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SURGERY

BIMBEL UKDI MANTAP


Surgery
dr. Andreas W Wicaksono
dr. Anindya K Zahra

GENERAL SURGERY

Lap belt marks: Correlate with small intestine rupture

Kehrs sign
Kehrs sign : pain in
the left tip shoulder
cause by irritation of
peritoneum that
covers inferior
surface of left
diaphragm >> a sign
of rupture spleen

Hematoma
HistoryRetroperitoneal
& Physical:

Cullen sign: Periumbilical


echymosis
Grey Turner Sign: Flank
echymosis

Plain Abdomen AP & Semierect: Subdiaphragmatic Air

Plain
Abdomen 3
LLD:
Abdomen
Posisi
Subdiaphragmatic Air

Anatomi Prostat

Ruptur
Uretra
Anterior

Straddle
Injury

Hematom penis

Butterfly
Hematome

Ruptur Uretra Posterior

Major trauma. Floating prostate

Snake Bite

Derajat Gigitan Ular (Depkes)


0

Eritem
(dalam
12jam)

< 3cm

3-12cm

>12-25cm

>25cm

> ekstremitas

Gejala
Sistemik

Mual,
pusing

Shock,
Gagal ginjal
Petechie, akut, coma,
echymosis perdarahan

DIGESTIVE SURGERY

Migrating pain
Acute Appendicitis
appendicitis

Periumbilical pain(colicky pain,


visceral) referred by N. Thoracal X

Mc. Burney pain (irritative


peritoneal pain, somatic)

Clinical Sign

Rovsings sign :
palpation in the left
lower quadrant of
abdomen increase the
pain in the right lower
quadrant
Obturator sign

Alvarado Score: MANTRELS

Pathophysiology

Ileus

Herring bone

Coil spring

Radiology Ileus

Stepladder pattern

Pneumoperitoneum

Colorectal Cancer

Clinical Manifestation

Apple Core

Filling Defect

How Does Colorectal Cancer Develop?


Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.

CRC Risk Factor

>60 yo
Family history (+): mutasi gen
Familial adenomatous polyposis
Low fiber diet
IBD

Screening Test:
FOBT
Colonoscopy
CEA (Carcinoembryonic Antigen). Normal <2,5ng/ml

Genetic analysis

DUKEs Staging

Hemorrhoid

External Hemorrhoids

Internal Hemorrhoids

Outside anal canal, around sphincter

Inside anal canal

Symptoms due to thrombosis

Symtomps due to bleeding and/or


irritation of mucosa
Painless, bleeding
Prolapse associated with defecation

Can not be inserted to anal canal

Can be inserted to anal canal up to grade


III

Internal Hemorrhoids
Internal hemorrhoidal plexus
V. Rectus Inferior
V. Rectus Media

External Hemorrhoids
external hemrroidal plexus
V. Rectus Inferior

Internal Hemorrhoid: Grading

Tx:
Non Farmakologis
Changing lifestyle
(menghindari risk
factor)
Diet tinggi serat
Endoskopi (Rubber
band & Sclerotherapy)

Farmakologis
Fecal softener
Fiber supplement
NSAID

Surgery
Electrocautery &
Cryosurgery
Hemorrhoidectomy
(excision or stapled)

Biliary Tract Disorders


Gallstone disease
(cholelithiasis)

Acute Cholecystitis

Gallstone in CBD
(choledocholithiasis)

4F: Female, forty, fat, fertile


Seringkali asimptomatik
Simptomatik: biliary colic (terutama stlh makan
berlemak) pd epigastrium atau RUQ
Trias dx: Fever, Leukositosis, RUQ Tenderness
Murphy sign (+)
Biliary colic > memburuk secara progresif, radiasi ke
interscapular area, scapula & bahu dextra
Asymptomatic
Biliary colic
Obstructive jaundice

Cholangitis

Trias Charcot: 1. jaundice, 2. fever, usually with rigors,


3. RUQ abdominal pain.
Severe: hypotension, altered mental status

Congenital : Atresia
bilier

Cholestasis jaundice with increase of direct bilirubin


80% pd bile duct di atas level porta hepatis

Gallstone Disease / Cholelithiasis

Terbentuk di gallbladder. Bisa bermigrasi ke distal : ductus cysticus, ductus


choledocus, ductus pancreaticus atau Ampula vater.
Tipe :
80% cholesterol & mixed stone
20% pigmented stone

Cholesterol & mixed stone


Konten : kolesterol monohidrat, garam Ca,
bile pigment, protein & fatty acid
Mekanisme penting : increased biliary secretion of
cholesterol, biasa pada pasien obese atau
diet tinggi kolesterol

Pigmented stone
Konten : kalsium bilirubinat (dominan)
Biasa pd pasien chronic hemolytic disease
atau alcoholic cirrhosis

