1. DIAGNOSIS OF MUSKULOSKLETAL TRAUMA
Dwikora Novembri Utomo
Lab/SMF Orthopaedi & Traumatologi FK Unair-RS dr Sutomo
S U R A B A Y A

2. TIU
PADA AKHIR MODUL PPGD INI,MAHASISWA FK SEMESTER 5 AKAN MAMPU MERENCANAKAN AWAL SECARA MANUAL MAUPUN MENGGUNAKAN ALAT, OBAT PADA KEGAWATDARURATAN TRAUMA MUSKULOSKLETAL SECARA TEPAT,CERMAT ,CEPAT, SEBELUM TINDAKAN DEFINITIF /SPESIALISTIK DILAKSANAKAN.

3. TIK
MAMPU MELAKSANAKAN TATACARA PENANGANAN TRAUMA MUSKULOSKLETAL DENGAN CEPAT,CERMAT DAN CEPAT

4. POKOK BAHASAN DIAGNOSA TRAUMA MUSKULOSKLETAL
JENIS TRAUMA MUSKULOSKLETAL
a. TRAUMA MSK SEDERHANA
b. TRAUMA MSK MENGANCAM JIWA
c. TRAUMA MSK YG MENGANCAM
EKSTREMITAS
PERTOLONGAN BEDAH AWAL PADA TRAUMA MSK
HAL HAL YANG MEMPERBURUK PROGNOSIS
INDIKASI KONSULTASI

7. WHAT IS THE DIFFERENCE ?????

8. Biomechanics of Fractures
Pelvis VM Vm M m
E ( Energy Kinetic ) = ½ MV 2

9. SOFT TISSUE INJURY : skin, subcutan fat,muscle, artery,venous, nerves etc
BONE INJURY : broken bones

10. Definition Emergency : Trauma :
A situation that involves a potential disabling or life threatening condition.
Trauma :
A physical wound or injury to living tissue caused by an extrinsic agent
Fracture : discontinuity of cortex or cartilage
Dislocation : discontinuity of joint
luxation – subluxation
Multitrauma : emergency, life threatening more than one organ requiring immediate treatment intervention

11. PRIMARY SURVEY
The ABCDEs of muskuloskletal trauma care identify life threatening condition.
Airway maintenance w/ cervical spine protection
Breathing and ventilation
Circulation w/ hemorrhage control
Disability : neurological status
Exposure : completely undress but prevent hypothermia
life threatening conditions are identified and simultaneous management is instituted

12. SECONDARY SURVEY Done after the patient “stable” Head to toe !
Every orificiums/ every tubes!!

13. Early Intervention on trauma/multitrauma patient (included MSK trauma problems)
A Airway and cervical spine protection, protec the cervical : inline imobilisation,collar brace ( head injury,
C Circulation w/ hemorrhage control (pelvic stabilisation
D Disability, neurological status(GCS), paraparese or paralysis…..spine fractures suspected…..inline imobilisation!!!
Exposure : deformity of extremity….imobilisation/splinting!!!

14. Early Intervention on trauma/multitrauma patient (included MSK trauma problems)

15. Early Intervention on trauma/multitrauma patient (included MSK trauma problems)

16. The first step toward cure is to know what the disease is (latin proverb)

17. Solving the mysteri of a diagnosis is the “detective work of medicine” (Sherlock Holmes)

18. How to diagnose the muskuloskletal trauma problems?
CLINICAL HYSTORY(not for the multitrauma patients)
PHYSICAL EXAM : LOOK, FEEL, MOVE,MEASUREMENT
DIAGNOSTIC IMAGING

19. MUSKULOSKLETAL TRAUMA PROBLEMS
FRACTURES : Closed, Open
DISLOCATIONS,FRACTURE-DISLOCATION
SOFT TISSUE INJURIES :tendon rupture,muscle rupture w/ or w/o neurovascular lesion.

20. FRACTURES
Close fracture
Open fracture
Compound fracture

21. FRACTURES FRACTURES IS NOT ONLY LESION OF THE BONE
DOCTORS MUST THINGS : BEYOND THE PICTURES!!!
THE BONE : LOOKLIKE THE TREE WITH THE ROOT IS THE SOFT TISSUE !!

22. FRACTURES

23. FRACTURES

24. DIAGNOSIS CLINICAL HISTORY (Not for multitrauma pts)
*WHEN (time) : golden periode
*HOW ..MOI (Mechanism of injury : Low velocity/High velocity trauma/trivial) !!!

25. LOOK Deformity – Angulation - DIscrepancy Position Edema
- Rotation
- DIscrepancy
Position
Edema
Appearance of the distal part
Pale
Darken

26. LOOK

27. FEEL
Crepitation
Temperature of the distal part
Pulse
Sensory

28. FEEL (neurovasc exam)

29. MOVE
Active
Passive
Power
False movement

30. MEASUREMENT MEASUREMENT- discrepancy True length,Anatomical length
Appearance length

31. CLINICAL DIAGNOSIS
“Patognomonis sign/definite sign” of fracture: deformity,false movement,
From Clinical History,Physical Exam ,the clinical diagnosis of fracture is established,
Investigation ( X RAY)…important for :
“fracture configuration & planning of definitive treatment” , prognosis.

