GANGGUAN MUSKULOSKELETAL SEHUBUNGAN DENGAN PENYAKIT KEGANASAN TULANG, TEKNIK AMPUTASI DAN PEMASANGAN TRAKSI

RAMSES INDRIAWAN
DEPARTMENT OF SURGERY NTB PROVINCE HOSPITAL MATARAM

TUMOR TULANG

Klasifikasi Tumor tulang
Tumor Jinak 1. Osteokondroma 2. Endokondroma 3. Kondroblastoma 4. Kondromiksoid Fibroma Tumor Ganas 1. Kondrosarkoma 2. Multiple Mieloma 3. Ewing Sarkoma

Tumor Jinak 1. OSTEOKONDROMA Definisi merupakan tumor jinak tulang yang terjadi pada daerah metafisis Lokasi ditemukan pada bagian metafisis tulang panjang (ujung distal femur.tipe sesil .tipe bertangkai (pedunculated) . ujung proksimal tibia dan ujung proksimal humerus) Klasifikasi .

dapat menjadi ganas dengan persentase 1% .mengenai dewasa muda .terdapat benjolan .Klinis .pada umumnya tidak nyeri .baik .penekanan tendon dan saraf menimbulkan nyeri Terapi Eksisi Prognosis .

dewasa muda . ENDOKONDROMA Definisi merupakan tumor jinak yang berasal dari dalam rongga sumsum tulang Lokasi sering mengenai tulang-tulang tubuler kecil pada tangan dan kaki Klinis .tidak nyeri .benjolan .2.

menjadi ganas sekitar 20-25% .Gambaran Radiologi gambaran lesi radiolusen dengan bercak-bercak klasifikasi tulang Terapi .kuretase .presentase keganasan meningkat jika mengenai tulang panjang besar atau pelvis .bone graft Prognosis .

3. KONDROBLASTOMA
Lokasi - humerus - femur - tibia Klinis - umur <20 tahun - benjolan - tidak nyeri Gambaran radiologi - tampak gambaran lesi osteolitik yang terletak eksentrik pada epifisi tulang panjang - bercak-bercak klasifikasi

Terapi - kuretase - bone graft Prognosis - baik

4. KONDROMIKSOID FIBROMA
Definisi merupakan tumor jinak tulang yang paling jarang ditemukan. Lokasi pada tulang-tulang ekstremitas bawah di daerah metafisis. Klinis - umur 20-30 tahun - benjolan - tidak nyeri

reaksi periosteal Terapi .gambaran korteks yang mengalami erosi .terletak eksentrik di metafisis .Gambaran Radiologi . .eksisi Prognosis dapat mengalami rekuren sampai 25%.gambaran daerah osteolitik dengan tepi sklerotik .

KONDROSARKOMA Definisi merupakan tumor ganas tulang rawan yang berasal dari degenerasi maligna lesi jinak Lokasi .humerus Klinis .tulang pelvis .femur .scapula .Tumor Ganas 1.benjolan yang disertai nyeri .

sel-sel ganas yang membentuk tulang rawan .proses dekstruksi korteks Patologi .gambaran lesi osteolitik dengan bercak-bercak klasifikasi .sel-sel mengalami mitosis Terapi operatif reseksi luas ajuvans radioterapi dan kemoterapi tidak begitu bermanfaat .Gambaran Radiologi .

MULTIPEL MIOLOMA Definisi merupakan tumor ganas primer tulang yang sering mengenai laki-laki usia >40 tahun Lokasi .tulang pelvis .tulang kranium .tulang vertebra .2.

berat badan menurun Pemeriksaan menunjang .benjolan .nyeri hebat .UL terdapat protein bence jone .anemia .Klinis .radiologi gambaran lesi osteolitik bulat (punched out) .BMP (Bone Marrow Puncture .malaise .demam .Bone Scan .

fiksasi internal jika ada komplikasi Prognosis buruk.Komplikasi fraktur patologis Terapi . Penderita umumnya meninggal dalam 2 tahun .radioterapi dan kemoterapi .

20 tahun Lokasi diafisis tulang-tulang panjang (femur. EWING SARKOMA Definisi merupakan tumor ganas yang jarang. tibia dan fibula) Klinis .benjolan .LED meningkat .leukositisis . biasanya mengenai usia .3.nyeri hebat .

