indirect

Pathologic fracture Bone weakened (abnormal) Change in structure :

osteoporosis, tumor Can occur even normal stresses

How fracture happen?

Descriptive terms pertaining of Fractures

1. Site.

2. Extent

3. Configuration

4. Relationship of the fragments

5. Relation to external environment

6. complications

1.Anatomical site Diaphyseal Metaphyseal Epiphyseal Intra-articular Fracture dislocation

2. Extent•Complete•Incomplete•Hard tissue •Soft tissue

extent

3. configuration Transverse Oblique Spiral Comminuted segmented

4. Relation of fragments

UndisplacedDisplaced

Translated Angulated Rotated Distracted Overriding impacted

5. Relationship to external environment

Close fracture• There no contact the external environment• Severity and configuration depend on

energy

Open fracture• Direct contact with external non steril

environment

Classification of Close fracturewith soft tissue damage (tscherne,1982)

Type 0 : minimal ST damage, indirect violence, simple # patterns

Type I : superficial abrasion caused by pressure from within, moderately severe fracture

Type II : deep, contaminated abrasion, skin or muscle contusion, impending compartment syndrome

Type III : extensive skin contusion or crush, underlying muscle damage, subcutaneous avulsion, comminuted fracture

Open fracture

Fracture Soft tissue injuries Contaminant from

external environment High risk :

1. Infection, tetanus, gas gangrene, sepsis

2. Nonunion

3. Limb threathening

Classification open factureGustilo-Anderson (1984)

Type I wound 1 cm or less, quite clean, inside to outside, minimal muscle contusion, simple # patterns

Type II laceration more than 1 cm long, with extensive soft tissue damage, flaps or avulsions, minimal

comminution.

Type III extensive soft tissue damage including muscles, neurovascular structures, often ahigh velocity

injury

IIIA adequate bone coverage, segmental #IIIB periosteal stripping and bone exposure, with

massive contaminationIIIC vascular injury requiring repair

Open Fracture grade I

Open Fracture grade II

Open Fracture grade III

6. complication

Uncomplicated Complicated

Neurovascular Compartment syndrome infection

Diagnosis of fracture1. History

• Mechanism of injury, environment, pre-injury status, finding at the incident site, pre-hospital care

2. Physical examination1. Look2. Feel3. Move/ask

3. Investigation1. Lab.2. X-ray3. Scanning

Mechanism of injury

Physical examination General conditions

Air way Breathing Circulation

Local conditions Look Feel move

Physical examinationsLook

Evidence of painSwellingDeformityWounds

FeelSharply locallized painAggravation of painTest artery & nerve

MovecrepitusAbnormal movement

Diagnostic imaging

X-ray (rule of Two) Two joints Two views Two limbs Two injuries Two occasions

CT Scan MRI

How fractures heal

Similar with wound healing

Two types of healing process Primary (bridging osteon) Secondary (callus

formations)1. Inflammation

2. Callus formation

3. consolidation

4. remodeling

Pre-hospital management

According ATLS procedure.

1. Primary survey

2. Secondary survey

A-B-C-D-E Reduction Immobilization Cover the wounds transportation

immobilization

Two joints minimal include immobilized

Splintage Prevent further injury Re-evaluation

neurovascular distal fracture

Goals treatment fracture

1. Relieve pain

2. To obtain and maintain satisfactory position of the fracture fragments

3. To allow bony union

4. Restore optimum function

Specific Methods of treatment for close fracture

1. Protection alone2. Immobilization with or

without reduction3. Closed reduction

followed by traction4. CR followed by

external fixation5. ORIF6. Excision of fragment

fracture

Immobilization by traction

Open Reduction and Internal Fixation (ORIF)

Indications1. Intra-articular fracture

2. Avulsion fracture

3. Soft tissue interposition

4. Grossly unstable fracture

5. Coexistent with vascular injury

6. Pathologic fracture

7. # in children cross epiphyseal plate

External Fixation

Excision fragment fracture

Treatment for Open Fractures:

1. Cleansing of the wound2. Excision of devitalized

tissue (debridement)3. Treatment of the fracture4. Closure of the wound5. Antibacterial drugs6. Prevention of tetanus

complications Immediately

Bleeding Injury to the nerve Soft tissue

Early Infections Delayed Union Joints stiffness

Late Malunion Osteoarthritis AVN

Risk AVN in head femur fracture

Fracture specific

Fracture in children Fracture incomplete most common Conservative treatment Heal faster than adult

Pathologic fracture In porotic bone Abnormal bone structure Abnormal metabolic process in bone

Joints

Anatomy Diarthodial Joint

dislocations

DISLOKASI

Keluarnya bagian tulang di persendian dari posisi yang normal

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

Gejala : hilangnya bentuk normal disertai hambatan gerak

dislokasi Anterior Sendi Bahu

•Sering terjadi (95%)•Sering terjadi pada usia muda•Lengan atas pada posisi abduksi, ekstensi dan rotasi eksternal•Harus segera direduksi

Dislokasi sendi panggul

DISLOKASI Dislokasi Posterior Sendi Panggul

• Akut Traumatik• Harus segera reduksi• Dalam anestesi umum• Teknik ; Allis, Bigelow, Hipocrates• Re-evaluasi neurovasluler problem• Imobilisasi sampai soft tissue healing• Bila disertai fraktur ----reduksi terbuka

Dislokasi elbow

•Reduksi tertutup mudah dilakukan•Imobilisasi 3 minggu•Re-evaluasi neurovaskuler

Bahan bacaan

Robert B. Salter(1999); Textbook of disorders and Injuries of the musculoskeletal System, 3rd ed.Williams & Wilkins, Baltimore. p: 1-3; 417-511.

Louis Solomon et.al (2001) ; Apley’s System of Orthopaedics and Fractures. 8th ed.Arnold, London. p: 521-583.