You are on page 1of 192

SURGERY

Surgery
BIMBEL UKDI MANTAP
dr. Andreas W Wicaksono
dr. Anindya K Zahra
GENERAL SURGERY
Lap belt marks: Correlate with small intestine rupture
Kehr’s sign
• Kehr’s sign : pain in
the left tip shoulder
cause by irritation of
peritoneum that
covers inferior
surface of left
diaphragm >> a sign
of rupture spleen
HistoryRetroperitoneal
& Physical: Hematoma

Cullen sign: Periumbilical


echymosis
Grey Turner Sign: Flank
echymosis
Plain Abdomen AP & Semierect: Subdiaphragmatic Air
Abdomen
Plain Abdomen 3 Posisi
LLD:
Subdiaphragmatic Air
Anatomi Prostat
Ruptur
Uretra
Straddle
Anterior Injury

Hematom penis

Butterfly
Hematome
Ruptur Uretra Posterior

Major trauma. Floating prostate


Snake Bite
Derajat Gigitan Ular (Depkes)

0 1 2 3 4
Eritem < 3cm 3-12cm >12-25cm >25cm > ekstremitas
(dalam
12jam)
Gejala - - Mual, Shock, Gagal ginjal
Sistemik pusing Petechie, akut, coma,
echymosis perdarahan
DIGESTIVE SURGERY
Migrating pain–
Acute Appendicitis
appendicitis

Periumbilical pain(colicky pain, Mc. Burney pain (irritative


visceral) referred by N. Thoracal X peritoneal pain, somatic)
Clinical Sign

• Rovsing’s sign :
palpation in the left
lower quadrant of
abdomen increase the
pain in the right lower
quadrant
Obturator sign
Alvarado Score: MANTRELS
Pathophysiology
Radiology– Ileus
Ileus

Herring bone Coil spring Stepladder pattern


Pneumoperitoneum
Colorectal Cancer
Clinical Manifestation
Apple Core
Filling Defect
How Does Colorectal Cancer Develop?
Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.
CRC Risk Factor
• >60 yo
• Family history (+): mutasi gen
• Familial adenomatous polyposis
• Low fiber diet
• IBD

Screening Test:
• FOBT
• Colonoscopy
• CEA (Carcinoembryonic Antigen). Normal <2,5ng/ml
• Genetic analysis
DUKE’s Staging
Hemorrhoid

External Hemorrhoids Internal Hemorrhoids


Outside anal canal, around sphincter Inside anal canal
Symptoms due to thrombosis Symtomps due to bleeding and/or
irritation of mucosa
Painless, bleeding
Prolapse associated with defecation
Can not be inserted to anal canal Can be inserted to anal canal up to grade
III
• Internal Hemorrhoids →
Internal hemorrhoidal plexus
– V. Rectus Inferior
– V. Rectus Media
• External Hemorrhoids →
external hemrroidal plexus
– V. Rectus Inferior
Internal Hemorrhoid: Grading
• Tx:
– Non Farmakologis
• Changing lifestyle
(menghindari risk
factor)
• Diet tinggi serat
• Endoskopi (Rubber
band & Sclerotherapy)
– Farmakologis
• Fecal softener
• Fiber supplement
• NSAID
– Surgery
• Electrocautery &
Cryosurgery
• Hemorrhoidectomy
(excision or stapled)
Biliary Tract Disorders
• 4F: Female, forty, fat, fertile
Gallstone disease • Seringkali asimptomatik
(cholelithiasis) • Simptomatik: biliary colic (terutama stlh makan
berlemak) pd epigastrium atau RUQ

• Trias dx: Fever, Leukositosis, RUQ Tenderness


• Murphy sign (+)
Acute Cholecystitis • Biliary colic > memburuk secara progresif, radiasi ke
interscapular area, scapula & bahu dextra

• Asymptomatic
Gallstone in CBD • Biliary colic
(choledocholithiasis) • Obstructive jaundice

