diagnosis of muskuloskletal_trauma-rev1
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DIAGNOSIS OF MUSKULOSKLETAL TRAUMA
Dwikora Novembri Utomo
Lab/SMF Orthopaedi & Traumatologi FK Unair-RS dr SutomoS U R A B A Y A
TIU
• PADA AKHIR MODUL PPGD INI,MAHASISWA FK SEMESTER 5 AKAN MAMPU MERENCANAKAN AWAL SECARA MANUAL MAUPUN MENGGUNAKAN ALAT, OBAT PADA KEGAWATDARURATAN TRAUMA MUSKULOSKLETAL SECARA TEPAT,CERMAT ,CEPAT, SEBELUM TINDAKAN DEFINITIF /SPESIALISTIK DILAKSANAKAN.
TIK
• MAMPU MELAKSANAKAN TATACARA PENANGANAN TRAUMA MUSKULOSKLETAL DENGAN CEPAT,CERMAT DAN CEPAT
POKOK BAHASAN1. DIAGNOSA TRAUMA MUSKULOSKLETAL2. JENIS TRAUMA MUSKULOSKLETAL a. TRAUMA MSK SEDERHANA b. TRAUMA MSK MENGANCAM JIWA c. TRAUMA MSK YG MENGANCAM EKSTREMITAS3. PERTOLONGAN BEDAH AWAL PADA TRAUMA
MSK4. HAL HAL YANG MEMPERBURUK PROGNOSIS5. INDIKASI KONSULTASI
WHAT IS THE DIFFERENCE ?????
Biomechanics of Fractures
E ( Energy Kinetic ) = ½ MV
Vm VMm M
2
Pelvis
• SOFT TISSUE INJURY : skin, subcutan fat,muscle, artery,venous, nerves etc
• BONE INJURY : broken bones
DefinitionEmergency :
A situation that involves a potential disabling or life threatening condition.
Trauma :A physical wound or injury to living tissue caused by an
extrinsic agent
Fracture : discontinuity of cortex or cartilage
Dislocation : discontinuity of joint
luxation – subluxation
Multitrauma : emergency, life threatening more than one organ requiring immediate treatment intervention
PRIMARY SURVEYThe ABCDEs of muskuloskletal
trauma care identify life threatening condition.
A. Airway maintenance w/ cervical spine protection
B. Breathing and ventilationC. Circulation w/ hemorrhage
controlD. Disability : neurological
statusE. Exposure : completely
undress but prevent hypothermia
life threatening conditions are identified and simultaneous management is instituted
SECONDARY SURVEY
• Done after the patient “stable”
• Head to toe !
• Every orificiums/ every tubes!!
Early Intervention on trauma/multitrauma patient (included MSK trauma problems)
• A Airway and cervical spine protection, protec the cervical : inline imobilisation,collar brace ( head injury,
• C Circulation w/ hemorrhage control (pelvic stabilisation
• D Disability, neurological status(GCS), paraparese or paralysis…..spine fractures suspected…..inline imobilisation!!!
• Exposure : deformity of extremity….imobilisation/splinting!!!
Early Intervention on trauma/multitrauma patient (included MSK trauma problems)
Early Intervention on trauma/multitrauma patient (included MSK trauma problems)
The first step toward cure is to know what the disease is (latin proverb)
Solving the mysteri of a diagnosis is the “detective work of medicine” (Sherlock
Holmes)
How to diagnose the muskuloskletal trauma problems?
• CLINICAL HYSTORY(not for the multitrauma patients)
• PHYSICAL EXAM : LOOK, FEEL, MOVE,MEASUREMENT
• DIAGNOSTIC IMAGING
MUSKULOSKLETAL TRAUMA PROBLEMS
• FRACTURES : Closed, Open
• DISLOCATIONS,FRACTURE-DISLOCATION
• SOFT TISSUE INJURIES :tendon rupture,muscle rupture w/ or w/o neurovascular lesion.
FRACTURES
Close fracture •Open fracture•Compound fracture
FRACTURES• FRACTURES IS NOT
ONLY LESION OF THE BONE
• DOCTORS MUST THINGS : BEYOND THE PICTURES!!!
• THE BONE : LOOKLIKE THE TREE WITH THE ROOT IS THE SOFT TISSUE !!
FRACTURES
FRACTURES
DIAGNOSIS
• CLINICAL HISTORY (Not for multitrauma pts)
*WHEN (time) : golden periode
*HOW ..MOI (Mechanism of injury : Low velocity/High velocity trauma/trivial) !!!
LOOK
• Deformity – Angulation -
Rotation -
DIscrepancy– Position– Edema– Appearance of the
distal part• Pale• Darken
LOOK
• FEEL
–Crepitation
–Temperature of the distal part
–Pulse
–Sensory
FEEL (neurovasc exam)
MOVE
–Active–Passive–Power–False
movement
MEASUREMENT• MEASUREMENT-
discrepancy– True
length,Anatomical length
– Appearance length
CLINICAL DIAGNOSIS
• “Patognomonis sign/definite sign” of fracture: deformity,false movement,
• From Clinical History,Physical Exam ,the clinical diagnosis of fracture is established,
• Investigation ( X RAY)…important for : “fracture configuration & planning of
definitive treatment” , prognosis.
INVESTIGATION• X-ray (Immobilization first)
– 2 VIEWS (AP-lateral)– 2 JOINTS (proximal & distal)– 2 SIDES (IF Necessary)– Special order
INVESTIGATION (X –RAY)
• Open fracture communication between the fracture and the external environment
• 30% pts with OF are polytrauma patients.