Dx :
Plain film > deteksi radiopaque kalsium (kasus: 10-15% kolesterol & 50%
pigmented stone)
USG

Sign & symptom :


Seringkali asymptomatik (terutama di dlm gall bladder)
Symptomatis jika sudah menimbulkan inflamasi atau obstruksi
Gejala plg spesifik & khas: biliary colic. Yaitu severe pain (akibat
biliary contraction, terutama stlh makan berlemak) pd
epigastrium atau RUQ yg sering radiasi ke daerah interscapular,
scapula dextra dan bahu dextra
Nausea & vomit sering menyertai biliary colic

Temuan Klinis :
Fever (biasanya sdh komplikasi / peradangan)
Serum bilirubin (++)
Alkaline phospatase (++)

Lokasi tersering terjadi sumbatan / inflamasi :


Ductus cysticus
Ductus choledocus / choledocholithiasis

Cholecystitis
Berdasar penyebab :
Calculous cholecystitis (90-95%) :
terutama akibat obstruksi gallstone pada
ductus cysticus
Acalculous cholecystitis (5-10%) :
jarang, penyebab bervariasi: trauma
adenocarcinoma gallbladder
torsi gallbladder dan DM.

Sign & symptom :


Biliary colic > memburuk secara progresif
Radiasi ke interscapular area, scapula & bahu dextra (tanda terjadi
iritasi pd diafragma sensasi nyeri o/ n.phrenicus > C3-C5 dextra)
Anorexia, nausea & vomit
Jaundice (uncommon)
Murphy sign (+)

Patofisiologi :
Prinsipnya sama dgn di appendicitis (monggo dibaca lg)

Temuan Klinis :

Fever
Trias
Leukositosis (10.000-15.000 cells/uL)
diagnosis
RUQ tenderness
Serum bilirubin (mildly elevated, no symptom)
Murphy Sign (+)

Dx :
Berdasar triad &
temuan klinis lain
USG (identifikasi thickening of gallbladder wall)
CT-scan

Komplikasi :
Gangren & perforasi > bs diikuti abscess jika ada
superinfeksi bakteri > bs generalized peritonitis
Fistulization : biliary-enteric fistula

Treatment :
Non surgery :

Analgetik & antispasmodik


Nutrisi parenteral (hindari oral intake)
Antibiotik profilaksis (mencegah peritonitis & cholangitis)
Bedrest

Surgery :
Laparoscopic cholecystectomy
Open cholecystectomy

Choledocholithiasis
10-15% pasien cholelithiasis
Penyebab :
Gallstone (pigmented stone)
Sering pada pasien dgn kronik
hemolytic disease

Sign & symptom :


Asymptomatic
Biliary colic
Obstructive jaundice

Px lab (mirip dgn cholelithiasis) :


Serum bilirubin (++)
Alkaline phospatase (almost always elevated in biliary obstruction)

Komplikasi :
Cholangitis
Terjadi akibat ascending infection dari bacteria di duodenum. Bisa
terjadi krn bile duct sudah terobstruksi oleh gallstone.
Medical emergency
Sign & symptom : jaundice, fever, malaise, rigor & abdominal pain
(severe : hypotension & confusion)
Gambaran duktus : dilated, sclerosed & strictured ducts
Initial Tx : IV fluid & antibiotik

Pancreatitis

Px penunjang :

cholangitis

Cholangiography
ERCP & MRCP
USG

Tx :
Choledocholithotomy
ERCP (Modalitas intervensi: endoscopic sphincterotomy,
stone removal, insertion of stent, dilation of stricture)

ERCP

Alat Dx sekaligus Tx
Pilihan Tx lihat slide
sebelumnya...

Biliary Atresia
Kelainan kongenital yg cukup jarang
(1 per 15.000 kelahiran), tapi
kejadian ini 25-30% berhubungan
dgn anomali lain seperti
stenosis/atresia duodeni, pancreas
annulare, dll.
80% pd bile duct di atas level porta
hepatis, 15% pada ductus
choledochus, dan 5% pada ductus
hepaticus communis.
Etiologi : intrauterine inflammatory
process caused by fibrosis of both
the intrahepatic & extra hepatic
biliary tree.
Tx : Kasai hepatoportoenterostomy

Murphys sign : the patient stop resp. effort


when we deep palpate the RUQ >
Cholecystitis
4F : Fat, Forty, Female, Fertile > Cholelithiasis
Trias Charcot : > Cholangitis
Fever
Ikterik
Pain in RUQ

PUDDLE SIGN
For ascites 120ml

Prone for 5 mins


Rise onto elbow & knee
Stethoscope at bottom
Flicks near flank repeatedly
Move stethoscope away sound
becomes louder