Gambaran Radiologi gambaran dektruksi tulang dengan batas yang tidak jelas gambaran union skin gambaran sunburst Terapi reseksi luas radioterapi dan kemoterapi Prognosis buruk .

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AMPUTASI. .

Overall Aims Gain an understanding of pathophysiology of amputation Differentiate between the different types of amputation Understanding of the nursing challenges of patients undergoing amputation The role of the multidisciplinary team Understanding the psychological response to limb loss .

wound care. Discussion .How will we achieve this? Theory 1 hour: main components Group work 1/2 hour : Care Plan Practical Session: bandaging. pressure reduction.

Content Pathophysiology of vascular disease When is amputation necessary ? Care of the patient before and after surgery The role of the multidisciplinary team in rehabilitation of patients Psychological and psychosocial issues .

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Conditions which may lead to amputation of a limb Peripheral Arterial occlusive disease Acute occlusion due to embolism Aneurysm Diabetic limb disease Necrotising fasciitis .

Peripheral Vascular Disease (PVD) Peripheral vascular disease Atherosclerotic plaque build up Vascular network compromised body attempts to compensate by collateral circulation Lactic acid build up (calf pain) Intermittent claudication Rest pain Eventual ischaemia Limb damage ensues .

flaky.Signs and Symptoms Pain due to reduced perfusion often relieved by lowering the limb Absence of pulses popliteal. dorsalis pedis Skin changes: temperature. ulcerated. Blue/ black discolouration. hairless. shiny. necrosis of toes/foot Anaerobic infection Aeromonas hydrophylia -’gas gangrene’ .

Treatment options Angiogram-angioplasty Sypathectomy Insertion of bypass graft Removal of affected toes or partial foot amputation Below through or above knee amputation .

Acute embolism Most often a saddle embolis which straddles the aortofemoral junction causing vascular occlusion Can be treated with surgery to remove. may occasionally have caused enough damage to require amputation Patient will require treatment for probable cardiac valve disease .

Aortic Aneurysm Wall of the aorta swells progressively over time. eventually rupturing Sudden pronounced cardiovascular shock often fatal graft can be inserted (ABG) Depending on size can affect peripheral circulation .

no sensation Ulcers develop due to trauma.Diabetes Damage to micro-vessels Peripheral neuropathy. infection often ensues Arterial blood supply is reduced Ulcer becomes chronic with bouts of acute infection leading to loss of digits/foot/limb .

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gunshot. bomb blast. Trauma: RTA. industrial machinery and burns. CCF. MI.Other Factors Malignancy: squamous cell carcinoma Cardiac disease: AF. . crushing injury.

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Types of Amputation: Toe Minimal interruption to blood supply Foot should be well perfused Toe should be easily isolated No evidence of infection Bone is ‘nibbled’ until skin flap can cover defect Care of wound is critical !! .

Transmetatarsal Long flap from sole of foot is brought round to meet upper flap to create weight bearing substance Most often used on diabetic patients High failure rate. Why? .

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Burgess op.Below Knee Amputation Long posterior flap. below knee joint Best chance of rehab due too presence of knee joint Only carried out if tissue is adequately perfused. 8cm down tibia. .

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Above knee Amputation (AKA, AKA)
Normally carried out to allow maximum length of femur to help balance Dependent on perfusion Equal anterior and posterior flaps Bone is divided and smoothed Less easy for rehabilitation

Sites for amputation
Aim: to provide a useful, functional, well moulded, healthy stump to allow prosthetic attachment Total excision of diseased tissue Maintenance of sufficient blood supply to allow healing Stump of sufficient length to allow prosthetic attachment

Caring for amputation patients Pre-op phase
Counselling and Support, regardless of the reason for the surgery Helping patient to cope with the loss, stages of bereavement Looking after relatives, involve when appropriate Prepare by introducing other members of the team, possibly an amputee who has coped well with the surgery

Pre op care Chest X ray. ECG. glucose. FBC U and E. epidural) Odour absorbent dressings on necrotic areas . NSAID. blood grouped and saved Lower foot of the bed. pain control (opiates.

pain control Building strength in other limbs which will be dependent in the post op phase Advice regarding pressure ulcers Limb should be marked pre-op Nutrition and hydration needs should be met .Specific Care Information esp. r/e mobility.

if needed. NSAID’s used. with stump in neutral position Pain: 3 sources. back pain and phantom pain. wound pain.Post Op Care Standard post op care Specific: Insert a bed cage to minimise pressure. . Wound pain can be controlled with opiates in the immediate phase and.

opiate narcosis. urine output Respirations to check for signs of atelectasis.Post op care (contd) Haemodynamic stability monitored through BP. Blood glucose monitoring . pulse.