• Trias Charcot: 1. jaundice, 2. fever, usually with rigors,


Cholangitis 3. RUQ abdominal pain.
• Severe: hypotension, altered mental status

Congenital : Atresia • Cholestasis  jaundice with increase of direct bilirubin


bilier • 80% pd bile duct di atas level porta hepatis
Gallstone Disease / Cholelithiasis
• Terbentuk di gallbladder. Bisa bermigrasi ke distal : ductus cysticus, ductus
choledocus, ductus pancreaticus atau Ampula vater.
• Tipe :
– 80% cholesterol & mixed stone
– 20% pigmented stone
• Cholesterol & mixed stone
– Konten : kolesterol monohidrat, garam Ca,
bile pigment, protein & fatty acid
– Mekanisme penting : increased biliary secretion of
cholesterol, biasa pada pasien obese atau
diet tinggi kolesterol
• Pigmented stone
– Konten : kalsium bilirubinat (dominan)
– Biasa pd pasien chronic hemolytic disease
atau alcoholic cirrhosis
• Dx :
– Plain film > deteksi radiopaque kalsium (kasus: 10-15% kolesterol & 50%
pigmented stone)
– USG
• Sign & symptom :
– Seringkali asymptomatik (terutama di dlm gall bladder)
– Symptomatis jika sudah menimbulkan inflamasi atau obstruksi
– Gejala plg spesifik & khas: biliary colic. Yaitu severe pain (akibat
biliary contraction, terutama stlh makan berlemak) pd
epigastrium atau RUQ yg sering radiasi ke daerah interscapular,
scapula dextra dan bahu dextra
– Nausea & vomit sering menyertai biliary colic
• Temuan Klinis :
– Fever (biasanya sdh komplikasi / peradangan)
– Serum bilirubin (++)
– Alkaline phospatase (++)
• Lokasi tersering terjadi sumbatan / inflamasi :
– Ductus cysticus
– Ductus choledocus / choledocholithiasis
Cholecystitis
• Berdasar penyebab :
– Calculous cholecystitis (90-95%) :
terutama akibat obstruksi gallstone pada
ductus cysticus
– Acalculous cholecystitis (5-10%) :
jarang, penyebab bervariasi: trauma
adenocarcinoma gallbladder
torsi gallbladder dan DM.

• Sign & symptom :


– Biliary colic > memburuk secara progresif
– Radiasi ke interscapular area, scapula & bahu dextra (tanda terjadi
iritasi pd diafragma – sensasi nyeri o/ n.phrenicus > C3-C5 dextra)
– Anorexia, nausea & vomit
– Jaundice (uncommon)
– Murphy sign (+)
• Patofisiologi :
Prinsipnya sama dgn di appendicitis (monggo dibaca lg)
• Temuan Klinis :
– Fever
Trias
– Leukositosis (10.000-15.000 cells/uL) diagnosis
– RUQ tenderness
– Serum bilirubin (mildly elevated, no symptom)
– Murphy Sign (+)
• Dx :
– Berdasar triad &
temuan klinis lain
– USG (identifikasi thickening of gallbladder wall)
– CT-scan
• Komplikasi :
– Gangren & perforasi > bs diikuti abscess jika ada
superinfeksi bakteri > bs generalized peritonitis
– Fistulization : biliary-enteric fistula
• Treatment :
– Non surgery :
• Analgetik & antispasmodik
• Nutrisi parenteral (hindari oral intake)
• Antibiotik profilaksis (mencegah peritonitis & cholangitis)
• Bedrest

– Surgery :
• Laparoscopic cholecystectomy
• Open cholecystectomy
Choledocholithiasis
• 10-15% pasien cholelithiasis
• Penyebab :
– Gallstone (pigmented stone)
– Sering pada pasien dgn kronik
hemolytic disease
• Sign & symptom :
– Asymptomatic
– Biliary colic
– Obstructive jaundice
• Px lab (mirip dgn cholelithiasis) :
– Serum bilirubin (++)
– Alkaline phospatase (almost always elevated in biliary obstruction)
• Komplikasi :
– Cholangitis
• Terjadi akibat ascending infection dari bacteria di duodenum. Bisa
terjadi krn bile duct sudah terobstruksi oleh gallstone.
• Medical emergency
• Sign & symptom : jaundice, fever, malaise, rigor & abdominal pain
(severe : hypotension & confusion)
• Gambaran duktus : dilated, sclerosed & strictured ducts
• Initial Tx : IV fluid & antibiotik
– Pancreatitis
cholangitis
• Px penunjang :
– Cholangiography
– ERCP & MRCP
– USG
• Tx :
– Choledocholithotomy
– ERCP (Modalitas intervensi: endoscopic sphincterotomy,
stone removal, insertion of stent, dilation of stricture)
ERCP

Alat Dx sekaligus Tx

Pilihan Tx lihat slide


sebelumnya...
Biliary Atresia
• Kelainan kongenital yg cukup jarang
(1 per 15.000 kelahiran), tapi
kejadian ini 25-30% berhubungan
dgn anomali lain seperti
stenosis/atresia duodeni, pancreas
annulare, dll.
• 80% pd bile duct di atas level porta
hepatis, 15% pada ductus
choledochus, dan 5% pada ductus
hepaticus communis.
• Etiologi : intrauterine inflammatory
process caused by fibrosis of both
the intrahepatic & extra hepatic
biliary tree.
• Tx : Kasai hepatoportoenterostomy
• Murphy’s sign : the patient stop resp. effort
when we deep palpate the RUQ >
Cholecystitis
• 4F : Fat, Forty, Female, Fertile > Cholelithiasis
• Trias Charcot : > Cholangitis
– Fever
– Ikterik
– Pain in RUQ
• PUDDLE SIGN Puddle Sign
– For ascites 120ml
– Prone for 5 mins
– Rise onto elbow & knee
– Stethoscope at bottom
– Flicks near flank repeatedly
– Move stethoscope away  sound
becomes louder

