Cidera Tulang

Dan Sendi
Dr. Armia Indra NA, Sp.OT (K), FICS
 The Skeletal System
 Parts of the skeletal system
 Bones (skeleton)
 Joints
 Cartilages
 Ligaments (bone to bone)(tendon=bone to
muscle)
 Newborn human has 350 bones
 Adult human has 206 bones
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide 5.1
 Functions of Bones

 Support of the body (framework)

 Protection of soft organs
 Serve as levers (with help from
muscles)
 Storage of minerals and fats (calcium)
 Blood cell formation
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide 5.2
Bones of the Human Body
 Two basic types of bone tissue
 Compact bone
 Dense/hard
 Spongy bone
 (Cancellous)
 Many open spaces
Decrease wt of bone/contain red bone
marrow

Slide 5.3
 Classification of Bones on the
Basis of Shape

Figure 5.1

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Gross Anatomy of a Bone
 Diaphysis
 Shaft
 Composed of
compact bone
 Epiphysis
 Ends of the bone
 Composed mostly of
spongy bone
Structure of a Long Bone
 Periosteum
 Outside covering of the
diaphysis
 Fibrous connective tissue
membrane
Serves as an attachment for
muscle
 Arteries
 Supply bone cells with
nutrients
Structure of a Long Bone

 Articular cartilage
 Covers the external
surface of the
epiphyses
 Made of hyaline
cartilage
 Decreases friction at
joint surfaces
Structure of a Long Bone
 Medullary cavity
 Cavity of the shaft
 Contains yellow marrow
(mostly fat) in adults
 Contains red marrow (for blood
cell formation) in infants
 Bone Fractures
 A break in a bone
 Types of bone fractures
 Closed (simple) fracture – break that does not
penetrate the skin
 Open (compound) fracture – broken bone penetrates
through the skin
 Bone fractures are treated by reduction and
immobilization
 Realignment of the bone
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 Common Types of Fractures

Table 5.2

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Greenstick
Fracture
• Type I
• Through physis only
• Type II
• Through physis & metaphysis
• Type III
• Through physis & epiphysis
• Type IV
• Through metaphysis, physis &
epiphysis
• Type V
• Crush injury to entire physis
• Others added later by
subsequent authors

Described by Robert B. Salter and W. Robert Harris in 1963.

Fracture Treatment in General Principles
• Children heal faster (factors)
• Age
• Mechanism of injury
• Fracture location
• Initial displacement
• Open vs. closed injury
• Growing bones remodel more readily
• Need less immobilization time
• Stiffness of adjacent joints less likely
Treatment Principles
• When possible, restore:
• Length, alignment & rotation
• Maintain residual angulation as small as possible using closed
treatment methods
• molded casts, cast changes, cast wedging, etc.
• Displaced intra-articular fractures will not remodel
• anatomic reduction mandatory
Treatment Principles Closed Methods
• Achieve adequate pain control and relaxation
• Anesthesia
• Local
• Regional
• General
• Conscious sedation (often combination of drugs)
• Propofol
• Ketamine
• Benzodiazepines
• Narcotics
Treatment Principles Closed Methods
• Vast majority of pediatric fractures treated by closed methods.
• Exceptions - open fractures, intra-articular fractures, multi-trauma
• Attempt to restore alignment (do not always rely on remodeling)
• Gentle reduction of physeal injuries (adequate relaxation, traction)
Treatment Principles Closed Methods
• Well molded casts/splints
• Use 3-point fixation principle
• Consider immobilization method on day of injury that will last through
entire course of treatment
• Limit splint or cast changes
• Consider likelihood of post-reduction swelling
• Cast splitting or splint
• If fracture is unstable, repeat radiographs at weekly intervals to
document maintenance of acceptable position until early bone healing
Excellent reduction maintained with thin, well-
molded cast/splint
Fiberglass cast applied with proper technique and split/spread is
excellent way to safely immobilize limb, maintain reduction and
accommodate swelling
Treatment Principles Open Methods
• Respect and protect physis
• Adequate visualization
• resect periosteum, metaphyseal bone, if needed
• Keep fixation in metaphysis / epiphysis if possible when
much growth potential remains
• Use smooth K-wires if need to cross physis
 Repair of Bone Fractures

