EAGLE Minggu kedua tanggal 23 Agustus 2015 – Starbucks Alam Sutera

Present: Wilson Kores (Tutor), Gilbert (Note Taker), Jessica Wiryanto, Elissa, Karunia,
Denny Intan, Karina Terry, Kelly, Ella, Regina, Hanny, Yesenia T

Pembahasan LO minggu lalu

 Definisi fraktur adalah disintegritas daripada cortical bone (Retak disebut

incomplete fracture NAMUN kalau fraktur sampai ke ujung cortical bone disebut
comple fracture)
 Dislocation bukanlah termasuk fraktur karena pengertian dislocation adalah suatu
struktur yang berpindah dari tempatnya (dislocation bukanlah selalu fraktur, tapi
biasanya kalau ada dislocation bakal ada fraktur  karena struktur sendi itu kuat
(sendi itu terdiri dari [dari luar ke dalam] skin, ligament, capsule, synovial membrane,
fluid dan cartilage)  Impact kuat dibutuhkan untuk membuat dislocation, sehingga
BIASANYA bakal ada fraktur kalo ada dislocation)
 Bahu dislokasi dapat menyebabkan Frozen Shoulder (Ada masalah struktural di bahu).
Humerus akan jatuh ke arah anterior sehingga terjadi kerusakan struktural dan bahu
akan membentuk sudut persegi yang tajam

Frozen Shoulder

 Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the
shoulder. Over time, the shoulder becomes very hard to move.
 Frozen shoulder occurs in about 2% of the general population. It most commonly
affects people between the ages of 40 and 60, and occurs in women more often than
men
 In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of
tissue — called adhesions — develop. In many cases, there is less synovial fluid in the
joint.
 The hallmark sign of this condition is being unable to move your shoulder - either on
your own or with the help of someone else. It develops in three stages:
 Freezing
In the"freezing" stage, you slowly have more and more pain. As the pain worsens,
your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9
months.
 Frozen

EAGLE CIMSA UPH

 Painful symptoms may actually improve during this stage, but the stiffness remains.
During the 4 to 6 months of the "frozen" stage, daily activities may be very
difficult.
 Thawing
Shoulder motion slowly improves during the "thawing" stage. Complete return to
normal or close to normal strength and motion typically takes from 6 months to 2
years.
 The causes of frozen shoulder are not fully understood. There is no clear connection
to arm dominance or occupation. A few factors may put you more at risk for
developing frozen shoulder.
 Diabetes. Frozen shoulder occurs much more often in people with diabetes, affecting
10% to 20% of these individuals. The reason for this is not known.
 Other diseases. Some additional medical problems associated with frozen shoulder
include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.
 Immobilization. Frozen shoulder can develop after a shoulder has been immobilized
for a period of time due to surgery, a fracture, or other injury. Having patients move
their shoulders soon after injury or surgery is one measure prescribed to prevent frozen
shoulder.
 Pain from frozen shoulder is usually dull or aching. It is typically worse early in the
course of the disease and when you move your arm. The pain is usually located over
the outer shoulder area and sometimes the upper arm.
 PF  Comparison between passive movement ROM and active movement ROM
(there is a decreased ROM in both)
 It gets better over time; in 3 years heal completely

Reference: http://orthoinfo.aaos.org/topic.cfm?topic=a00071

 Klasifikasi dari fraktur 

1. Dari jenis patah  Complete &
Incomplete
 Complete (Fraktur yang patahnya
dari satu ujung cortical bone ke ujung
cortical bone lainnya)
 Incomplete

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 2. Dari pecahan  Simple, fragmanted (communited  retak lebih dari 3
pecahan), oblique, spiral, transverse, segmental (retak lebih dari 2 pecahan).
Dokter perlu tahu fracture itu oblique atau transverse karena dari sana dokter
dapat mengetahui mechanism, kekuatan force, usia, fase penyembuhan,
indikasi tindakan, TINGKAT KERUSAKAN JARINGAN SEKITAR 
menentukan komplikasinya; contoh comminuted --> force harus besar,
pecahan bisa jadi emboli (fat embolism).

3. Dari et causa  ada trauma, pathologi (OA, OI, Osteoporosois, Rickets,

Pagets) dan stress fracture (atlet, drug induced) [ Nice to know  pasien apa
yang kondisi apa yang meningkatkan resiko Osteoporosis  menopause,
obesitas but indirectly, transplantasi, ASMA (kalau sudah kronis dikasih
corticosteroid  inhaled; kerjanya mirip satu hormon steroid, glucocorticoid
menghambat sistem immune, mengurangi kerja osteoblast, kerja osteoclast
seolah olah lebih tinggi; bone remodelling lebih aktif)

4. Salter – Harris Fracture

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 5. Fractures that happen often in children:
 Smith’s Fracture
o A transverse fracture of the radius just above the wrist; distal
fragments are displaced anteriorly
o Sometimes it is called “Reversed Colles” Fracture
o Presents with a wrist injury and a ‘garden spade’ deformity
o The fracture is reduced by traction, supinaton, and extension of
the wrist, and the forearm is immobilized in a cast for 6 weeks.
o X-rays should be taken at 7-10 days to ensure that the fracture
has not slipped.

