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FRACTURE AND

DISLOCATION
Nucki N Hidajat, dr, MS, SpBO (K), FICS
Department Orthopaedi & Traumatology
Faculty of Medicine, Padjadjaran University
Dr Hasan Sadikin Hospital - Bandung

Orthopaedic tree
orthos
paedos

introduction

1741, Nicolas Andry


Orthopaedia, the Art of Preventing and Correcting
Deformities in Children
The present scope of orthopaedics:
Include all ages
Consist of art and science of prevention, investigation,
diagnosis, and treatment of disorders and injuries of the
musculoskeletal system by medical, surgical, and
physical means
Orthopedist
Surveys in North America at least 15% of the total
patients
80% of the blunt trauma in ER.

introduction

The musculoskeletal system


Organ system include bones,
cartilage, muscles, tendons,
ligaments, neurovascular in
upper and lower extremities,
joints, and vertebrae

Congenital deformities,
infections and inflammation,
Neoplasms, fracture and
associated trauma,
degenerative.

fracture

Definition
A fracture is a break in the
structural continuity of bone,
or cartilage, or epiphyseal
plate

Must constantly think

soft tissue surrounding the bone


Physical factors in the
production of fracture

How fractures happen?

Fracture due to a traumatic


incident

Caused by sudden and


excessive force
Direct or Indirect

Pathologic fracture

Bone weakened (abnormal)


Change in structure :
osteoporosis, tumor
Can occur even normal stresses

How
fracture
happen?

Descriptive terms
pertaining of Fractures
1.
2.
3.
4.
5.

6.

Site.
Extent
Configuration
Relationship of the fragments
Relation to external
environment
complications

1.Anatomical site

Diaphyseal
Metaphyseal
Epiphyseal
Intra-articular
Fracture dislocation

2. Extent
Complete
Incomplete
Hard tissue
Soft tissue

extent

3. configuration

Transverse
Oblique
Spiral
Comminuted
segmented

4. Relation of fragments
Undisplaced
Displaced

Translated
Angulated
Rotated
Distracted
Overriding
impacted

5. Relationship to external environment


Close fracture

There no contact the external environment


Severity and configuration depend on
energy

Open fracture

Direct contact with external non steril


environment

Classification of Close fracture


with soft tissue damage (tscherne,1982)
Type 0 : minimal ST damage,
indirect violence, simple #
patterns
Type I : superficial abrasion caused
by pressure from within,
moderately severe fracture
Type II : deep, contaminated
abrasion, skin or muscle
contusion, impending
compartment syndrome
Type III : extensive skin contusion or
crush, underlying muscle
damage, subcutaneous avulsion,
comminuted fracture

Open fracture

Fracture
Soft tissue injuries
Contaminant from
external environment
High risk :
1.

2.
3.

Infection, tetanus, gas


gangrene, sepsis
Nonunion
Limb threathening

Classification open facture


Gustilo-Anderson (1984)
Type I

wound 1 cm or less, quite clean, inside to outside,


minimal muscle contusion, simple # patterns

Type II

laceration more than 1 cm long, with extensive


soft tissue damage, flaps or avulsions, minimal
comminution.

Type III

extensive soft tissue damage including muscles,


neurovascular structures, often ahigh velocity injury

IIIA
IIIB
IIIC

adequate bone coverage, segmental #


periosteal stripping and bone exposure, with
massive contamination
vascular injury requiring repair

Open Fracture grade I

Open Fracture grade II

Open Fracture grade III

6. complication

Uncomplicated
Complicated

Neurovascular
Compartment syndrome
infection

Diagnosis of fracture
History

1.

Mechanism of injury,
environment, pre-injury status,
finding at the incident site, prehospital care

Physical examination

2.
1.
2.
3.

Look
Feel
Move/ask

Investigation

3.
1.
2.
3.

Lab.
X-ray
Scanning

Mechanism of
injury

Physical examination
General

Air way
Breathing
Circulation

Local

conditions

conditions

Look
Feel
move

Physical examinations
Look
Evidence of pain
Swelling
Deformity
Wounds

Feel
Sharply locallized pain
Aggravation of pain
Test artery & nerve

Move
crepitus
Abnormal movement

Diagnostic imaging
X-ray

(rule of Two)

Two joints
Two views
Two limbs
Two injuries
Two occasions

CT

Scan
MRI

How fractures heal


Similar with wound healing
Two types of healing process

Primary (bridging osteon)

Secondary (callus
formations)
1.
2.
3.
4.

Inflammation
Callus formation
consolidation
remodeling

Pre-hospital management
According ATLS procedure.
1. Primary survey
2. Secondary survey
A-B-C-D-E
Reduction
Immobilization
Cover the wounds
transportation

immobilization

Two joints minimal


include immobilized
Splintage
Prevent further injury
Re-evaluation
neurovascular distal
fracture

Goals treatment fracture


1.
2.

3.
4.

Relieve pain
To obtain and maintain satisfactory
position of the fracture fragments
To allow bony union
Restore optimum function

Specific Methods of treatment for close


fracture
1.
2.
3.
4.
5.
6.

Protection alone
Immobilization with or
without reduction
Closed reduction
followed by traction
CR followed by
external fixation
ORIF
Excision of fragment
fracture

Immobilization by traction

Open Reduction and Internal


Fixation (ORIF)
Indications
1.
2.
3.

Intra-articular fracture
Avulsion fracture
Soft tissue
interposition

4.

5.

6.
7.

Grossly unstable
fracture
Coexistent with
vascular injury
Pathologic fracture
# in children cross
epiphyseal plate

External

Fixation

Excision

fragment fracture

Treatment for Open Fractures:


1.
2.
3.
4.
5.
6.

Cleansing of the wound


Excision of devitalized
tissue (debridement)
Treatment of the fracture
Closure of the wound
Antibacterial drugs
Prevention of tetanus

complications

Immediately

Early

Bleeding
Injury to the nerve
Soft tissue
Infections
Delayed Union
Joints stiffness

Late

Malunion
Osteoarthritis
AVN

Risk AVN in head femur


fracture

Fracture specific

Fracture in children

Fracture incomplete most common


Conservative treatment
Heal faster than adult

Pathologic fracture

In porotic bone
Abnormal bone structure
Abnormal metabolic process in bone

Joints

Anatomy Diarthodial Joint

dislocations

DISLOKASI
Keluarnya bagian tulang di persendian dari
posisi yang normal
Lokasi : hip, shoulder, elbow, finger, patella,
knee, ankle, acromioclavicular
Gejala : hilangnya bentuk normal disertai
hambatan gerak

dislokasi Anterior Sendi


Bahu
Sering terjadi (95%)
Sering terjadi pada usia muda
Lengan atas pada posisi
abduksi, ekstensi dan rotasi
eksternal
Harus segera direduksi

Dislokasi sendi panggul

DISLOKASI
Dislokasi Posterior Sendi Panggul
Akut Traumatik
Harus segera reduksi
Dalam anestesi umum
Teknik ; Allis, Bigelow, Hipocrates
Re-evaluasi neurovasluler problem
Imobilisasi sampai soft tissue healing
Bila disertai fraktur ----reduksi terbuka

Dislokasi elbow
Reduksi tertutup mudah
dilakukan
Imobilisasi 3 minggu
Re-evaluasi neurovaskuler

Bahan bacaan

Robert B. Salter(1999); Textbook of disorders and Injuries of


the musculoskeletal System, 3rd ed.Williams & Wilkins,
Baltimore. p: 1-3; 417-511.

Louis Solomon et.al (2001) ; Apleys System of


Orthopaedics and Fractures. 8th ed.Arnold, London. p: 521583.