Phantom Pain A phenomenon which sees the patient experiencing pain in the missing limb. which can last for months post op. TENS machine has been shown to aid this pain Local nerve blocks Longer term use of Carbimazapine Relaxation /complimentary therapy .

BKA patients will often have a brace in situ to prevent post popliteal tendon contracture.Preventing Contracture Patient should be prone with the stump flat at first. Physio involvement is tentative at this stage to avoid wound problems .

used on parallel bars for support . standing and early walking with crutches supervised with physio. Use of the PPAM aid.Mobilising Sitting out of bed within 48 hrs Wheelchair used to assist mobility Practice in transferring. inflatable tube in metal frame with rocker foot.

e. tucking in sleeves to pockets. we should be aware of the effect this may have .Clothing Patients need to come to terms with clothing issues. i. pinning of trouser legs Can be psychologically traumatic.

Wound Care Initial contact layer should be absorbent non-adherent and occlusive to avoid infection Vacuum drains may be in place until drainage subsides sufficiently (48 hrs) Padding should be applied for comfort and protection and bandaging should be firm but not restrictive .

. bleeding and/or exudate.Wound care Wound Checks should note the following: Colour. discolouration of wound edges. presence of erythema. odour. temperature (systemic also). pain levels (should be decreasing).

poor healing. dependence and poor venous drainage Infection:high risk due to ischaemia. wound breakdown. particularly diabetic patients. Flap tension: tightness of skin over bone causing tension in the wound Oedema: Due to tissue damage. infection.Potential Wound Care Problems Ischaemia: poor perfusion. . pain.

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Dealing with wound care issues Regular reassessment of the wound and surrounding skin is necessary Accurate documentation is essential to ensure monitoring of the wound progress. improvement or detereoration Knowledge of appropriate dressing regimes Use of prophylactic antibiotics .

.Prognosis Dependent on: indication for surgery. pain. length of time to surgery. level of amputation. anxiety and ability to cope with the situation. cardiac status. infection.

Body Image Body reality.body ideal and body presentation Potential sexual problems Socialisation issues. feeling of inadequacy Nurses must strengthen perceptions of self worth and improve confidence .

using moisturiser. checking for pressure points. Carer or relative taught to apply stump bandage correctly to ensure good fit for prosthesis Encourage social interaction and meeting of friends .Promoting Independence Encourage the patient to take care of the skin on the stump.

social work. district nurse for wound checks and/or control of diabetes. Involvement in local amputee groups Medical follow up at o/p clinic .Rehabilitation and Discharge Involvement of the multidisciplinary team is essential: physio for mobility. motability car. provision of stump board for wheelchair OT for home assessment and safety issues. benefits.

with chair access Possible hoist for bath Adapted furniture .Adaptations to Home External ramps required Stair lift. railings. Doors widened Kitchen worktops and sinks adjusted Shower on level.

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Wound may be left open until signs of oedema and signs of infection reduce Psychosocial issues are often far reaching Discuss these: .Traumatic Amputation: Special considerations Potentially greater psychological impact Patient more likely to have been younger and fitter.

cardiology Care of the other limb Support groups . hyperlipidaemia.Ongoing Care Continued visit to the limb fitting centre Outpatient follow up Risk factor modification : Smoking cessation clinic.

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CARA PERAWATAN PENDERITA DENGAN TRAKSI .

Keuntungan Tindakan Traksi Menghindari tindakan bedah pada keadaan tertentu Memudahkan tindakan bedah selanjutnya Mencegah kerusakan jaringan lunak pada fraktur Memungkinkan pergerakan sendi sehingga menghindarkan kekakuan .

digestivus (obstipasi). respiratorius (pneumonia orthostatik). dll. .Kerugian Tindakan Traksi Tidak dapat digunakan untuk semua jenis fraktur Tirah baring yang lama Tirah baring yang lama juga meningkatkan risiko terjadinya komplikasi di tr. tr. system kardiovaskular (penyakit tomboemboli).