• SHIFTING DULLNESS
– For ascites
500ml
Hernia
Trigonum hasselbach
Dibentuk tepi MRA, a.
epigastrica inferior, lig.
Inguinalis

Hernia Inguinalis Direct/Medial (trigonum hasselbach)


Hernia Inguinalis indirect/lateral (canalis inguinalis)
Hernia Femoralis (canalis femoralis)
Spatium Subinguinal
UROLOGIC SURGERY
Benign Prostat Hyperplasia

• Screening test :
PSA ( Prostat
Specific Antigen),
normal value <4
ng / ml
• Rectal toucher:
–Suspect
malignancy IF
hard, nodular,
irregular
PENANGANAN / PENGOBATAN BPH
Dulu: Mencegah / menurunkan angka
kematian karena BPH
IPSS: WISE & FUN Sekarang: Meningkatkan kualitas hidup

W eak stream
ALTERNATIF PENANGANAN BPH
I ntermittensi
• IPSS <8  Watchful Waiting
S training • IPSS 8-18 Pemberian obat
E mptying incomplete • Alpha1 adrenergik blocker
F requecy (Prazosin)
U rgency • 5 Alpha reductase inhibitor
(Finasterid)
N octuria
• IPSS >18 Operatif
 Invasive: open prostatecomy
 Less Invasive: TURP
WATCHFUL WAITING
• Sebagian besar tanpa keluhan
• Tanpa penyulit / gejala
• Kualitas hidup tetap baik

INDIKASI
• BPH dengan IPSS ringan (<8)
• Baseline data normal
• Flowmetri : non obstruktif

FOLLOW-UP
• Tiap 3-6 bulan
• Ulangi :
• IPSS
• Flow (6 bulan)
• PSA (6-12 bulan)
Prostate
TERAPI BPH DENGAN  BLOCKER

INDIKASI :
• IPSS ringan dan sedang

SYARAT :
• Normotensi / hipertensi ringan
• Urin normal
• Faal Ginjal Normal
• PSA  4 ng%
• Miokard Infark (-), CVA (-)

KONTRAINDIKASI
• Hipotensi postural / ortostatik
• Alergi terhadap  bloker
TERAPI PEMBEDAHAN BPH PEMBEDAHAN BPH
Di Amerika : 300.000 – 400.000/tahun • TUR Prostat: 90 – 95%
Di Urologi RS Dr. Soetomo • Open prostatektomi
Ke 2 terbanyak setelah urolithiasis : 5 – 10 %
 150/tahun
• BPH yang besar
INDIKASI TERAPI PEMBEDAHAN BPH (>50 – 100 gram)
• Retensi urin akut Tidak habis
• Retensi urin kronis (selalu > 300 ml) direseksi dalam
• Residual urin > 100 ml 1 jam
• BPH dengan penyulit
• Disertasi :
• Terapi medikamentosa tidak berhasil
• Flowmetri obstruktif • Batu buli besar
(> 2.5 cm)
INDIKASI KONTRA TERAPI PEMBEDAHAN BPH • Multipel
• Infark miokard Akut • Fasilitas TUR tidak
• CVA Akut
ada
Batu Saluran Kemih

 Nephrolithiasis

 Ureterolithiasis

 Vesikulolithiasis

 Uretrolithiasis
Urinary Tract Reffered Pain
Lokasi Gejala
GINJAL Nyeri regio flank, dapat berupa
- Nyeri kolik akibat aktivitas peristaltik otot polos sistem kalises, atau
- Nonkolik akibat peregangan kapsul ginjal, hidronefrosis, atau infeksi
pada ginjal
• menyerupai tanduk rusa.
URETER Nyeri pinggang kolik dan menjalar, tergantung letak batu:
• rektum.
- Proksimal  pinggang setinggi pusar (T10)
- Medial  medial paha/skrotum (L1-3)
- Distal  ujung penis (S2-3), +disuria
VESICA Gejala iritasi, miksi tiba-tiba berhenti dan menjadi lancar kembali
dengan perubahan posisi tubuh.
Nyeri berkemih pada ujung penis, skrotum, perineum, pinggang, atau
kaki. Anak sering mengeluh enuresis nokturna, sering menarik-narik
penisnya (laki-laki) atau menggosok-gosok vulva (perempuan)

URETHRA Miksi tiba-tiba berhenti retensi urin. Batu pada uretra - Anterior 
benjolan keras di penis, atau tampak di meatus uretra eksterna. Nyeri
pada glans penis.
- Posterior  nyeri pada perineum atau rektum
Jenis-jenis batu
Diagnosis –Px Penunjang

