FRAKTUR UMUM

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FRAKTUR

The golden rule is Treat

the patient, not simply
the part

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FRAKTUR
Putusnya hubungan kesinambungan/
diskontinuitas tulang dan atau tulang
rawan

Fraktur tertutup :Bila kulit sekitar intak

Fraktur terbuka :Bila ada luka, sehingga
kemungkinan terjadi kontaminasi atau
infeksi

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KLASIFIKASI
I. Berdasarkan hub dengan dunia luar :

1.Fraktur 2. Fraktur
tertutup terbuka

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KLASIFIKASI
• Gustillo – Anderson :
I. Luka < 1 cm
II. Luka 1 – 10 cm
III. Luka > 10 cm
A. Soft tissue coverage
B. Bone exposed
C. Neurovascular injury

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KLASIFIKASI

• Gustillo – Anderson :

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 Fractures due to a traumatic incident

Caused by sudden and exessive force, which

may be tapping, crushing, bending, twisting
or pulling.

• Direct violence : blow on the arm which

shatters the ulna at the point of impact
• Indirect violence: forcible traction by a
tendon or ligament which literally pulls the
bone apart

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Fatigue or stress fractures

• Due to repetitive stress

• Most often seen in the tibia or fibula
or metatarsals, especially in atheletes,
dancers and army recruits.

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Pathological fractures

• Fractures may occur even with normal

stresses if the bone has been
weakened (by a tumor) or if it is
excessivelly brittle (paget’s disease)

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How fractures are disposed

• Complete fractures
The bone is compeletely broken into 2 or
more fragments.
Transverse
oblique or spiral,
Impacted fracture
Comminuted fracture

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•Incomplete fracture
The bone is incompeletely divided and
the periosteum remains in continuity.
•Greenstick fracture
•Compression fracture

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KLASIFIKASI
II. Berdasarkan garis
patah

1.Komplet 2.Inkomplet

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KLASIFIKASI
III. Jumlah garis patah

1. Simple 2. Komunitif 3. Segmental

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 KLASIFIKASI
IV. Arah garis patah

1. Transversal 2. Oblique 3. Spiral 4. Kompresi

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KLASIFIKASI
V. Lokasi
1. Tulang Panjang
• 1/3 proksimal
• 1/3 tengah
• 1/3 distal
2. Tulang Melintang
• 1/4 medial
• 1/4 lateral

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KLASIFIKASI
VI. Dislokasi Fragmen
– Undisplaced
– Displaced
• Fragmen tlg searah (ad latus)
• Fragmen tlg membentuk sudut (ad axim)
• Fragmen distal memutar (ad periferum)

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How fractures heal

• Tissue destruction and haematoma

formation
• Inflamation and cellular proliferation
• Callus formation
• Consolidation
• Remodelling

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Stadium Penyembuhan
Fraktur

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Healing by direct repair

• Fractures of cancellous bone

• Fractures treated by rigid internal
fixation

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The time factor
Rate of repair depends upon :
• the type of bone (cancellous bone heals
faster than cortical bone.
• type of fracture (transverse fracture takes
longer than spiral fracture)
• Blood supply (poor circulation means slow
healing)
• General constitution (healthy bone heals
faster
• Age (healing is almost twice as fast in
children as in adults) 20
Time table
Upper limb Lower limb

Callus visible 2-3 weeks 2 - 3 weeks

on x-ray
Union (fracture 4-6 weeks 8 - 12 weeks
firm)
Consolidation 6-8 weeks 12 - 16 weeks
(bone secure)

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Fractures that fail to unite

Causes of non union

Distraction and separation of the
fragments
Interposition of soft tissue between
the fragments
Excessive movement at fracture line
Poor blood supply
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Most fracture will unite provide
the bone fragments are
• Placed in contact with each other and
• Held more or less immobile until new
bone formation is apparent

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Anamnesa

• The fracture is not always at the site

of the injury

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ANAMNESIS
- Umur, jenis kelamin - Pekerjaan
- Pendidikan - Lingkungan
rumah
- Riwayat trauma:
• Arah
• Jenis
- Lokalisasi nyeri - Gangguan fungsi
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Examination

• General signs
A broken bone is part of a patient. It is
important to look for evidence of : (1)
shock or haemorrhage; (2) associted
damage to brain, spinal cord or viscera;
and (3) a prediposing cause

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Look

• Swelling,
• bruising,
• Deformity
• Skin intact ?

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Feel

• Local tenderness
• Examine distal to the fracture in order
to feel the pulse and test the
sensation
• Compartement syndrome ?