SHIFTING DULLNESS
For ascites
500ml

Puddle Sign

Hernia

Trigonum hasselbach
Dibentuk tepi MRA, a.
epigastrica inferior, lig.
Inguinalis

Hernia Inguinalis Direct/Medial (trigonum hasselbach)

Hernia Inguinalis indirect/lateral (canalis inguinalis)

Hernia Femoralis (canalis femoralis)

Spatium Subinguinal

UROLOGIC SURGERY

Benign Prostat Hyperplasia


Screening test :
PSA ( Prostat
Specific Antigen),
normal value <4
ng / ml

Rectal toucher:
Suspect
malignancy IF
hard, nodular,
irregular

PENANGANAN / PENGOBATAN BPH


Dulu: Mencegah / menurunkan angka
kematian karena BPH

IPSS: WISE & FUN


W eak stream
I ntermittensi
S training
E mptying incomplete
F requecy
U rgency
N octuria

Sekarang: Meningkatkan kualitas hidup

ALTERNATIF PENANGANAN BPH


IPSS <8 Watchful Waiting
IPSS 8-18 Pemberian obat
Alpha1 adrenergik blocker
(Prazosin)
5 Alpha reductase inhibitor
(Finasterid)
IPSS >18 Operatif
Invasive: open prostatecomy
Less Invasive: TURP

WATCHFUL WAITING
Sebagian besar tanpa keluhan
Tanpa penyulit / gejala
Kualitas hidup tetap baik
INDIKASI
BPH dengan IPSS ringan (<8)
Baseline data normal
Flowmetri : non obstruktif

FOLLOW-UP
Tiap 3-6 bulan
Ulangi :
IPSS
Flow (6 bulan)
PSA (6-12 bulan)

Prostate

TERAPI BPH DENGAN BLOCKER


INDIKASI :
IPSS ringan dan sedang
SYARAT :
Normotensi / hipertensi ringan
Urin normal
Faal Ginjal Normal
PSA 4 ng%
Miokard Infark (-), CVA (-)
KONTRAINDIKASI
Hipotensi postural / ortostatik
Alergi terhadap bloker

PEMBEDAHAN BPH
TUR Prostat: 90 95%
Di Amerika : 300.000 400.000/tahun
Di Urologi RS Dr. Soetomo
Open prostatektomi
Ke 2 terbanyak setelah urolithiasis
: 5 10 %
150/tahun
BPH yang besar
(>50 100 gram)
INDIKASI TERAPI PEMBEDAHAN BPH
Tidak habis
Retensi urin akut
Retensi urin kronis (selalu > 300 ml)
direseksi dalam
Residual urin > 100 ml
1 jam
BPH dengan penyulit
Disertasi :
Terapi medikamentosa tidak berhasil
Batu buli besar
Flowmetri obstruktif
(> 2.5 cm)
INDIKASI KONTRA TERAPI PEMBEDAHAN BPH
Multipel
Infark miokard Akut
Fasilitas TUR tidak
CVA Akut
ada

TERAPI PEMBEDAHAN BPH

Batu Saluran Kemih

Nephrolithiasis

Ureterolithiasis

Vesikulolithiasis

Uretrolithiasis

Urinary Tract Reffered Pain

Lokasi
GINJAL

Gejala
Nyeri regio flank, dapat berupa
- Nyeri kolik akibat aktivitas peristaltik otot polos sistem kalises, atau
- Nonkolik akibat peregangan kapsul ginjal, hidronefrosis, atau infeksi
pada ginjal

menyerupai tanduk rusa.


URETER
Nyeri pinggang kolik dan menjalar, tergantung letak batu:
rektum.
- Proksimal pinggang setinggi pusar (T10)
- Medial medial paha/skrotum (L1-3)
- Distal ujung penis (S2-3), +disuria
VESICA

Gejala iritasi, miksi tiba-tiba berhenti dan menjadi lancar kembali


dengan perubahan posisi tubuh.
Nyeri berkemih pada ujung penis, skrotum, perineum, pinggang, atau
kaki. Anak sering mengeluh enuresis nokturna, sering menarik-narik
penisnya (laki-laki) atau menggosok-gosok vulva (perempuan)

URETHRA

Miksi tiba-tiba berhenti retensi urin. Batu pada uretra - Anterior


benjolan keras di penis, atau tampak di meatus uretra eksterna. Nyeri
pada glans penis.
- Posterior nyeri pada perineum atau rektum

Jenis-jenis batu

Diagnosis Px Penunjang
Urinalisis
Hematuria, kristal, tanda infeksi

Darah Rutin dan Kimia Darah


Terutama ureum, creatinin, asam urat

Radiologi

BNO hanya untuk batu radioopak (kalsium, sistin)


IVP bisa untuk batu non-opak (urat, struvit)
USG aman untuk ibu hamil dan yang KI IVP
Pyelografi antegrad/retrograd bila fungsi voiding terganggu

Struvite Stones
>> women
Struvite (magnesium ammonium phosphate) stone
Infection with urease producing bacteria (e.g. Proteus,
Klebsiella, Pseudomonas and Enterobacter), resulting in
hydrolysis of urea into ammonium and increase in the
urinary pH 6,10.
They can grow very large and form a cast of the renal pelvis
and calices resulting in so-called staghorn calculi. The
struvite accounts for approximately 70% of these calculi,
and is usually mixed with calcium phosphate thus
rendering them opaque. Uric acid and cystine are also
found as minor components.