Urinalisis
• Hematuria, kristal, tanda infeksi

Darah Rutin dan Kimia Darah


• Terutama ureum, creatinin, asam urat

Radiologi
• BNO  hanya untuk batu radioopak (kalsium, sistin)
• IVP  bisa untuk batu non-opak (urat, struvit)
• USG  aman untuk ibu hamil dan yang KI IVP
• Pyelografi antegrad/retrograd  bila fungsi voiding terganggu
Struvite Stones
• >> women
• Struvite (magnesium ammonium phosphate) stone
• Infection with urease producing bacteria (e.g. Proteus,
Klebsiella, Pseudomonas and Enterobacter), resulting in
hydrolysis of urea into ammonium and increase in the
urinary pH 6,10.
• They can grow very large and form a cast of the renal pelvis
and calices resulting in so-called staghorn calculi. The
struvite accounts for approximately 70% of these calculi,
and is usually mixed with calcium phosphate thus
rendering them opaque. Uric acid and cystine are also
found as minor components.
Staghorn
Faktor Risiko –Batu Kalsium (70-80%):
• Hiperkalsiuri
– absobtif
– renal (reabsorbsi turun)
– resorptif (kalsium tulang)  pada hiperparatiroidisme
• Hiperoksaluri
– post operasi usus atau banyak konsumsi makanan yang kaya oksalat (teh, kopi
instan, soft drink, dll)
• Hiperurikosuria
– asam urat bertindak sebagai inti batu/nidus untuk terbentuknya batu kalsium
oksalat.
• Hipositraturia
– Di dalam urine, sitrat bereaksi dengan kalsium membentuk kalsium sitrat 
cegah ikatan kalsium dengan oksalat atau fosfat.
• Hipomagnesuria.
– Di dalam urine magnesium bereaksi dengan oksalat menjadi magnesium
oksalat  cegah ikatan kalsium dengan oksalat.
Prevensi Batu Kalsium
• Menurunkan konsentrasi kalsium dan oksalat
• Meningkatkan konsumsi sitrat  minum jeruk nipis/air
lemon sesudah makan malam
• Meningkatkan asupan cairan
• Hindari soft drink (>1 L/minggu)
• Batasi asupan protein (1 gr/kgBB/hari).
– Protein tinggi  ekskresi kalsium & asam urat,  sitrat
• Batasi asupan natrium   reabsorpsi kalsium
• Pembatasan asupan kalsium tidak dianjurkan
Tatalaksana
Bladder Carcinoma
• Cancer age
• Painless gross
hematuria all along
micturition, reccurent
• Risk factor
– Male
– Cigarette
– Amine aromatic
substance exposure
(paint, textile)
– UTI
• 90%: Transitional Cell
Carcinoma (TCC)
Retrograde Urethrography
4. Continuous: fistula 5. functional: paralysis, cognitive impairment
Urinary Incontinence
Scrotal Swelling
Disorders Etiology Clinical
Testicular torsion Intra/extra-vaginal Sudden onset of severe testicular pain followed by
torsion inguinal and/or scrotal swelling. Gastrointestinal
upset with nausea and vomiting.
Hidrocele Congenital anomaly, accumulation of fluids around a testicle, swollen
blood blockage in the testicle,Transillumination +
spermatic cord
Inflammation or
injury

Varicocoele Vein insufficiency Scrotal pain or heaviness, swelling. Varicocele is


often described as feeling like a bag of worms
Hernia skrotalis persistent patency of Mass in scrotum when coughing or crying. Bowel
the processus sound on scrotum. Strangulated → nausea,
vaginalis vomiting, fever, edematous, erythematous,
discolored
Orchitis Mumps virus Testicular pain and swelling, fatigue, fever, chills,
Testicular enlargement, induration of the testis,
Erythematous scrotal skin
Testicular Torsion
• Sign : Sudden pain in
scrotal, nausea and
vomiting, no fever
• Physical Exam
– Cremaster reflex (–)
– Phren sign (-)
• Tx : Orchidectomy
Phren’s sign
• Prehn's sign, the physical lifting of the testicles
relieves the pain
– Negative Prehn's sign indicates no pain relief with
lifting the affected testicle, which points towards
testicular torsion which is a surgical emergency
and must be relieved within 6 hours
– Positive Prehn's sign indicates there is pain relief
with lifting the affected testicle, which points
towards orchidoepididymitis.
Orchitis
Varicocele
Hydrocele
Hydrocele Types
• Translumination test
/ diapanoscopy
• Positive : Hydrocele,
Hernia Scortalis
• Negative : Mass
Fimosis and Parafimosis
Epispadia and Hypospadia
Cryptoorchidismus
Management
ORTHOPAEDIC SURGERY
Fracture
Colle’s and Smith’s
Complication of Fracture
Early complications
• Local:
– Vascular injury causing haemorrhage, internal or external
– Visceral injury causing damage to structures such as brain, lung or
bladder
– Damage to surrounding tissue, nerves or skin
– Haemarthrosis
– Compartment syndrome (or Volkmann's ischaemia)
– Wound infection, more common for open fractures
• Systemic:
– Fat embolism
– Shock
– Thromboembolism (pulmonary or venous)
Fracture Complication
• Late Complications
– Local:
• Delayed Union
• Non-union
• Malunion
• Joint stiffness
• Contractures
• Osteomyelitis
• Growth disturbance or deformity
• Systemic:
– Gangrene
– Tetanus
– Septicaemia
Non-Union and Mal-Union
Fraktur clavicula: Fraktur scapula:
>> di 1/3 lateral, pada anak2. Banyak terjadi pada acromion.
• Fragmen medial clavicula terangkat
krn m. SCM, fragmen lateral jatuh Fraktur scaphoid:
(shoulder drop), dan proksimal humerus Fraktur carpal tersering.
tertarik ke medial krn m. pectoralis major. Fraktur – avaskuler – nekrosis –
• Pada anak, fraktur terjadi inkomplit, degenerasi; diTx bedah penyatuan
disebut greenstick fracture. os carpal = arthrodesis