 Colles’ Fracture
o a transverse fracture of the
radius just above the wrist,
with dorsal displacement
of the distal fragment.
o It is the most common of
all fractures in older
people, the high incidence
being related to the onset
of postmenopausal
osteoporosis.
o Thus the patient is usually an older woman who gives a history
of falling on her outstretched hand
o Force is applied in the length of the forearm with the wrist in
extension.
o Dinner-fork deformity

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  Green Stick Fracture
o A greenstick fracture occurs when a bone bends and cracks, instead
of breaking completely into separate pieces.
o This type of broken bone most commonly occurs in children
because their bones are softer and more flexible than are the bones
of adults.

 Monteggia Fracture
o A fracture of the shaft of the ulna associated with dislocation of
the proximal radio-ulnar joint; the radiocapitellar joint is
inevitably dislocated or subluxated as well.
o More recently the definition has been extended to embrace
almost any fracture of the ulna associated with dislocation of
the radio-capitellar joint, including trans-olecranon fractures in
which the proximal radioulnar joint remains intact.
o In children, the ulnar injury may be an incomplete fracture
(greenstick or plastic deformation of the shaft).
o Usually the cause is a fall on the hand; if at the moment of
impact the body is twisting, its momentum may forcibly pronate
the forearm.
o Sometimes the causal force is hyperextension.
o The ulnar deformity is usually obvious but the dislocated head
of radius is masked by swelling. (More info on Appley page
613)

EAGLE CIMSA UPH

  Galeazzi Fracture (Dislocation of the radius)
o The usual cause is a fall on the hand; probably with a
superimposed rotation force.
o The radius fractures in its lower third and the inferior radio-
ulnar joint subluxates or dislocates.
o The Galeazzi fracture is much more common than the
Monteggia.
o Prominence or tenderness over the lower end of the ulna is the
striking feature.
o It may be possible to demonstrate the instability of the radio-
ulnar joint by ballotting the distal end of the ulna (the piano-key
sign) or by rotating the wrist.
o It is important also to test for an ulnar nerve lesion, which may
occur

 Greenstick, Monteggia, Galeazzi, Colles dan Smith mempunyai suatu kondisi yang
sama dimana salah satu retaknya harus intact  karena biasanya force tidak terlalu
besar dan juga periosteum menjaga bentuk tulang (periosteum lebih tebal di anak
anak)
 Alphanumeric classification developed by Muller:
1. the first digit specifies the bone (1 = humerus, 2 = radius/ulna, 3 = femur, 4 =
tibia/fibula)
2. the second specifies the
segment (1 = proximal, 2
= diaphyseal, 3 = distal, 4
= malleolar).
3. A letter specifies the
fracture pattern (for the
diaphysis: A = simple, B =
wedge, C = complex; for
the metaphysis: A = extra-
articular, B = partial
articular, C = complete
articular)

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 4. Two further numbers specify the detailed morphology of the fracture

 Karakteristik property tulang --> ada 2 properti utama; collagen dan calcium; collagen
 tensile strength sedangkan calcium untuk mengeraskan tulang; tulang pada
dasarnya bersifat elastic, fraktur terjadi kalau tension berlebih  transverse fracture,
compressed fracture kalau force berlebih) compressed fracture contohnya di vertebrae;
 Greenstick Fracture  terjadi karena periosteum tebal dan tulang masih agak lentur
 Buckle Fracture (Torus)  Impacted sama seperti compression; tapi patahnya tidak
jelas (lihat dari samping kelihat “gompal”) kepecah jadi satu garis yang dilihat dari
samping  biasanya di diaphysis)

 Signaling untuk pertumbuhan  IGF1 dirangsang oleh growth hormone; IGF1 akan
menstimulasi mesenchymal menjadi osteoblast; osteoblast akan deposisi tulang
 Acromegaly (orang yg neanderthal dan gigantism)
 Marfan Syndrome  arm span lebih panjang dari tinggi, cara periksanya  sering
joint pain, resiko OA naik, scoliosis, ada hubungan sama cardiomyopathy, soft tissue
nya bermasalah makanya lari ke mana mana (systemic).
 Patof dari fracture  ada batas tensile strength (elastisitas); kalau exceed; akan terjadi
kerusakan struktur
 Clinical Manifestations  swelling (ecchymoses), deformity, bleeding, skin abrasion,
contusion
 Gustillo Anderson grading fracture open fracture:
 Type 1 – The wound is usually a small, clean puncture through which a bone
spike has protruded. There is little soft-tissue damage with no crushing and the
fracture is not comminuted (i.e. a low-energy fracture).
 Type II – The wound is more than 1 cm long, but there is no skin flap. There is
not much soft-tissue damage and no more than moderate crushing or
comminution of the fracture (also a low- to moderate-energy fracture).
 Type III – There is a large laceration, extensive damage to skin and underlying
soft tissue and, in the most severe examples, vascular compromise. The injury

