Langkah langkah praktis menangani kasus kegawatan dalam orthopaedi

bagi dokter umumSUNARYO

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CVSUNARYO, dr., SpOT., SH., MH.Kes.

Fellow International College Surgeon

Lahir di Solo, 1 Agustus 1956Status : Menikah. Istri : Dr. Hj. Rina Dewi Hafil

Anak : 1. Ayu Puspita Sari (Mhs.FK Undip). 2. M. Nadhil Sunaryo Putra (Mhs.FK Undip).

• Riwayat Pendidikan : 1. SD s/d SMA di Jakarta. 2. Dokter : FK UKI Jakarta (1984).3. SpOT : FK UI Jakarta (1999). 4. SH : Univ. Langlangbuana Bandung (2009).5. MH.Kes. : Unika Soegiyapranata Semarang (2007). 6. Lulus Advokat Peradi : (2010).

• Riwayat Pekerjaan : 1. Asisten Bagian Bedah FK UKI/RS PGI Cikini (1985-1987). 2. Staf Bagian Bedah RSU Dr. Abdoel Moeloek Bandar Lampung (1988).3. Kepala Puskesmas Kec. Padang Cermin Lampung Selatan (1989-1990).4. Kepala Puskesmas Kec. Kedondong Lampung Selatan (1991-1992).5. Dokter SpOT dan Kepala Instalasi Bedah Sentral RSUD Kota Tasikmalaya (sekarang)

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• Riwayat Organisasi 1. Ketua MKEK IDI Cabang Tasikmalaya (2010-2016).2. Ketua Komite Medik RSUD Kota Tasikmalaya (2010-2013).3. Ketua Komite Medik RSU Jasa Kartini Tasikmalaya (2010-2013).4. Ketua IDI Cabang Tasikmalaya (2004-2007, 2007-2010). 5. Wkl Ketua I IDI Wilayah Jawa Barat : Bidang Organisasi dan Pembinaan

Wilayah (2010-2013).6. Wkl Ketua II Ikatan Sarjana Hukum Indonesia Cab. Priangan Timur (2010-

2013)7. Wkl Ketua Komite Medik RSJK Tasikmalaya (2006-2009).8. Wkl Ketua Komite Medik RSUD Tasikmalaya (2006-2009).

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PendahuluanRuang lingkup orthopaedi dan traumatologi Kelainan bawaan Infeksi Inflamasi Tumor Trauma extremitas dan tulang belakang Kelainan metabolik Cedera olah raga Degeneratif Rehabilitasi

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Kasus kasus emergensi dalam trauma orthopaedi

• A. Fraktur terbuka• B. Dislokasi• C. Fraktur dan dislokasi• D. Fraktur dengan dislokasi• E. Fraktur dengan gangguan NVD • F. Fratur Teramputasi

A. Fraktur Terbuka

Fraktur : Terputusnya kontinuitas (discontinuitas)

jaringan tulang, tulang rawan dan tulang rawan epiphysis.

Fraktur Terbuka : apabila terdapat hubungan antara fragment

tulang dengan dunia luar

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Principles of management of open fractures

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• 1. Classification of open fractures• 2. Principles of surgical care for open fractures• 3. Débridement• 4. Fixation of open fractures• 5. Soft-tissue care• 6. Primary amputation• 7. Modifiable risk factores

Fraktur Terbuka

• In 1895, Stanley Boyd said “The most important divisions of fractures - simple, compound and complicated - are based upon the condition of the soft parts.”

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Dr. Ramon Gustilo

Seorang Professor Orthopaedi dari University of Minessota AS,Kelahiran Philipina mengelompokan fraktur terbuka berdasarkan kondidi jaringan lunaknya.

Gustilo RB, Mendoza RM, Williams DN (1984) Problems in the management of type III (severe) open fractures. A new classification of type III open fractures. J.Traum Aug;24(8):742-6)

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1. Open fracture classification (Wound-severity classification) Gustilo and Anderson. (JBJS 1976)

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Ramon Gustilo classification of open fracture

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Grade I: fraktur dengan luka terbuka kurang dari 1 Cm, luka bersih, grs fr

simple

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Grade II : Frakrur terbuka dengan luka > 1Cm, contaminated, grs fr simple

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Grade III : Fraktur terbuka, kerusakan jar lunak yg luas, kotor, grs fraktur

segmental/komminutif

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Ramon Gustilo Grade III

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Ramon Gustilo Grade III

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Contoh Gr.III C Open Fracture• The Gustilo-Mendoza-Williams

open-fracture classification separately identifies, as type IIIC, those grade III open fractures with arterial injuries that require vascular repair to restore limb viability. Gustilo et al. demonstrated a 50% risk of osteomyelitis after such injuries, with amputation (early or late) a frequent outcome (Gustilo et al. (1990) The management of open fractures. J Bone Joint Surg 72(2):299-304).