Staghorn

Faktor Risiko Batu Kalsium (70-80%):

Hiperkalsiuri
absobtif
renal (reabsorbsi turun)
resorptif (kalsium tulang) pada hiperparatiroidisme
Hiperoksaluri
post operasi usus atau banyak konsumsi makanan yang kaya oksalat (teh, kopi
instan, soft drink, dll)
Hiperurikosuria
asam urat bertindak sebagai inti batu/nidus untuk terbentuknya batu kalsium
oksalat.

Hipositraturia
Di dalam urine, sitrat bereaksi dengan kalsium membentuk kalsium sitrat
cegah ikatan kalsium dengan oksalat atau fosfat.

Hipomagnesuria.
Di dalam urine magnesium bereaksi dengan oksalat menjadi magnesium
oksalat cegah ikatan kalsium dengan oksalat.

Prevensi Batu Kalsium


Menurunkan konsentrasi kalsium dan oksalat
Meningkatkan konsumsi sitrat minum jeruk nipis/air
lemon sesudah makan malam

Meningkatkan asupan cairan


Hindari soft drink (>1 L/minggu)
Batasi asupan protein (1 gr/kgBB/hari).
Protein tinggi ekskresi kalsium & asam urat, sitrat

Batasi asupan natrium reabsorpsi kalsium


Pembatasan asupan kalsium tidak dianjurkan

Tatalaksana

Bladder Carcinoma
Cancer age
Painless gross
hematuria all along
micturition, reccurent
Risk factor
Male
Cigarette
Amine aromatic
substance exposure
(paint, textile)
UTI

90%: Transitional Cell


Carcinoma (TCC)

Retrograde Urethrography

4. Continuous: fistula

5. functional: paralysis, cognitive impairment

Urinary Incontinence

Scrotal Swelling
Disorders

Etiology

Clinical

Testicular torsion

Intra/extra-vaginal
torsion

Sudden onset of severe testicular pain followed by


inguinal and/or scrotal swelling. Gastrointestinal
upset with nausea and vomiting.

Hidrocele

Congenital anomaly, accumulation of fluids around a testicle, swollen


blood blockage in the testicle,Transillumination +
spermatic cord
Inflammation or
injury

Varicocoele

Vein insufficiency

Scrotal pain or heaviness, swelling. Varicocele is


often described as feeling like a bag of worms

Hernia skrotalis

persistent patency of
the processus
vaginalis

Mass in scrotum when coughing or crying. Bowel


sound on scrotum. Strangulated nausea,
vomiting, fever, edematous, erythematous,
discolored

Orchitis

Mumps virus

Testicular pain and swelling, fatigue, fever, chills,


Testicular enlargement, induration of the testis,
Erythematous scrotal skin

Testicular Torsion
Sign : Sudden pain in
scrotal, nausea and
vomiting, no fever
Physical Exam
Cremaster reflex ()
Phren sign (-)

Tx : Orchidectomy

Phrens sign
Prehn's sign, the physical lifting of the testicles
relieves the pain
Negative Prehn's sign indicates no pain relief with
lifting the affected testicle, which points towards
testicular torsion which is a surgical emergency
and must be relieved within 6 hours
Positive Prehn's sign indicates there is pain relief
with lifting the affected testicle, which points
towards orchidoepididymitis.

Orchitis

Varicocele

Hydrocele

Hydrocele Types

Translumination test
/ diapanoscopy
Positive : Hydrocele,
Hernia Scortalis
Negative : Mass

Fimosis and Parafimosis

Epispadia and Hypospadia

Cryptoorchidismus

Management

ORTHOPAEDIC SURGERY

Fracture

Colles and Smiths

Complication of Fracture
Early complications
Local:
Vascular injury causing haemorrhage, internal or external
Visceral injury causing damage to structures such as brain, lung or
bladder
Damage to surrounding tissue, nerves or skin
Haemarthrosis
Compartment syndrome (or Volkmann's ischaemia)
Wound infection, more common for open fractures

Systemic:
Fat embolism
Shock
Thromboembolism (pulmonary or venous)

Fracture Complication
Late Complications
Local:

Delayed Union
Non-union
Malunion
Joint stiffness
Contractures
Osteomyelitis
Growth disturbance or deformity

Systemic:
Gangrene
Tetanus
Septicaemia

Non-Union and Mal-Union

Fraktur clavicula:
>> di 1/3 lateral, pada anak2.
Fragmen medial clavicula terangkat
krn m. SCM, fragmen lateral jatuh
(shoulder drop), dan proksimal humerus
tertarik ke medial krn m. pectoralis major.
Pada anak, fraktur terjadi inkomplit,
disebut greenstick fracture.