Fraktur Humerus: Fraktur hamatum:


• >> di collum chirurgicum, pada lansia Bisa melukai n. et a. ulnaris
osteoporosis.
• Pada tuberculum majus : avulsion Fraktur metakarpal:
fracture. Fraktur metakarpal 5 (boxer’s
• Direct contact bagian humerus dgn fracture)
nervus:
1) collum chirurgicum: n. axillaris, Fraktur falang:
2) sulcus radialis: n. radialis, Distal – comminuted, painful
3) akhir distal: n. medianus, hematome. Proksimal – hati2
4) epicondylus medial: n. ulnaris tendon flexor
Humeral Fracture
• Collum chirurgicum:
n. axillaris
• Sulcus radialis (shaft) :
n. radialis
• Distal end :
n. medianus/ n.radial
• Epicondylus medial:
n. ulnaris
Cubital Tunnel syndrome:
Penekanan n. ulnaris saat melewati cubital tunnel.
Cubital tunnel = saluran yang terbentuk oleh arcus tendineus m. flexor
carpi ulnaris yang mengubungkan humerus dan ulna.
Tanda gejala: lesi n. ulnaris pada sulcus ulnaris di posterior epycondylus
medialis.

Guyon Tunnel Syndrome:


Penekanan n. ulnaris saat melewati canalis ulnaris (Guyon tunnel).
Guyon tunnel = saluran yanng dibentuk oleh os pisiform dan hammulus os
hammati

Carpal Tunnel Syndrome:


Penekanan struktur-struktur yang melewati carpal tunnel (canalis carpalis),
terutama n. medianus.
Canalis carpalis = saluran yang berada di pergelangan tangan dan dibentuk
oleh os carpal dan retinaculum flexorum.
Tanda gejala: paresthesia, hypoesthesia, atau anesthesia pada 3 ½ lateral
jari tangan
Nerve Injury
• N. Axilaris : • N. Ulnaris: Claw hand
m.deltoideus, sensoris: • N. Radialis: Drop hand
bahu (can’t extend hand)
• N. Muskulokutaneus: • N. Medianus:
compartemen anterior Preacher’s hand
brachium
– m.bisep brachii
– m. brachialis
– m.coracobrachialis
Carpal Tunnel
Syndrome
N. medianus
Cubital Tunnel GuyonTunnel
Syndrome Syndrome

Epicondylus medial
Claw hand
N. Ulnaris
Drop hand
N. Radialis
Preacher’s Hand
N. medianus
Orbita
Management of Fracture

• 4R :
– 1. Recognition
– 2. Reduction
– 3. Retention
– 4. Rehabilitation
Recognition
• Anamnesis
– History of trauma?
– Mechanism of injury?
– Localized pain, aggravated by movement
– Decreased function
– “heard the bone break”
– “feel the ends of the bone grating”
Physical Examination
LOOK (Inspection)
 Symetricity right-left
 Swelling, wound, deformity (angulation, rotation,
shortening), abnormal movement, discoloration
(ecchymoses)
 Bone exposure

FEEL (Palpation)
 Localized tenderness
 Distal neurological status (S&M), pulsation
 Aggravation of pain and muscle spasm during even the
slightest passive movement
 Feeling and listening the crepitus  unnecesary!
Reduction
• Restore a fracture to correct allignment
• Closed Reduction
– Traction : Skin traction, skeletal traction
• Open Reduction
– ORIF
– OREF
Traction
Skeletal Traction

