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Aryadi Kurniawan

A.D ohar A. L. Tobing


D ep. of S urgery
D iv. O rthopaedics & Traumatology,
FKUI/R S C M
Kuliah MS D es 08

M usculoskeletal system
A system of organs that
enables man to mobilize
physically, utilizing the
muscular and skeletal
system.
Bones are connected one
another on their articular
joints, bound together by
the ligaments , caps ules,
muscles and connective
tissues around the joint.
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Basic Knowledge

Anatomy
P hysiology
Histology
B iochemistri

Kinesiology
B iomechanic
Kinemathics
E ngineering

Comprehensive understanding on
normal musculoskeletal system will
ensure a better knowledge on
musculoskeletal pathologies

Musculoskeletal pathologies in
general
Trauma
Infection
C ongenital anomalies
Neoplasma / tumor
D egenerative (osteoporosis, osteoarthritis)
M etabolic

Musculoskeletal injury
Bone:
E piphyseal plate
C ortical bone
C ancellous bone

Joint:
Articular cartilage
Joint C apsule
Ligaments

M uscles
Tendon
P eripheral nerve
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Forces responsible
for the injury
M echanism of injury :
D irect
Indirect

O rientation :
Axial / compres ion
S hearing
Twisting / rotation

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Forces responsible
for the injury
C apacity of the forces :
High energy
Low energy

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FRACTURE

S tructural discontinuity of bone, articular


cartilage or epiphyseal growth plate

D epending on the skin and soft tissue


coverage around the fracture site
1. C losed : intact
2. O pen / C O M P O UND : The soft tissue coverage

is breech and there is an open communication


with the outer environment

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FRACTURE ETI OLOGI ES


Non P athological
1. S I N G L E T R A U M A
2. R epetitive stress
P athological
1. M alignancy
2. Infection
3. O steoporosis (insufficient fracture)
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Pattern of Complete Fracture


S IM P LE
Transvers e
O blique
S piral
Impacted
C O M P LE X
C omminutive
S egmental
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Incomplete Fracture
Involve only one cortex
Intact P eriosteum
C hildren/ P aediatric
Greenstick #, torus #

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S t r es s Fr ac t ur e /
Fat i gue Fr ac t ur e
M ostly on tibia/fibula
Occurs frequently on athlete, dancer, new

army recruits

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Pathological fracture
Normal S tress for normal bone
D eteriorated bone microstructural
O steoporosis
M alignancy
P aget diseas e

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Sites associated with low BMD

HIP

SPINE

WRIST
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Paget DISEASE

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Open Fracture
Gustillo & Anderson clasification :
Grade I
Grade II
Grade III :

III A
III B
III C
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Grade I
Open wound < 1 cm
C lean
Low energy trauma

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Grade II
Wound > 1 cm
No extensive soft tissue stripping
Moderate energy trauma

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Grade III
High energy trauma
High velocity trauma
Gun shot
Grosly contaminated ( farm injury,

barnyard injury )
Associated Neurovascular injury
Open fracture > 8 jam

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Grade III
III A : Adequate soft tissue coverage
III B :
B one expos ed
E xtensive periosteal s tripping
G rosly comminutive

III C :

With vascular injury which otherwise


repaired will jeopardize the limb vitality
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FRACTURE DISPLACEMENT
o/Trauma force
o/ M uscle pull
o/ G ravity

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FRACTURE DISPKACEMENT

Aposition
Angulation
R otation
S hortening/D istraction

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FRACTURE HEALING

Hematoma
Inflamation and cell proliferation
C allus formation
C onsolidation
R emodelling

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PHYSICAL EXAMINATION

PR IM ARY S U RV E Y
Look :

S welling and edema


D eformity
open wound
S kin colour

Feel :
Tenderness
Neurovascular distal
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PHYSICAL EXAMINATION
M ove :
Functio Laesa

M obilize the uninvolved joint to

asses the motoric scale

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X- ray

Fracture configuration
Further management
Follow up
M edical record

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X ray
2 views :
AP /Lat/O blik

2 joints
C onfirm no intra articular injury

2 extremities
especially in children

2 times
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I MAGI NG

B one scanning
C T scan (computerized tomography)
M R I (M agnetic R esonance Imaging)
M S C T (M ulti S liced C T)