Fraktur scapula:
Banyak terjadi pada acromion.

Fraktur Humerus:
>> di collum chirurgicum, pada lansia
osteoporosis.
Pada tuberculum majus : avulsion
fracture.
Direct contact bagian humerus dgn
nervus:
1) collum chirurgicum: n. axillaris,
2) sulcus radialis: n. radialis,
3) akhir distal: n. medianus,
4) epicondylus medial: n. ulnaris

Fraktur hamatum:
Bisa melukai n. et a. ulnaris

Fraktur scaphoid:
Fraktur carpal tersering.
Fraktur avaskuler nekrosis
degenerasi; diTx bedah penyatuan
os carpal = arthrodesis

Fraktur metakarpal:
Fraktur metakarpal 5 (boxers
fracture)
Fraktur falang:
Distal comminuted, painful
hematome. Proksimal hati2
tendon flexor

Humeral Fracture
Collum chirurgicum:
n. axillaris
Sulcus radialis (shaft) :
n. radialis
Distal end :
n. medianus/ n.radial
Epicondylus medial:
n. ulnaris

Cubital Tunnel syndrome:


Penekanan n. ulnaris saat melewati cubital tunnel.
Cubital tunnel = saluran yang terbentuk oleh arcus tendineus m. flexor
carpi ulnaris yang mengubungkan humerus dan ulna.
Tanda gejala: lesi n. ulnaris pada sulcus ulnaris di posterior epycondylus
medialis.
Guyon Tunnel Syndrome:
Penekanan n. ulnaris saat melewati canalis ulnaris (Guyon tunnel).
Guyon tunnel = saluran yanng dibentuk oleh os pisiform dan hammulus os
hammati
Carpal Tunnel Syndrome:
Penekanan struktur-struktur yang melewati carpal tunnel (canalis carpalis),
terutama n. medianus.
Canalis carpalis = saluran yang berada di pergelangan tangan dan dibentuk
oleh os carpal dan retinaculum flexorum.
Tanda gejala: paresthesia, hypoesthesia, atau anesthesia pada 3 lateral
jari tangan

Nerve Injury
N. Axilaris :
m.deltoideus, sensoris:
bahu
N. Muskulokutaneus:
compartemen anterior
brachium
m.bisep brachii
m. brachialis
m.coracobrachialis

N. Ulnaris: Claw hand


N. Radialis: Drop hand
(cant extend hand)
N. Medianus:
Preachers hand

Carpal Tunnel
Syndrome
N. medianus

Cubital Tunnel
Syndrome

Epicondylus medial

GuyonTunnel
Syndrome

Claw hand
N. Ulnaris

Drop hand
N. Radialis

Preachers Hand
N. medianus

Orbita

Management of Fracture
4R :
1. Recognition
2. Reduction
3. Retention
4. Rehabilitation

Recognition
Anamnesis
History of trauma?
Mechanism of injury?
Localized pain, aggravated by movement
Decreased function
heard the bone break
feel the ends of the bone grating

Physical Examination
LOOK (Inspection)
Symetricity right-left
Swelling, wound, deformity (angulation, rotation,
shortening), abnormal movement, discoloration
(ecchymoses)
Bone exposure

FEEL (Palpation)
Localized tenderness
Distal neurological status (S&M), pulsation
Aggravation of pain and muscle spasm during even the
slightest passive movement
Feeling and listening the crepitus unnecesary!

Reduction
Restore a fracture to correct allignment
Closed Reduction
Traction : Skin traction, skeletal traction

Open Reduction
ORIF
OREF

Traction

Skeletal Traction

Femur fracture managed with skeletal traction and use of a Steinmann pin in the
distal femur.