Femur fracture managed with skeletal traction and use of a Steinmann pin in the
distal femur.
ORIF vs OREF
Indications for External Fixation
• Open fractures that have
significant soft-tissue
disruption (eg, type II or III
open fractures)
• Soft-tissue injury (eg, burns)
• Pelvic fractures
• Severely comminuted and
unstable fractures
• Fractures that are associated
with bony deficits
• Fractures associated with
infection or nonunion
• Closed reduction is needed if the fracture is significantly displaced or
angulated. Indications for surgical intervention include the following:
– Failed nonoperative (closed) management
– Unstable fractures that cannot be adequately maintained in a reduced
position
– Displaced intra-articular fractures (>2 mm)
– Patients with fractures that are known to heal poorly following
nonoperative management (eg, femoral neck fractures)
– Large avulsion fractures that disrupt the muscle-tendon or ligamentous
function of an affected joint (eg, patella fracture)
– Impending pathologic fractures
– Multiple traumatic injuries with fractures involving the pelvis, femur, or
vertebrae
– Unstable open fractures or complicated open fractures
– Fractures in individuals who are poor candidates for nonoperative
management that requires prolonged immobilization (eg, elderly patients
with proximal femur fractures)
– Fractures in growth areas in skeletally immature individuals that have
increased risk for growth arrest (eg, Salter-Harris types III-V)
– Nonunions or malunions that have failed to respond to nonoperative
treatment
Retention / Immobilization
Bidai /Splint adalah alat yang digunakan untuk mengimobilisasi
bagian tubuh, alat tersebut dapat bersifat lunak ataupun kaku
(rigid)
• Plaster slab adalah lempengan gips untuk imobilisasi sendi atau
daerah cidera sehingga terjadi penyembuhan. Sebagian besar
fraktur dislab untuk 24-48 pertama untuk mengakomodasi
pembengkakan, sebelum dipasang gips sirkuler.
• Lempengan Gips/CAST → Dapat Digunakan Pada
– Imobilisasi Fraktur
– Imobilisasi pada penyakit tulang dan sendi
– Pencegahan deformitas muskuloskeletal

* Aryadi K, Syaiful AH. Penggunaan Gips Paris. In: Petunjuk pemasangan gips paris pada kasus orthopaedi, Divisi Orthopaedi dan
traumatologi, 2006. hal 2-6
GIPS/CAST
Supracondylar Fracture of Humerus
Open Reduction To Prevent
Arm Sling
Brachial Artery Injury!
U Slab
• Humeral shaft
fracture
Volar Slab
Compartment Syndrome

• 6 P of Compartment
Syndrome
– Pain
– Pallor
– Pulseless
– Paresthesis
– Paralysis
– Pressure
• Tx : Fasciotomy
Compartment Syndrome

• Fasciotomy
• Casts and tight
bandages
–remove or
loosen any
constricting
bandages
Muscle of Calf
Artery of Calf
Paget’s Disease
• Paget disease is a localized disorder of bone
remodeling that typically begins with
excessive bone resorption followed by an
increase in bone formation. This osteoclastic
overactivity followed by compensatory
osteoblastic activity leads to a structurally
disorganized mosaic of bone (woven bone),
which is mechanically weaker, larger, less
compact, more vascular, and more susceptible
to fracture than normal adult lamellar bone.
• Sign and Sympton including the following:
– Bone pain (the most common symptom)
– Secondary osteoarthritis (when Paget disease
occurs around a joint)
– Bony deformity (most commonly bowing of an
extremity)
– Excessive warmth (due to hypervascularity)
– Neurologic complications (caused by the
compression of neural tissues)
• Skull involvement may lead to the following:
– Deafness
– Vertigo
– Tinnitus
– Dental malocclusion
– Basilar invagination
– Cranial nerve disorders
Multiple Myeloma

• Sign : bone pain


• X-ray
“punched out lession”
Multiple Myeloma
• Symptomatic myeloma:
– Clonal plasma cells >10% on bone marrow biopsy or (in
any quantity) in a biopsy from other tissues
(plasmacytoma)
– A monoclonal protein (paraprotein) in either serum or
urine (except in cases of true non-secretory myeloma)
– Evidence of end-organ damage felt related to the plasma
cell disorder (related organ or tissue impairment, ROTI,
commonly referred to by the acronym "CRAB"):
• HyperCalcemia (corrected calcium >2.75 mmol/L)
• Renal insufficiency attributable to myeloma
• Anemia (hemoglobin <10 g/dL)
• Bone lesions (lytic lesions or osteoporosis with compression
fractures)
• Asymptomatic (smoldering) myeloma:
– Serum paraprotein >30 g/L AND/OR
– Clonal plasma cells >10% on bone marrow biopsy AND
– NO myeloma-related organ or tissue impairment
• Monoclonal gammopathy of undetermined
significance (MGUS):
– Serum paraprotein <30 g/L AND
– Clonal plasma cells <10% on bone marrow biopsy AND
– NO myeloma-related organ or tissue impairment
Osteomyelitis
• Inflammation of the bone and bone marrow
caused by an infecting organism.
• Although bone is normally resistant to bacterial
colonization, events such as trauma, surgery,
presence of foreign bodies, or prostheses may
disrupt bony integrity and lead to the onset of
bone infection
• Pathogenesis (Waldvogel, 1971) :
1. Hematogenous
2. Contiguous focus of infection
3. Direct inoculation
Osteomyelitis
• Osteomyelitis is often diagnosed clinically with nonspecific
symptoms
– fever,
– chills,
– fatigue,
– lethargy,
– irritability.
• The classic signs of inflammation, including local pain,
swelling, or redness, may also occur and normally disappear
within 5-7 days
Osteomyelitis
• S aureus is the most common pathogenic
organism recovered from bone, followed
by Pseudomonas and Enterobacteriaceae.
• Less-common organisms involved include
anaerobe gram-negative bacilli.
• Intravenous drug users may acquire
pseudomonal infections
• Acute hematogenous osteomyelitis has a
predilection for the long bones of the body.
• The ends of the bone near the growth
plate (the metaphysis) is made of a maze
like bone called cancellous bone.
• It is here in the rapidly growing metaphysis
that osteomyelitis often develops
Supracondylar Fracture
• Outstretched arm
• >> children
Elbow Dislocation
• Elbow dislocations are not common
• Falls onto an outstretched hand, usually there is a
turning motion in this force  drive and rotate
the elbow out of its socket
• Elbow dislocations can also happen in car
accidents
• The elbow is stable because of the combined
stabilizing effects of bone surfaces, ligaments,
and muscles. When an elbow dislocates, any or
all of these structures can be injured to different
degrees.
Osteoporosis
A systemic skeletal disease characterized
by low bone mass and micro architectural
deterioration of bone tissue lead to bone
fragility and susceptibility to fracture
Densitometri Osteoporosis
World Health Organization Definitions Based on Bone Density Levels