 Hematoma (blood-filled swelling) is formed

 Break is splinted by fibrocartilage to form a soft callus
 Blood vessels grow into the hematoma
 Fibrocartilage callus is replaced by a bony callus
 Bony callus is remodeled to form a permanent patch

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide 5.18
 Stages in the Healing of a Bone
Fracture

Figure 5.5

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide 5.19
Complications of Fractures - Bone -
• Malunion
• Limb length discrepancy
• Physeal arrest
• Nonunion (rare)
• Crossunion
• Osteonecrosis
Complications of Fractures - Soft Tissue -
• Vascular Injury
• Especially elbow/knee
• Neurologic Injury
• Usually neuropraxia
• Compartment Syndrome
• Especially leg/forearm
• Cast sores/pressure ulcers
• Cast burns
• Use care with cast saw
 Joints
 Articulations of bones
 Functions of joints
 Hold bones together
 Provide flexibility
 Ways joints are classified
 By their function
 By their structure
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings
 Joints
A joint, or articulation, is the place where two bones
come together.

• Fibrous- Immovable:connect bones, no movement. (skull

and pelvis).
• Cartilaginous- slightly movable, bones are attached by
cartilage, a little movement (spine or ribs).
• Synovial- freely movable, much more movement than
cartilaginous joints. Cavities between bones are filled with
synovial fluid. This fluid helps lubricate and protect the
bones.
 Fibrous Joints
 Bones united by fibrous tissue –
synarthrosis or largely immovable.

Figure 5.27d, e

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide 5.46
 Cartilaginous Joints – mostly
amphiarthrosis
 Bones connected by cartilage
 Examples
 Pubic
symphysis
 Intervertebral
joints

Figure 5.27b, c

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide 5.47
 Synovial Joints

 Articulating bones
are separated by a
joint cavity
 Synovial fluid is
found in the joint
cavity
 Reinforced by
ligaments Figure 5.27f–h

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide 5.48
 The Synovial Joint

Figure 5.28

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 Types of Synovial Joints Based on
Shape

Figure 5.29a–c

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide

 Types of Synovial Joints Based on
Shape

Figure 5.29d–f

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide

Why are they called Synovial
Joints?

They all have some thing called

Synovial Fluid in them.
• This lubricates the joint, like oil in a working engine. It enables all
parts of the joint to move against each other smoothly.
• This is inside the synovial (joint) capsule which holds the fluid
in place.

• The synovial membrane lies inside the capsule where the fluid is produced.
Pipkin Fracture

• I - Posterior dislocation of the hip with fracture of the femoral

head caudad to the fovea centralis
• II - Posterior dislocation of the hip with fracture of the femoral
head cephalad to the fovea centralis
• III - Type I and type II with associated fracture of the femoral neck
• IV - Type I, II, or III with associated fracture of the acetabulum
Dislocation of joint
• Displacement of bones at the joint
• Often caused by impact trauma to that joint
• Can be more damaging and painful than a
fracture
• Damage to the joint capsule and surrounding
ligaments and tendons often takes much
longer to heal than bone tissue.
ANTERIOR DISLOCATION INFERIOR DISLOCATION POSTERIOR SHOULDER
(Slight abducted and internal DISLOCATION
rotated arm) (adducted and internally
rotated arm)
TREATMENT
REDUCTION :

1) KOCHERS MANOEUVRE
2) HIPPOCRATES MANOUEVRE
3)STIMSONS MANOUEVRE
COMPLICATION
1. NERVE INJURY :Axillary and musculocutaneous nerve injury
2. Recurrent dislocation
SURGICAL OPERATIONS

1. PUTTI PLATT OPERATION:Double breasting of subscapularis to

prevent ER and Adduction.
2. BANKARTS OPERATION:Glenoid labrum and capsule reattached to
front of glenoid rim.
3. BRISTOWS OPERATION:Coracoid process osteomized at base and
fixed to lower half of the anterior margin of glenoid
ACROMIO CLAVICULAR JOINT DISLOCATION

MECHANISM:
FALL ON OUTSTRETCHED HAND
GRADE 1 & • Rest In Triangular
Sling
2 INJURY • Analgesics