ORIF vs OREF

Indications for External Fixation


Open fractures that have
significant soft-tissue
disruption (eg, type II or III
open fractures)
Soft-tissue injury (eg, burns)
Pelvic fractures
Severely comminuted and
unstable fractures
Fractures that are associated
with bony deficits
Fractures associated with
infection or nonunion

Closed reduction is needed if the fracture is significantly displaced or


angulated. Indications for surgical intervention include the following:
Failed nonoperative (closed) management
Unstable fractures that cannot be adequately maintained in a reduced
position
Displaced intra-articular fractures (>2 mm)
Patients with fractures that are known to heal poorly following
nonoperative management (eg, femoral neck fractures)
Large avulsion fractures that disrupt the muscle-tendon or ligamentous
function of an affected joint (eg, patella fracture)
Impending pathologic fractures
Multiple traumatic injuries with fractures involving the pelvis, femur, or
vertebrae
Unstable open fractures or complicated open fractures
Fractures in individuals who are poor candidates for nonoperative
management that requires prolonged immobilization (eg, elderly patients
with proximal femur fractures)
Fractures in growth areas in skeletally immature individuals that have
increased risk for growth arrest (eg, Salter-Harris types III-V)
Nonunions or malunions that have failed to respond to nonoperative
treatment

Retention / Immobilization
Bidai /Splint adalah alat yang digunakan untuk mengimobilisasi
bagian tubuh, alat tersebut dapat bersifat lunak ataupun kaku
(rigid)
Plaster slab adalah lempengan gips untuk imobilisasi sendi atau
daerah cidera sehingga terjadi penyembuhan. Sebagian besar
fraktur dislab untuk 24-48 pertama untuk mengakomodasi
pembengkakan, sebelum dipasang gips sirkuler.
Lempengan Gips/CAST Dapat Digunakan Pada
Imobilisasi Fraktur
Imobilisasi pada penyakit tulang dan sendi
Pencegahan deformitas muskuloskeletal
* Aryadi K, Syaiful AH. Penggunaan Gips Paris. In: Petunjuk pemasangan gips paris pada kasus orthopaedi, Divisi Orthopaedi dan
traumatologi, 2006. hal 2-6

GIPS/CAST

Supracondylar Fracture of Humerus

Arm Sling

Open Reduction To Prevent


Brachial Artery Injury!

U Slab
Humeral shaft
fracture

Volar Slab

Compartment Syndrome
6 P of Compartment
Syndrome

Pain
Pallor
Pulseless
Paresthesis
Paralysis
Pressure

Tx : Fasciotomy

Compartment Syndrome

Fasciotomy

Casts and tight


bandages
remove or
loosen any
constricting
bandages

Muscle of Calf

Artery of Calf

Pagets Disease
Paget disease is a localized disorder of bone
remodeling that typically begins with
excessive bone resorption followed by an
increase in bone formation. This osteoclastic
overactivity followed by compensatory
osteoblastic activity leads to a structurally
disorganized mosaic of bone (woven bone),
which is mechanically weaker, larger, less
compact, more vascular, and more susceptible
to fracture than normal adult lamellar bone.

Sign and Sympton including the following:


Bone pain (the most common symptom)
Secondary osteoarthritis (when Paget disease
occurs around a joint)
Bony deformity (most commonly bowing of an
extremity)
Excessive warmth (due to hypervascularity)
Neurologic complications (caused by the
compression of neural tissues)

Skull involvement may lead to the following:


Deafness
Vertigo
Tinnitus
Dental malocclusion
Basilar invagination
Cranial nerve disorders

Multiple Myeloma
Sign : bone pain
X-ray
punched out lession

Multiple Myeloma
Symptomatic myeloma:
Clonal plasma cells >10% on bone marrow biopsy or (in
any quantity) in a biopsy from other tissues
(plasmacytoma)
A monoclonal protein (paraprotein) in either serum or
urine (except in cases of true non-secretory myeloma)
Evidence of end-organ damage felt related to the plasma
cell disorder (related organ or tissue impairment, ROTI,
commonly referred to by the acronym "CRAB"):

HyperCalcemia (corrected calcium >2.75 mmol/L)


Renal insufficiency attributable to myeloma
Anemia (hemoglobin <10 g/dL)
Bone lesions (lytic lesions or osteoporosis with compression
fractures)

Asymptomatic (smoldering) myeloma:


Serum paraprotein >30 g/L AND/OR
Clonal plasma cells >10% on bone marrow biopsy AND
NO myeloma-related organ or tissue impairment

Monoclonal gammopathy of undetermined


significance (MGUS):
Serum paraprotein <30 g/L AND
Clonal plasma cells <10% on bone marrow biopsy AND
NO myeloma-related organ or tissue impairment

Osteomyelitis
Inflammation of the bone and bone marrow
caused by an infecting organism.
Although bone is normally resistant to bacterial
colonization, events such as trauma, surgery,
presence of foreign bodies, or prostheses may
disrupt bony integrity and lead to the onset of
bone infection
Pathogenesis (Waldvogel, 1971) :
1.
2.
3.