Level Definition

Normal Bone density is within 1 SD (+1 or −1) of the young adult mean.

Bone density is between 1 and 2.5 SD below the young adult


Low bone mass
mean (−1 to −2.5 SD).

Bone density is 2.5 SD or more below the young adult mean


Osteoporosis
(−2.5 SD or lower).

Severe
Bone density is more than 2.5 SD below the young adult mean,
(established)
and there have been one or more osteoporotic fractures.
osteoporosis
Incidence of osteoporotic Fx

Vertebral
Fracture
Forearm
Fracture

Hip
Fracture
Osteoporosis
ATLS
Shoulder Dislocation
Anterior Shoulder
Subluxation/Dislocation
• Radiographs:

Axillary View

True AP

Y view
Anterior Shoulder Subluxation/Dislocation
• Dislocation: • Mechanism:
– Complete separation of articular
surfaces – Forced extension, abduction,
external rotation
• Subluxation:
– Direct blow to posterior or
– Abnormal translation of humeral
head on glenoid without posterolateral shoulder
complete separation of articular – Repeated episodes of overuse
surfaces (subluxation)
• Humeral head can dislocate • Physical Exam:
anteriorly, posteriorly or – Intense pain
inferiorly – Arm held in adduction & external
• Anterior dislocation most rotation
common – Humeral head palpable anteriorly
– Unable to completely internally
rotate or abduct the shoulder
– Thorough neuro exam (close
relation of axillary nerve)
Hip Dislocation
Posterior Anterior
(flexi, adduksi, endorotasi) (flexi, abduksi, exorotasi)
Osteosarcoma
• X-rays of area of suspected infection would
not demonstrate darkened areas typical of
osteomyelitis.
• Conventional features
– Destruction of normal trabecular bone pattern
– a mixture of radiodense and radiolucent areas
– periosteal new bone formation
– formation of Codman's triangle (triangular
elevation of periosteum)
No osteoblastic appearance, Notice the osteoblastic-
fracture can be seen osteolytic appearance
Codman triangles (white Osteosarcoma of the distal femur,
arrow); and the large soft demonstating dense tumor bone formation
tissue mass (black arrow) and a sunburst pattern of periosteal reaction.
Periosteal reactions
• Radiographs of the primary
tumor usually show a large,
destructive, mixed lytic and
blastic mass. The tumor
frequently breaks through the
cortex and lifts the periosteum,
onion-skin "sunburst" and "hair-on- resulting in reactive periosteal
(Ewing’s sarkoma) end" periosteal reaction bone formation. The triangular
shadow between the cortex
and raised ends of periosteum
is known radiographically as
Codman triangle and is
characteristic, but not
Codman's triangle
diagnostic of this tumor.
The Canadian Journal of Diagnosis / May 2001
Ewing’s Sarkoma