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2. Principles of surgical care for open fractures

Open fractures need : • prompt diagnosis • appropriate intravenous

antibiotics • meticulous injury zone

excision (débridement) * • fracture stabilization • second look • early soft-tissue cover

after soft-tissue recovery

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Intravenous antibiotics for open fractures(Geroulanos & Hell /1989, Antimicrobial Prophylaxis in Surgery)

• Most infecting bacteria, except in very dirty wounds, are typical skin flora. A first generation cephalosporin (e.g., cefazolin 1-2 grams/8 hours) is often used, except for patients with penicillin allergy. For more severe open-fracture wounds, add an aminoglycoside (e.g., gentamycin 80 mg/8-12 hours).If “agricultural” contamination is present, high-dose intravenous penicillin is usually added (e.g., 5 million-10 million units/24 hours) and consider metronidazole.They should be started as soon as the open fracture is diagnosed, but continued for only 2-3 days.

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3. Débridement• Bacterial contamination is always present with open

fractures. Bacterial count and infection rate can be significantly reduced by prompt administration of intravenous antibiotics, in combination with surgical débridement.

• Such surgery is frequently referred to as débridement. This term is open to interpretation and denotes different procedures in different surgical contexts.

• Débridement, as used in this discussion, means the surgical exposure of the whole pathological injury zone and the removal of all necrotic, contaminated, and/or damaged tissue, whether bony or soft-tissue.

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Débridement of the injury zone in open fractures

• The injury zone excision must be complete, meticulous and radical.Early wound débridement is the most important component of the care of any open fracture.

• The surgical site should be thoroughly irrigated (several liters of fluid – optimally, a balanced salt solution, such as Ringer-lactate - to reduce the bacterial population). The epithet “dilution is the solution to pollution” has certain merit in this context.

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4. Fixation of open fractures

Open fractures need : • surgical stabilization,

usually external • consider delayed

definitive ORIF• Surgical fixation, external,

or internal, is the best way to stabilize an open fracture. This is done only after thorough injury zone débridement.

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5. Soft-tissue care

Open wound care :• Avoid contamination • Avoid desiccation • Consider special

dressings • Cover promptly• Any open wound needs

to be protected from secondary contamination

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Second look

• In cases with significant amounts of contaminated, dead, or possibly ischaemic, tissue, additional wound excision 48 hours later (second look) is often necessary – if in doubt, look again.

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6. Primary amputation for OF• A mangled extremity is a

life-threatening injury.• Some extremity injuries

are so severe that amputation is a safer and more humane option than attempted limb preservation.

• Injudicious efforts at salvage may be doomed to failure, with the risk of life-threatening complications, particularly infection.

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The decision whether to amputate, or to try to save, a severely injured limb is one of the most controversial in trauma surgery

7. Modifiable risk factores Poor nutrition • In the malnourished, dietary

supplements, vitamins and other forms of nutritional support should be instituted as soon as possible after emergency surgery.

• Malnourished patients have difficulty healing wounds and resisting infection.

• Simple screening tests, such as total lymphocyte count (<1.2 x 109 / L), or serum albumen level (<3.4 - 5.4 g/dL), together with a careful dietary history and physical examination, help to identify patients with inadequate nourishme

Temperature control • Should a patient’s core

temperature fall during surgery, the risk of delay of soft-tissue healing, and of infection becomes greater.

• For this reason, every effort must be made to minimize intraoperative heat loss, using appropriate covers and external warming devices

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B. DISLOKASI

• Keluar / bergesernya salah satu permukaan tulang persendian dari tempatnya

• Merupakan kasus emergensi yg harus segera di reposisi

• Pada kasus neglected sering harus dilakukan open reduction /reposisi terbuka

• Dapat menimbulkan AVN dikemudian hari

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Contoh kasus dislokasi dan reposisi

C. Fraktur dan dislokasi

D. Fraktur dengan dislokasi

E. Fraktur dengan gangguan NVD

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F. Fraktur teramputasi

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Pasca Amputasi

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Post amputation activities

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PRINSIP PENANGANAN TRAUMA DG FR TERBUKA

• AIR WAY DGN MENGAMANKAN C SPINE• BREATHING• CIRCULATION• DISABILITY• EXPOSURE• ATASI PERDARAHAN, dgn KLEM

ATAUPUN BALUT TEKAN• 4 R• MM : ATS, AB, ANALGETIK

KASUS-KASUS LAIN

• Ada kasus-kasus lain yang sebenarnya tidak fraktur atau simple fraktur tetapi mengalami “overtreatment”.

• Kasus-kasus tumor ekstremitas yang sebenarnya dapat diselamatkan harus diakhiri dengan amputasi.

• Kasus kongenital yang tidak mendapat pertolongan sejak awal

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Kasus-kasus pasca dukun

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Kasus-kasus tumor tulang

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Kasus-kasus neglected pd tumor

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Kasus-kasus kongenital

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PENUTUP

• Hadapi semua kasus dengan tenang• Jangan membuat keadaan menjadi

lebih parah• Kerjakan sesuai kewenangan dan

kemampuan• Selalu berada dalam lingkup SOP dan

SPK

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Sekian dan terimakasih

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