Hematogenous
Contiguous focus of infection
Direct inoculation

Osteomyelitis
Osteomyelitis is often diagnosed clinically with nonspecific
symptoms
fever,
chills,
fatigue,
lethargy,
irritability.
The classic signs of inflammation, including local pain,
swelling, or redness, may also occur and normally disappear
within 5-7 days

Osteomyelitis
S aureus is the most common pathogenic
organism recovered from bone, followed
by Pseudomonas and Enterobacteriaceae.
Less-common organisms involved include
anaerobe gram-negative bacilli.
Intravenous drug users may acquire
pseudomonal infections
Acute hematogenous osteomyelitis has a
predilection for the long bones of the body.
The ends of the bone near the growth
plate (the metaphysis) is made of a maze
like bone called cancellous bone.
It is here in the rapidly growing metaphysis
that osteomyelitis often develops

Supracondylar Fracture
Outstretched arm
>> children

Elbow Dislocation
Elbow dislocations are not common
Falls onto an outstretched hand, usually there is a
turning motion in this force drive and rotate
the elbow out of its socket
Elbow dislocations can also happen in car
accidents
The elbow is stable because of the combined
stabilizing effects of bone surfaces, ligaments,
and muscles. When an elbow dislocates, any or
all of these structures can be injured to different
degrees.

Osteoporosis
A systemic skeletal disease characterized
by low bone mass and micro architectural
deterioration of bone tissue lead to bone
fragility and susceptibility to fracture

Densitometri Osteoporosis
World Health Organization Definitions Based on Bone Density Levels

Level

Definition

Normal

Bone density is within 1 SD (+1 or 1) of the young adult mean.

Low bone mass

Bone density is between 1 and 2.5 SD below the young adult


mean (1 to 2.5 SD).

Osteoporosis

Bone density is 2.5 SD or more below the young adult mean


(2.5 SD or lower).

Severe
(established)
osteoporosis

Bone density is more than 2.5 SD below the young adult mean,
and there have been one or more osteoporotic fractures.

Incidence of osteoporotic Fx

Forearm
Fracture

Vertebral
Fracture

Hip
Fracture

Osteoporosis

ATLS

Shoulder Dislocation

Anterior Shoulder
Subluxation/Dislocation
Radiographs:

Axillary View

True AP

Y view

Anterior Shoulder Subluxation/Dislocation


Dislocation:
Complete separation of articular
surfaces

Subluxation:
Abnormal translation of humeral
head on glenoid without
complete separation of articular
surfaces

Humeral head can dislocate


anteriorly, posteriorly or
inferiorly
Anterior dislocation most
common

Mechanism:
Forced extension, abduction,
external rotation
Direct blow to posterior or
posterolateral shoulder
Repeated episodes of overuse
(subluxation)

Physical Exam:
Intense pain
Arm held in adduction & external
rotation
Humeral head palpable anteriorly
Unable to completely internally
rotate or abduct the shoulder
Thorough neuro exam (close
relation of axillary nerve)

Hip Dislocation
Posterior
(flexi, adduksi, endorotasi)

Anterior

(flexi, abduksi, exorotasi)

Osteosarcoma
X-rays of area of suspected infection would
not demonstrate darkened areas typical of
osteomyelitis.
Conventional features
Destruction of normal trabecular bone pattern
a mixture of radiodense and radiolucent areas
periosteal new bone formation
formation of Codman's triangle (triangular
elevation of periosteum)

No osteoblastic appearance,
fracture can be seen

Notice the osteoblasticosteolytic appearance

Codman triangles (white


arrow); and the large soft
tissue mass (black arrow)

Osteosarcoma of the distal femur,


demonstating dense tumor bone formation
and a sunburst pattern of periosteal reaction.

Periosteal reactions

onion-skin
(Ewings sarkoma)

"sunburst" and "hair-onend" periosteal reaction

Codman's triangle

Radiographs of the primary


tumor usually show a large,
destructive, mixed lytic and
blastic mass. The tumor
frequently breaks through the
cortex and lifts the periosteum,
resulting in reactive periosteal
bone formation. The triangular
shadow between the cortex
and raised ends of periosteum
is known radiographically as
Codman triangle and is
characteristic, but not
diagnostic of this tumor.

The Canadian Journal of Diagnosis / May 2001

Ewings Sarkoma
Annual
incidence at
birth to 20 y.o
(teenagers and
young adult)
Most common
site : pelvis
Radiologic :
onion peel

Ewings Sarkoma

Acute Achilles Tendon Rupture


Adults 40-50 y.o.
primarily affected (M>F)
Athletic activities,
usually with sudden
starting or stopping
Snap in heel with pain,
which may subside
quickly

Acute Achilles
Tendon Rupture
Diagnosis

Weakness in plantar flexion


Gap in tendon
Palpable swelling
Positive Thompson test

Open Fracture

Vertebral Fracture

ONCOLOGIC SURGERY

The Breast
Tumors

Onset

Feature

Breast cancer

30-menopause

Invasive Ductal Carcinoma , Pagets disease (Ca Insitu),


Peau dorange , hard, Painful, not clear border,
infiltrative, discharge/blood, Retraction of the
nipple,Axillary mass

Fibroadenoma
mammae

< 30 years

They are solid, round, rubbery lumps that move freely in


the breast when pushed upon and are usually painless.