• Annual
incidence at
birth to 20 y.o
(teenagers and
young adult)
• Most common
site : pelvis
• Radiologic :
onion peel
Ewing’s Sarkoma
Acute Achilles Tendon Rupture
• Adults 40-50 y.o.
primarily affected (M>F)
• Athletic activities,
usually with sudden
starting or stopping
• “Snap” in heel with pain,
which may subside
quickly
Acute Achilles Tendon Rupture
Diagnosis
• Weakness in plantar flexion
• Gap in tendon
• Palpable swelling
• Positive Thompson test
Open Fracture
Vertebral Fracture
ONCOLOGIC SURGERY
The Breast
Tumors Onset Feature
Breast cancer 30-menopause Invasive Ductal Carcinoma , Paget’s disease (Ca Insitu),
Peau d’orange , hard, Painful, not clear border,
infiltrative, discharge/blood, Retraction of the
nipple,Axillary mass
Fibroadenoma < 30 years They are solid, round, rubbery lumps that move freely in
mammae the breast when pushed upon and are usually painless.
Fibrocystic 20 to 40 years lumps in both breasts that. increase in size and
mammae tenderness just prior to menstrual bleeding. occasionally
have nipple discharge
Mastitis 18-50 years Localized breast erythema, warmth, and pain. May be
lactating and may have recently missed feedings.fever.
Philloides 30-55 years intralobular stroma . “leaf-like”configuration.Firm,
Tumors smooth-sided, bumpy (not spiky). Breast skin over the
tumor may become reddish and warm to the touch.
Grow fast.
Duct Papilloma 45-50 years occurs mainly in large ducts, present with a serous or
bloody nipple discharge , mass ussually small, not always
palpable
Benign Breast Lumps
Breast Cancer
Biopsy
Excisional or incisional biopsy
• In this type of biopsy, a surgeon cuts through the skin to remove the entire tumor
(called an excisional biopsy) or a small part of a large tumor (called an incisional
biopsy).

Enucleation
• surgical removal of a mass without cutting into or dissecting it. Eg: eye, oral pathology,
uterine fibroids (without hysterectomy)
FNA
• does not require an incision

Core biopsy
• uses needles that are slightly larger than those used in FNA
• Local anasthesia
• Sometimes uses a special vacuum tools to get larger core biopsies from breast tissue
Epidermoid Cyst
• Benign cyst underneath
skin that arise with
ruptured pilosebaceous
follicle
• Associated with trauma
(piercing-needle)
• Common location :
auricular lobe, plantar
Demoid Cyst
• An abnormal growth
(teratoma) containing
epidermis, hair follicles,
and sebaceous glands,
derived from residual
embryonic cells.
• Common site :
– Periorbital
– Ovarian
– Spinal
Atheroma

• Cause by blockage of
the duct of
sebacceous gland
• Also known as
Retention Cyst
• Puncta (+)
Callus & Clavus

• Callus: toughened area of


skin which has become
relatively thick and hard
in response to repeated
friction, pressure, or
other irritation.
• Clavus: specially-shaped
callus of dead skin that
usually occurs on thin or
glabrous (hairless and
smooth) skin surfaces,
especially on the dorsal
surface of toes or fingers.
Diagnosis banding benjolan payudara
• infeksi payudara dengan tanda radang lengkap, dapat
Mastitis menjadi abses, terjadi pada ibu menyusui

Fibroadenoma • tumor jinak, biasa terjadi pada usia muda (15-30


tahun), konsistensi kenyal, batas tegas, tidak nyeri, dan
mammae (FAM) mobile

• tumor berbatas tidak tegas, konsistensi kenyal atau


Kelainan fibrokistik kistik, nyeri terutama saat menjelang haid, membesar,
bilateral atau multipel.

Kistosarkoma • menyerupai FAM yang besar, bulat lonjong, batas


filoides tegas, mobile, ukuran dapat mencapai 20-30 cm

• massa kistik akibat tersumbatnya duktus laktiferus


Galaktokel pada ibu yang baru menyusui
Mastitis and Abscess Mammae
Galactocele

• Galaktokel
merupakan massa
berisi susu yang
tersumbat apada
duktus laktiferus.
• Px :
– Solid mass
– Tanda radang (-)
TERIMA KASIH
Brief Introduction

Appendicitis Ileus Peritonitis


• The most common Obstructive Ileus: -Primary, secondary
general surgical - Inside lumen, In the - Localized,
emergency wall, outside the wall generalized
• Peak 10-30 y.o - High level, low level
• Male > 1.3x
• Obstruction: lymphoid
hyperplasia, fecalith, etc
Anamnesis

Appendicitis Ileus Peritonitis


Cardinal - migrating pain - abdominal pain - abdominal pain
symptoms (periumbilical to - vomiting - meteorismus
RLQ) - no defecation - nausea, vomiting
- nausea and and flatus - no defecation
vomiting - meteorismus, and flatus
distension - restlessness
Physical
Examination
Appendicitis Ileus Peritonitis
Physical • tenderness and • scar, distension, darm • absence of
Examination rebound contour, darm steifung bowel sound
tenderness at • hyperperistaltic (early), • loss of liver
McBurney point metallic sound, absence dullness
• Rovsing’s sign of bowel sound (late) (perforation)
• Psoas sign • diffuse tenderness, • shifting dullness
• Obturator sign hernia • defans muscular

Rectal touche • tenderness • impact faeces • tenderness


• rectal tumour
• blood or mucus
• collapse of ampulla
recti (obstructive)