GRADE 3 • Sugical Repair

INJURY
Dislocation of the hip joint
Three types of hip dislocation : -
1 . Anterior dislocation ( 10 – 15 %)
2 . Posterior dislocation ( 70 % )
3 . Central dislocation ( rest )
Posterior dislocation of hip
• Common in the hip joint ( 70 % )
Mechanism of injury :
• Dashbroad injury as in RTA
• Simple dislocation :
- Flexed knee + neutral adduction
• Fracture dislocation :
- flexed knee + slight abduction
Femur bone showing fovea centralis
Clinical features
• Limb shortening
• Flexion , adduction and medial rotation deformity of the affected limb
• Thigh rest on the contralateral limb
• Head felt in the gluteal region
• Movement of hip decrease
• Feature of sciatic nerve palsy
Feature of sciatic nerve palsy
• SCIATICA or pain localized to the hip,
• PARESIS or PARALYSIS of posterior thigh
muscles and muscles innervated by the
peroneal and tibial nerves,
• sensory loss involving the lateral and
posterior thigh, posterior and lateral leg,
and sole of the foot.
- Pain when sitting, sneezing or coughing
- tingling sensation or numbness down the
leg
- Foot drop
Radiology
• X – ray AP and Lateral view
of the pelvis showing both
the hip joints
• CT scan and MRI ( for
acetabular fracture)
Treatment
• Closed reduction ( to reduce pain ) : -

• 1 . Stimson`s method : -
• Position : prone , at the edge of the
table
• An assistant stabilizes the pelvis
• Physician applies downward pressure
on the calf with one hand while
applying external rotation to the femur.
2 .Allis traction
• Position : supine
• An assistant stabilizes the
pelvis
• The physician simultaneously
distract (to pull away ) the
femur and rocks it medial to
lateral .
3 . Bigelow`s method

• Position : supine
• Physician applied
upwards traction on the
femur while an assistant
stabilize the pelvis
4. Classical watson`s – jones method

• Position : supine
• Limb is brought to the
neutral position first then
longitudinal traction in the
of femur is given.
After treatment
• After reduction , the patient is put on a skin traction or immobilised in
a Thomas split for 3 weeks .
• Full weight bearing after 6 weeks .
• Indication of open reduction : -
• 1 . Failure of close reduction : due to obstruction by bony fragments or by soft
tissues .
• 2 . Instability after reduction
• 3 . Sciatic nerve palsy
Complications
Early : -
• Sciatic nerve palsy
• Irreducible fracture dislocation
• Missed knee injuries
• Recurrent dislocation
Late : -
• Myositis ossificans
• Avascular necrosis of bone
• Post – traumatic arthritis
• Unreduced posterior dislocation
Knee Injuries
• ACL injury
• What is it?
-is the tearing of the anterior cruciate ligament, or ACL, inside your knee joint
What is it caused by?
- sudden stops and change of direction
Other common causes:
Twisting your knee with the foot planted
Getting hit on the knee
Extending the knee too far
Jumping and landing on a flexed knee
Stopping suddenly when running
Suddenly shifting weight from one leg to the other
**common in basketball, soccer, tennis and volleyball.
Symptoms & Treatments
• ACL Symptoms
-Knee swelling
-A loud pop sound
-Severe pain and inability to continue activity

Treatments
-Depending on the severity of your ACL injury,
treatment may include surgery to replace the torn
ligament followed by rehabilitation exercises to help
you regain strength and stability.
-rest
-elevate
-ice
-compress
• PCL Injury
• What is it?
- is the tearing of the posterior cruciate ligament also known as PCL.
What is it caused by?
- Falling on a bent knee
- Striking the front of the knee
- Twisting
- Over extending
Symptoms & Treatments
• PCL Symptoms
-Mild knee swelling
-Mild pain at the back of the knee that feels worse when you kneel.

Treatments
-Physical Therapy
-rest
-ice
-compress
-elevate
SHOULDER DISLOCATION
MOVEMENT AT SHOULDER JOINT

MECHANISM OF INJURY

• COMMONEST :Fall on an outstretched hand with the shoulder

abducted and externally rotated

• POSTERIOR DISLOCATION:by direct blow from the front of the

shoulder or from epileptiform convulsions or electric Shock.
Terimakasih