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Move

• Crepitus and abnormal movement may

be present, but it is more important to
ask if the patient can move the joint distal
to injury

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Pemeriksaan Fisik
Move : aktif
– Nyeri gerak
– Sensorik pasif

– Motorik

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Special imaging

• Tomography
• CT- scan
• MRI
• Radioisotope scanning

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RADIOLOGI
Rule of 2 :
• 2 proyeksi
• 2 sendi
• 2 ekstremitas
• 2 waktu

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PRINCIPLES OF FRACTURE
TREATMENT

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First aid
• Make sure that the airway is clear
• If there is a wound, cover it with clean
material
• Stop bleeding by local compression
• Give something for pain
• If the neck or the bak is injured, prevent
flexion which may damage the spinal cord
• If there is fracture,prevent movement
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Assesment in hospital
• Examine the airway and treat asphyxia
• Make sure the patient can breathe
• Note the obvious haemorrhage and stop it
• Assess the degree of blood loss and shock
• Check for spinal cord injury
• Look for injuries of abdominal or pelvic viscera
• Examine for the presence of fractures or dislocation
• Look for soft tissue complications, especially nerve and
vascular injury
• Arrange for an x-ray

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Definitive treatment of closed
fracture
• Manipulation to improve the position of
the fragments, followed by splintage
to hold them together until they unite;
meanwhile joint movement and
function must be preserved

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Reposisi
Mengembalikan kedudukan tulang
Cara :
• Manual
• Traksi
• Operatif

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 Fracture involving an articular
surface; this should be reduced
as near to perfection as
possible because any
irregularity will
predispose to degenerative
arthritis

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Closed reduction

• The distal part of limb is pulled in the

line of the bone
• As the fragment disengage, they are
repositioned
• Alignment is adjusted in each plane

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Reposisi

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Reposisi
Keberhasilan dinilai dari :
• Alignment
• Contact > 50 %
• Rotation (-)
• Discrepancy (-)
• Sudut < 15 °

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Indikasi konservatif
• Anak dalam masa pertumbuhan
• Impending infeksi
• Jenis fraktur tidak cocok untuk ORIF
• Toleransi operasi tidak baik
• Pasien menolak operasi

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Indikasi Operasi
• Sukar reposisi tertutup
• Fraktur multipel
• Fraktur patologis
• Fraktur intra artikular

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HOLD REDUCTION

• In order to unite, a fracture must be

imobilized
• We splint most fractures, not to ensure
union but (1) to alliviate pain and (2) to
ensure that union takes place in good
position

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Immobilisasi
(mempertahankan reposisi)
• Fiksasi eksterna
– Gips
– Roger Anderson
• Fiksasi interna
– Plate + Screw
– K-nail

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ORIF ; indications
• # that cannot be reduced except by operation
• # that inherently unstable and prone to
redisplacemaent after reduction (#mid shaft
forearm)
• # that unite poorly and take long time (#
femoral neck)
• Pathological #
• Multiple #
• # in patients who prsent nursing difficulties
(paraplegics, multiple injuries and very elderly

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ORIF; complications

• INFECTION
• NON – UNION
• IMPLANT FAILURE
• REFRACTURE

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OREF (open reduction external
fixation) ; indications
• # associated wih severe soft tissue
damage
• # associated with nerve or vessel damage
• Severely comminuted and unstable #
• # pelvis
• Infected #

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OREF ; Complication

• Overdistraction
• Reduced load transmission trough bone,
which delays fracture healing causes
osteoporosis (EF shoul be removed after
6-8 wo,and replace)
• Pin tract infection

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OPEN FRACTURE

• EMERGENCY
• GOLDEN PERIOD 6 – 8 HO

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OPEN FRACTURE; assesment

• Is circulation intact ?
• Peripheral nerve intact ?
• State of skin arround the wound
• Does the wound communicate with # ?

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Fraktur Terbuka

• Perbaiki KU
• Debridement, kultur/resistensi
• ATS-Toxoid, Antibiotik
• Tutup luka dengan kasa bersih
• Reposisi
• Imobilisasi

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ANTIBACTERIAL

• Antibiotics : asap, combination ampicilline

and cloxacillin, given 6ho; if wound
heavily contaminated, give gentamycin
or metronidazole for 4-5 do
• Tetanus prophylaxis

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TREATMENT OF WOUND

• To cleanse the wound of foreign

material
• Remove devitalized tissue (debridement)
4 C : Colour
Consistency
Contractility
Capacity of bleeding

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Complications of fracture
General complication
• Shock
• Crush syndrome
• Venous thrombosis and pulmonary
embolism
• Tetanus
• Gas gangrene
• Fat embolism
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Complication involving # bone
• Infection
• Delayed union and non union
• Malunion
• Growth disturbance
• Avascular necrosis

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Complication involving soft tissue

• Vascular injury
• Compartement syndrome (Volkmann”s
ischaemia)
• Nerve injury
• Visceral injury
• Myositis osificans

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Compartement syndrome
Arterial ischaemia reduced painful

Damage blood flow pale

pulseless

paresthetic
paralysed
Direct oedema
Injury fasciotomy

incr comp pressure

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Complication involving joints

• Joint stiffness
• Osteoarthritis
• Sudeck’s atrophy

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 TERIMA KASIH

Created by : “ Tepeng “ 61