• Require emergency treatment
• Significant morbidity
OPEN FRACTURES
OPEN FRACTURES
Grade I open fracture
Grade II open fracture
Grade III A open fracture
GRADE IIIb open fract
Grade III C open fracture
AO Principles of Fracture Management, 2000, pp 671
Gustilo, Burgess, Tscherne, the AO-ASIF group, recommended the following steps for open injuries: – Treat OF as emergencies – Initial evaluation to diagnose life & limb-threatening
injuries – Appropriate antibiotic tx in the emergency OR and
continue treatment for 2 to 3 days only – Immediately debride the wound of contaminated and
devitalized tissue, copiously irrigate, repeat debridement within 24 to 72 hours
– Stabilize the fracture with the method determined at initial evaluation
– Leave the wound open – Rehabilitate the involved extremity aggressively
Principles of Management
• Prevention of infection• Soft tissue healing and bone
union• Restoration of anatomy• Functional recovery
AO Principles of Fracture Management, 2000,
• Prevention of infection• Soft tissue healing and bone union• Restoration of anatomy• Functional recovery
• Golden 6 hours - Bacterial colonization and subsequent wound infection
• Once the skin barrier is disrupted, bacteria enter from the local environment and attempt to attach and grow
• Assess contamination - appropriate antibiotics• Radical Debridement - dead tissue is culture
media( can’t be replaced /prolonged GP by anykind of AB)
• Copious lavage > 10 litres - decrease bacterial load
ORTHOPAEDIC INFECTION:Diagnosis and treatment,1989 pp8
Debridement
• Radical• Wound extended
adequately for visual• Decompress tight
compartments• Copious lavage
• Avoid further soft tissue damage reduce and splint fractures
• Zones of Injury - Repeated Debridement
• Gentle handling• Bony stability• Early coverage < 1 week• Delay closure
• Prevention of infection• Soft tissue healing and bone union• Restoration of anatomy• Functional recovery
• Prevention of infection• Soft tissue healing and bone union• Restoration of anatomy• Functional recovery
• Prevention of infection• Soft tissue healing and bone union• Restoration of anatomy• Functional recovery
FRACTURES OF THE SPINEFRACTURES OF THE SPINE
Cervical Dislocation Thorax Dislocation
Lumbar Fracture
How to decide the level of injury? (based on clinical exam)
SENSORY
MOTOR
REFLEX (PHYSIOLOGIC)
REFLEX (PATOLOGIC)
DISLOCATIONS
• All joint s are surrounded by a joint capsule and ligaments, a dislocation to occur, at least a part of capsule and its ligaments must be torn
DISLOCATION
COMPLICATION OF MUSKULOSKLETAL TRAUMA
1.DAMAGED OF NERVE OR SPINAL CORD
2. DAMAGED OF THE VASCULAR
COMPLICATION OF MUSKULOSKLETAL TRAUMA
COMPARTEMENT SYNDROME
• Compression of nerve & bloodvessels
• Within enclosed anatomic space (osteofacial)
• Leading to impaired bloodflow
Pathophysiology
2 main pathways*
– Increasing fluid content within the compartment (ex : haemorrhage, oedema)
– Decreasing the compartment size
(ex : external compression)
* Whitesides, Acute compartment syndr, J Am Acad Orthop Surg 1996;4
How to Diagnosed ?
• Mainly by clinical examination!!!
Sign & Symptoms
Classic signs 5 P– Pain
Severe extremity pain out of proportion to injury
Early sign, worse with passively stretching involved muscle
– Paresthesia or anesthesia to light touch
– Paralysis
– Pulselessness
Not present in early cases
• Pallor
LATE COMPLICATION OF FRACTURES
INFECTION IN OPEN FRACT
• Grade I less than 1%
• Grade II 1-10 %
• Grade III 10-50%
SIMPLE MUSKULOSKLETAL TRAUMA
LIFE THREATENING MUSKULOSKLETAL TRAUMA
LIMB THREATENING MUSKULOSKLETAL TRAUMA
FACTORS THAT MAKE THE PROGNOSIS BECOME WORSE
• Bad pre hospital management * no imobilisation/splint * improper transfer of patients (ex : to
transfer spine fract w/o inline imobilisation)
*delayed transfer (over golden periode,under diagnosis of vascular injury)
Pre Hospital– Control :
Airway
Circulation
Immobilization
Transportation
INDICATION OF CONSULTATION• ALL FRACTURES & DISLOCATION ARE PATOLOGIC
CONDITION.
• IMOBILISATION /SPLINT FIRST
• STRICTLY NO DELAY OF TRANSFERING PATIENTS W/ FRACT + NEUROVASCULAR INJURY, OPEN FRACTURES , DISLOCATION.
• DO NOT DO HARM
SUMMARY
• 30% of OF ARE POLYTRAUMA PATIENTS.• FRACTURES IS NOT ONLY LESION ON THE
BONE.• EARLY INTERVENTION OF MSK TRAUMA
SHOULD BE DONE PROPERLY, FOR BETTER PROGNOSIS.
• TO KNOW THE BASIC KNOWLEDGE FOR MAKING DIAGNOSIS OF MSK TRAUMA IS MANDATORY BEFORE TREATING PATIENTS.
• DO NOT DO HARM
REFERENCE