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

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.

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

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

WHAT IS THE DIFFERENCE ?????

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

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

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

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

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

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!!!

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

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

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

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

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

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

FRACTURES Close fracture Open fracture Compound fracture

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 !!

FRACTURES

FRACTURES

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

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

LOOK

FEEL Crepitation Temperature of the distal part Pulse Sensory

FEEL (neurovasc exam)

MOVE Active Passive Power False movement

MEASUREMENT MEASUREMENT- discrepancy True length,Anatomical length Appearance length

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.

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

INVESTIGATION (X –RAY)

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

OPEN FRACTURES

Grade I open fracture

Grade II open fracture

Grade III A open fracture

GRADE IIIb open fract

Grade III C open fracture

AO Principles of Fracture Management, 2000, pp 671

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

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

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

ORTHOPAEDIC INFECTION:Diagnosis and treatment,1989 pp8

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

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.

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

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

FRACTURES OF THE SPINE Thorax Dislocation Cervical Dislocation

Lumbar Fracture

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

SENSORY

MOTOR

REFLEX (PHYSIOLOGIC)

REFLEX (PATOLOGIC)

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

DISLOCATION

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

COMPLICATION OF MUSKULOSKLETAL TRAUMA

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

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

How to Diagnosed ? Mainly by clinical examination!!!

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

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

LATE COMPLICATION OF FRACTURES INFECTION IN OPEN FRACT Grade I less than 1% Grade II 1-10 % Grade III 10-50%

SIMPLE MUSKULOSKLETAL TRAUMA

LIFE THREATENING MUSKULOSKLETAL TRAUMA

LIMB THREATENING MUSKULOSKLETAL TRAUMA

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)

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

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

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

REFERENCE

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