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 is caused by high-energy transfer to the bone and soft tissues. Contamination
can be significant.
 There are three grades of severity. In type III A the fractured bone can be
adequately covered by soft tissue despite the laceration. In type III B there is
extensive periosteal stripping and fracture cover is not possible without use of
local or distant flaps. The fracture is classified as type III C if there is an
arterial injury that needs to be repaired, regardless of the amount of other soft-
tissue damage.

 Patah yang paling berbahaya dan mempunyai komplikasi paling tinggi adalah apabila
mengenai artery  sepsis
 PNS bisa regenerasi walaupun lambat dan fungsi tidak dapat kembali dengan bagus,
CNS tidak dapat regenerasi.
 Closed infection bisa ada infection karena ada perlambatan dari aliran darah jadi bisa
nempel bakterinya  aliran darah laminar; kerusakan struktur  aliran darah menjadi
turbulensi dan kecepatan berkurang, resiko adhesi meningkat
 Muscle tear grade  Grade 1  muscle strain; Grade 2  ada partial tear ; Grade 3
complete tear

 There are three degrees of joint instability:

1. Occult joint instability  apparent only when the joint is stressed
2. Subluxation (less than a luxation)  in which the joint surfaces have lost their
normal relationship but still retain considerable contact
3. Dislocation (luxation)  in which the joint surfaces have completely lost
contact with each other.

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  Memeriksa joint instability dengan cara dipencet untuk tenderness, alignment, traction
 untuk melihat laxity  kalo hyperlaxity bisa keseleo (sprain)
 Occult joint instability (ankle)  normal dikasih traction bisa, subluxation apabila
permukaan dilihat dari jauh masih terlihat menyatu tapi sebenarnya tidak menyatu,
apabila berjalan sakit
 Complication Fracture  Compartment syndrome (peningkatan pressure di fascia
karena aliran darah  bisa terjadi di gips  gejalanya 5P; pallor (karena darahnya
kegencet;vasocontriksi), pulselessness, parasthesia  electrolyte imbalance karena
hypoperfusi (kenapa electrolyte imbalance bisa menganggu action potential?  Ca
keluar dan merangsang acetylcholine secretion; membrane resting potential
mempengaruhi action potential; repolarisasi lebih lambat pas hyperkalemia 
Ibaratnya ada 10 pintu (channels) untuk 20 orang [ions] dengan 10 pintu (channels)
untuk 200 orang [ions]; di kasus 200 orang, itu adalah kasus hyperkalemia dimana
inward and outward movement bakal lebih lambat dikarenakan electrical gradient
lebih rendah sehingga diffusion lebih lambat.)
 Compartment syndrome terjadi di tempat yang ada fascia di pergelangan dan
retinaculum (fascia  berfungsi fiksasi struktur; kurang elastic  kalau ada
peningkatan tekanan; menganggu struktur yang ada di distal  golden hour di bawah
6 jam harus dilakukan fasciotomy)
 Management 4R: Recognition, Reduction, Reposition and Rehabilitaiton
 Bone Healing

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  Clinical union  soft callus, nggak ada tenderness, nggak ada crepitasi, nggak bisa
digerakin (PF pakai bending, twisting and compression); Radiographic union  garis
fraktur udah nyambung, radioopaque callus (hard callus)
 Management fracture  lihat dari fraktur; open surgery  indikasinya untuk pecah
serpihan (communited); closed reduction itu pecahnya tidak serpihan  kalau weight
bearing joint yang kena bisa internal fixation
 Pseudo-arhtrosis (mal-union)  terjadi separasi, mesenychme jadi fibroblast dan
bukan osteoblast

LO:
1) T score sama Z score; bone scan; DEXA screening
2) Septic arthritis, reactive arthritis
3) Etiologi Back Pain durasi karakteristik
4) Bone metabolic disease itu apa (definisi, ada apa aja)
5) Metabolism dan pembentukan tulang  RANKL OPG RANK
6) Osteoporosis itu apa ya; paget’s disease itu
7) Alignment tulang yang normal, yang spine (lordosis kyphosis)
8) Faktor resiko OP; penyebab paget
9) Penyebab fraktur pathological apa aja; DD dan karakteristik
10) Pemeriksaan OP apa aja
11) Peak bone mass itu apa
12) Patof Osteoporosis  sampai molecular  sampai tau obatnya

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