32. INVESTIGATION X-ray (Immobilization first) 2 VIEWS (AP-lateral)
2 JOINTS (proximal & distal)
2 SIDES (IF Necessary)
Special order

33. INVESTIGATION (X –RAY)

34. OPEN FRACTURES
Open fracture  communication between the fracture and the external environment
30% pts with OF are polytrauma patients.
Require emergency treatment
Significant morbidity

36. OPEN FRACTURES

37. Grade I open fracture

38. Grade II open fracture

39. Grade III A open fracture

40. GRADE IIIb open fract

41. Grade III C open fracture

42. AO Principles of Fracture Management, 2000, pp 671

43. Gustilo, Burgess, Tscherne, the AO-ASIF group, recommended the following steps for open injuries:
Treat OF as emergencies
Initial evaluation to diagnose life & limb-threatening injuries
Appropriate antibiotic tx in the emergency OR and continue treatment for 2 to 3 days only
Immediately debride the wound of contaminated and devitalized tissue, copiously irrigate, repeat debridement within 24 to 72 hours
Stabilize the fracture with the method determined at initial evaluation
Leave the wound open
Rehabilitate the involved extremity aggressively

44. Principles of Management
Prevention of infection
Soft tissue healing and bone union
Restoration of anatomy
Functional recovery
AO Principles of Fracture Management, 2000,

45. Prevention of infection
Soft tissue healing and bone union
Restoration of anatomy
Functional recovery
Golden 6 hours - Bacterial colonization and subsequent wound infection
Once the skin barrier is disrupted, bacteria enter from the local environment and attempt to attach and grow
Assess contamination - appropriate antibiotics
Radical Debridement - dead tissue is culture media( can’t be replaced /prolonged GP by anykind of AB)
Copious lavage > 10 litres - decrease bacterial load

46. ORTHOPAEDIC INFECTION:Diagnosis and treatment,1989 pp8

47. Debridement Radical Wound extended adequately for visual
Decompress tight compartments
Copious lavage

48. Prevention of infection Soft tissue healing and bone union
Restoration of anatomy
Functional recovery
Avoid further soft tissue damage  reduce and splint fractures
Zones of Injury - Repeated Debridement
Gentle handling
Bony stability
Early coverage < 1 week
Delay closure
Reduction & Splinting alleviate pressure on injured ischemic soft tissue
Haematoma spread controlled by sterile dressing
Zones of injury
Tissues of questionable viability left over from previous debridement might be dead on the next debridement.

50. Prevention of infection
Soft tissue healing and bone union
Restoration of anatomy
Functional recovery

51. Prevention of infection
Soft tissue healing and bone union
Restoration of anatomy
Functional recovery

52. FRACTURES OF THE SPINE
Thorax Dislocation
Cervical Dislocation

53. Lumbar Fracture

54. How to decide the level of injury? (based on clinical exam)

55. SENSORY

56. MOTOR

57. REFLEX (PHYSIOLOGIC)

58. REFLEX (PATOLOGIC)

59. DISLOCATIONS
All joint s are surrounded by a joint capsule and ligaments, a dislocation to occur, at least a part of capsule and its ligaments must be torn

61. DISLOCATION

62. COMPLICATION OF MUSKULOSKLETAL TRAUMA
1.DAMAGED OF NERVE OR SPINAL CORD
2. DAMAGED OF THE VASCULAR

63. COMPLICATION OF MUSKULOSKLETAL TRAUMA

64. COMPARTEMENT SYNDROME
Compression of nerve & bloodvessels
Within enclosed anatomic space (osteofacial)
Leading to impaired bloodflow

65. Pathophysiology 2 main pathways*
Increasing fluid content within the compartment (ex : haemorrhage, oedema)
Decreasing the compartment size
(ex : external compression)
* Whitesides, Acute compartment syndr, J Am Acad Orthop Surg 1996;4

66. How to Diagnosed ?
Mainly by clinical examination!!!

67. Sign & Symptoms Classic signs 5 P Pain
Severe extremity pain  out of proportion to injury
Early sign, worse with passively stretching involved muscle

68. Pallor Paresthesia or anesthesia to light touch Paralysis
Pulselessness
Not present in early cases
Pallor

71. LATE COMPLICATION OF FRACTURES
INFECTION IN OPEN FRACT
Grade I less than 1%
Grade II %
Grade III %

72. SIMPLE MUSKULOSKLETAL TRAUMA

73. LIFE THREATENING MUSKULOSKLETAL TRAUMA

74. LIMB THREATENING MUSKULOSKLETAL TRAUMA

75. FACTORS THAT MAKE THE PROGNOSIS BECOME WORSE
Bad pre hospital management
* no imobilisation/splint
* improper transfer of patients (ex : to transfer spine fract w/o inline imobilisation)
*delayed transfer (over golden periode,under diagnosis of vascular injury)

76. Pre Hospital Airway Circulation Immobilization Transportation
Control :
Airway
Circulation
Immobilization
Transportation

77. INDICATION OF CONSULTATION
ALL FRACTURES & DISLOCATION ARE PATOLOGIC CONDITION.
IMOBILISATION /SPLINT FIRST
STRICTLY NO DELAY OF TRANSFERING PATIENTS W/ FRACT + NEUROVASCULAR INJURY, OPEN FRACTURES , DISLOCATION.
DO NOT DO HARM

78. SUMMARY 30% of OF ARE POLYTRAUMA PATIENTS.
FRACTURES IS NOT ONLY LESION ON THE BONE.
EARLY INTERVENTION OF MSK TRAUMA SHOULD BE DONE PROPERLY, FOR BETTER PROGNOSIS.
TO KNOW THE BASIC KNOWLEDGE FOR MAKING DIAGNOSIS OF MSK TRAUMA IS MANDATORY BEFORE TREATING PATIENTS.
DO NOT DO HARM

79. REFERENCE

80. THANK YOU FOR YOUR ATTENTION