Transcript DIAGNOSIS OF MUSKULOSKLETAL TRAUMA

DIAGNOSIS OF
MUSKULOSKLETAL TRAUMA
Dwikora Novembri Utomo
Lab/SMF Orthopaedi & Traumatologi FK Unair-RS dr Sutomo
SURABAYA
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 BAHASAN
1.
2.
DIAGNOSA TRAUMA MUSKULOSKLETAL
JENIS TRAUMA MUSKULOSKLETAL
a. TRAUMA MSK SEDERHANA
b. TRAUMA MSK MENGANCAM JIWA
c. TRAUMA MSK YG MENGANCAM
EKSTREMITAS
3. PERTOLONGAN BEDAH AWAL PADA TRAUMA
MSK
4. HAL HAL YANG MEMPERBURUK PROGNOSIS
5. INDIKASI KONSULTASI
WHAT IS THE DIFFERENCE ?????
Biomechanics of Fractures
Pelvis
Vm
m
M
VM
E ( Energy Kinetic ) = ½ MV 2
• SOFT TISSUE INJURY : skin, subcutan
fat,muscle, artery,venous, nerves etc
• BONE INJURY : broken bones
Definition
Emergency
:
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 SURVEY
The ABCDEs of muskuloskletal
trauma care identify life
threatening condition.
A. Airway maintenance w/
cervical spine protection
B. Breathing and ventilation
C. Circulation w/ hemorrhage
control
D. Disability : neurological
status
E. 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
• MEASUREMENTdiscrepancy
– 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 FRACTURES
• Open
fracture

communication
between the fracture
and
the
external
environment
• 30% pts with OF are
polytrauma patients.
• Require emergency
treatment
• Significant morbidity
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
•
•
•
•
Prevention of infection
Soft tissue healing and bone union
Restoration of anatomy
Functional recovery
• 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
FRACTURES 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