Fibrocystic
mammae

20 to 40 years

lumps in both breasts that. increase in size and


tenderness just prior to menstrual bleeding. occasionally
have nipple discharge

Mastitis

18-50 years

Localized breast erythema, warmth, and pain. May be


lactating and may have recently missed feedings.fever.

Philloides
Tumors

30-55 years

intralobular stroma . leaf-likeconfiguration.Firm,


smooth-sided, bumpy (not spiky). Breast skin over the
tumor may become reddish and warm to the touch.
Grow fast.

Duct Papilloma

45-50 years

occurs mainly in large ducts, present with a serous or


bloody nipple discharge , mass ussually small, not always
palpable

Benign Breast Lumps

Breast Cancer

Biopsy
Excisional or incisional biopsy
In this type of biopsy, a surgeon cuts through the skin to remove the entire tumor
(called an excisional biopsy) or a small part of a large tumor (called an incisional
biopsy).

Enucleation
surgical removal of a mass without cutting into or dissecting it. Eg: eye, oral pathology,
uterine fibroids (without hysterectomy)

FNA
does not require an incision

Core biopsy
uses needles that are slightly larger than those used in FNA
Local anasthesia
Sometimes uses a special vacuum tools to get larger core biopsies from breast tissue

Epidermoid Cyst
Benign cyst underneath
skin that arise with
ruptured pilosebaceous
follicle
Associated with trauma
(piercing-needle)
Common location :
auricular lobe, plantar

Demoid Cyst
An abnormal growth
(teratoma) containing
epidermis, hair follicles,
and sebaceous glands,
derived from residual
embryonic cells.
Common site :
Periorbital
Ovarian
Spinal

Atheroma
Cause by blockage of
the duct of
sebacceous gland
Also known as
Retention Cyst
Puncta (+)

Callus & Clavus


Callus: toughened area of
skin which has become
relatively thick and hard
in response to repeated
friction, pressure, or
other irritation.
Clavus: specially-shaped
callus of dead skin that
usually occurs on thin or
glabrous (hairless and
smooth) skin surfaces,
especially on the dorsal
surface of toes or fingers.

Diagnosis banding benjolan payudara


Mastitis

infeksi payudara dengan tanda radang lengkap, dapat


menjadi abses, terjadi pada ibu menyusui

Fibroadenoma
mammae (FAM)

tumor jinak, biasa terjadi pada usia muda (15-30


tahun), konsistensi kenyal, batas tegas, tidak nyeri, dan
mobile

Kelainan fibrokistik

tumor berbatas tidak tegas, konsistensi kenyal atau


kistik, nyeri terutama saat menjelang haid, membesar,
bilateral atau multipel.

Kistosarkoma
filoides

menyerupai FAM yang besar, bulat lonjong, batas


tegas, mobile, ukuran dapat mencapai 20-30 cm

Galaktokel

massa kistik akibat tersumbatnya duktus laktiferus


pada ibu yang baru menyusui

Mastitis and Abscess Mammae

Galactocele
Galaktokel
merupakan massa
berisi susu yang
tersumbat apada
duktus laktiferus.
Px :
Solid mass
Tanda radang (-)

TERIMA KASIH

Brief Introduction

Appendicitis
The most common
general surgical
emergency
Peak 10-30 y.o
Male > 1.3x
Obstruction: lymphoid
hyperplasia, fecalith, etc

Ileus
Peritonitis
Obstructive Ileus:
-Primary, secondary
- Inside lumen, In the - Localized,
wall, outside the wall generalized
- High level, low level

Anamnesis

Cardinal
symptoms

Appendicitis

Ileus

Peritonitis

- migrating pain
(periumbilical to
RLQ)
- nausea and
vomiting

- abdominal pain
- vomiting
- no defecation
and flatus
- meteorismus,
distension

- abdominal pain
- meteorismus
- nausea, vomiting
- no defecation
and flatus
- restlessness

Physical
Examination
Appendicitis

Ileus

Peritonitis

Physical
Examination

tenderness and
rebound
tenderness at
McBurney point
Rovsings sign
Psoas sign
Obturator sign

scar, distension, darm


contour, darm steifung
hyperperistaltic (early),
metallic sound, absence
of bowel sound (late)
diffuse tenderness,
hernia

absence of
bowel sound
loss of liver
dullness
(perforation)
shifting dullness
defans muscular

Rectal touche

tenderness

impact faeces
rectal tumour
blood or mucus
collapse of ampulla
recti (obstructive)

tenderness