Jenis Traksi Menurut cara pemasangannya: Skin Traction (Traksi kulit) Skeletal Traction (Traksi skeletal) .

Traksi Kulit (Skin Traction) Bryant’s traction Buck’s Extension Dunlop’s traction dll .

Bryant’s traction Traksi untuk fraktur femur pada anak usia kurang dari 1 tahun (sebelum bisa berjalan) Keuntungannya: memudahkan perawatan pada saat BAB dan BAK lama traksi: 10 hari .2 minggu .

Bryant’s traction .

Buck’s extension pada anak Tindakan definitif untuk fraktur femur pada usia lebih dari 1 tahun (sudah bisa berjalan) Pemasangan traksi setinggi tempat fraktur Sesudah terbentuk callus atau sticky dapat dilanjutkan dengan pemasangan gips Lama traksi: 3 minggu .

Buck’s extension pada dewasa Tujuan: imobilisasi sementara fraktur femur sebelum operasi imobilisasi pasca reduksi dislokasi hip Pemasangan traksi di bawah lutut Beban kurang dari 5 kg Lama traksi: tidak lebih dari 15 hari .

Buck’s extension Cara Pemasangan • Bersihkan ekstremitas. cukur bila rambut lebat • pemasangan pada kulit di bawah lutut • Beri padding pada tulang yang menonjol (maleolus dan head fibula) • Counter traction .

Buck’s extension (1) .

Buck’s extension (2) .

cegah rotasi dengan diganjal Jaga kebersihan: BAK dan BAB .Buck’s Extension: Cara Perawatan Selalu perhatikan posisi kelurusan (alignment) ekstremitas Pada Buck Extension.

Bryant’s traction dan Buck’s extension Komplikasi (1) Lokal (pada tempat traksi): edema distal obstruksi pembuluh darah lesi nervus peroneus nekrosis kulit di atas tulang yang menonjol bula/ blister bila beban terlalu besar elastis dibuka dan dikendorkan .

Bryant’s traction dan Buck’s extension Komplikasi (2) General: Hipotermi. terutama pada bayi dan anak kecil Traktus respiratorius Traktus urogenital Trakstus digestifus kekakuan sendi (stiffness) .

atau closed reduction dengan fleksi elbow berisiko mencederai vaskularisasi Dilakukan selama 7-10 hari sampai edema berkurang dan dapat dipasang gips .Dunlop’s traction untuk fraktur supra dan intercondylar pada anak yang sulit dilakukan closed reduction karena edema.

pulseless.Dunlop’s traction Komplikasi Volkman’s ischemic contracture Pada 2 hari pertama harus dilakukan evaluasi terhadap: pain. parestesia. pallor. paralisis SETIAP JAM!!! .

Dunlop’s traction .

Traksi Skeletal (Skeletal Traction) Traksi skeletal femoral distal Traksi skeletal tibial proksimal dll .

Traksi skeletal femoral distal .

5 bulan dilanjutkan pemasangan gips .5 – 12.Traksi skeletal femoral distal Bila diperlukan beban yang lebih besar pada fraktur femur proksimal Berat beban 7.5 kg Arah tarikan berorientasi sesuai aksis panjang femur lama traksi: traksi sementara: maksimal 3 minggu traksi definitif: 1.

7.5 kg Kontraindikasi pada penderita dengan cedera ligamen lutut Arah tarikan berorientasi sesuai aksis panjang femur lama traksi: idem sebelumnya .Traksi skeletal tibial proksimal Bila diperlukan beban yang tidak terlalu besar pada fraktur femur 2/3 distal Berat beban 5 .

Cara pemasangan: .

nekrosis skletal dan kulit pressure sore pada bagian tulang yang menonjol kekakuan sendi malplacement pin lesi nervus peroneus Komplikasi general: idem traksi kulit (karena imobilisasi lama) .Komplikasi lokal pin tract infection bila beban terlalu besar.

obstipasi.Perawatan ganti balut pada tempat masuknya pin secara steril dan bekala. . tromboemboli. dll. misalnya 2 hari sekali. misalnya pneumonia. pemberian talk pada lipatan kulit dan lipatan sendi padding pada bagian tulang yang menonjol bed exercise untuk mencegah komplikasi general.

Terima Kasih .

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