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BONE SCAN

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3D CT SCAN

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CT SCAN

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PRINCIPLE OF MANAGEMENT
R ecognize
R educe
R etain
R ehabilitation

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REDUCTION
R educe = reposition
reduction
closed manipulation
open surgery reduksi a vue

( direct vision)

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CLOSED REDUCTION
General anaesthesia
M uscle relaxant
3 M anouvre manipulation
Apply taction on the distal fragment along its

longitudinal axis (disengagement)


R educe to anatomical pos ition
R ealign on 2 dimension

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OPEN REDUCTION
D ebridemen open fracture
C losed frakture
Failed clos ed reduction
Intra articular fracture
Avulsion fraktur

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OPEN FRACTURE

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RETAINMENT / IMOBILIZATION
S plint
S kin traction
C ircular cast
Internal fixation
E xeternal fixation

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GIPS
= P laster
= P O P = P laster of P aris
S plint
C ircular cast

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OPEN FRACTURE
C ontamination higher risk of infection
P rinciples of management eradicate

infection
S tart with primary survey
Therapeutic IV antibiotic (not prophylactic)
Tetanus P rophylactic : Toxoid, ATS

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OPEN FRACTURE

E mergency
D ebridement
D econtamination from dirt, foreign body

(The best solution for pollution is dilution)


E xcision of non vital tis sue
O pen reduction

General anaesthesia
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EPIPHYSEAL PLATE INJURY


P aediatric
If managed unproperly may lead to growth

disturbance or even cessation

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FRACTURE COMPLICATION
E arly :
Viseral injury
Vaskuler injury
C ompartment syndrome

( Volkmanns is chemia)
Nerve injury
Infection

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COMPARTMENT SYNDROME
An increased pressure in closed

osseofasial compartment that compromise


the intrinsic vascularization and jeopardize
the vitality of the involved limb
The plaster is too tight
Vascular injury
Haemophillia

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COMPARTMENT SYNDROME
High risk elbow fracture, forearm, tibia

proksimal
5 P S IGN:

P ain
P araesthes ia
P allor
P aralisis
P ulselessnes s

Tx : fasiotomi
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FRACTURE COMPLICATION
Late :
D elayed union
Non-union
M alunion
Joint stifness
M uscle Hypotrofi/atrofi
M iositis osifikans
Avascular Necrosis
Algodystrophy (S udecks atrophy)
O steoarthritis
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Del ay ed Uni on
At the time of estimated union such

fracture healing is not attained yet


C ause :
S evere soft tiss ue injury
Infection
Inadequate s tabilization

TX : bone graft

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Non- union
Fracture site is filled with fibrosis
P seudoarthrosis
No sign of fracture healing process at all
X ray : obvious fracture line

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Malunion
Fracture united in malposition leading to

impairment of fucntion

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Avascular Necrosis

D islokation B one ischemic avascular

necrosis
O ccurs frequently : feoral head, proximal
scafoid, lunate, talus

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Fr ac t ur e di s eas e
P rolonged immobilization
M uscle hypotrofi/atrofi
D isuse osteoporosis
Joint stifness

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Sprain ligament
Ligamentous injury without any structural

discontinuity
i.e. sprain ankle
C linical sign : tenderness, swelling,
blueish

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Sprain ankle

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Strain ligament
Ligamentous injury with partial structural

discontinuity which doesnt affect the joint


stability

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LIGAMENTOUS RUPTURE
P artial or total structural discontinuity
M ay be associated with aulsion fracture
Knee, ankle,
Haematoma, severe tenderness and

swelling

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DISLOCATION
Total loss of joint contact
S evere pain, deformity, limited range of

motion

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Dislokasi posterior
kaput femur

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Dislokasi

D islok C M C 1

D islok TM J

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SUBLUXATION
P artial joint contact is maintained

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S t r ai n mus c l e

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Strain Muscle

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Tendon
Tendonitis : inflamation on the tendon

sheath
example :
tendonitis achilles (heel cord )
tendonitis s upras pinnatus
dll

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SPONTANEOUS RUPTURE OF
ACHILLES TENDON

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Rupture of long head of biceps

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THANK YOU

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