Trauma Muskuloskeletal/Extremitas

Yokhanan Muryadi
SBY Yogyakarta
 MUSCULOSKELETAL INJURIES
Sprains/Strains
 Sprain
 Injury to ligaments (bands of tissue that holds
bones in position in the joints)
 Strain
 Injury to muscles or tendons that attach muscles
to bones or to both
 May be found on x-ray as avulsion fractures those
in which a small piece of bone is pulled away from
main shaft. Seen most commonly in ankles
 Crush Injuries
 Kerusakan jaringan
lunak yang hebat
 Kerusakan seluler,
vaskuler dan saraf
 Hancurnya tulang dan
otot
 Syok hipovolemia
 Trauma Muskuloskeletal
 Sering terjadi, jarang
mengancam jiwa
 Bisa merupakan
bagian dari multi
trauma
 Ingat ABC
 Perdarahan pada trauma
muskuloskeletal
Mekanisme fisiologis tubuh :
 Mengaktifkan sistim pembekuan darah
untuk mengurangi perdarahan
 Memperbaiki integritas membran sell dan
kapiler untuk meningkatkan reabsorbsi
cairan
 Meningkatkan aliran darah kolateral untuk
merangsang penyembuhan
Cedera jaringan lunak
 Terganggunya integritas kulit  tempat
masuknya mikro organisme
 Macam kerusakan jaringan lunak :
 Abrasi
 Avulsi
 Kontusi
 Laserasi
 Puncture
Cedera Pada Sendi

Occult joint
instability

Subluksasi Dislokasi
 Fraktur Femur
 Trauma mayor
 Pada orang tua : fraktur collum femur
 Fraktur femur tertutup : 1 – 1,5 liter
 Gambaran klinis :
 Nyeri, tidak dapat menahan BB
 Deformitas : pemendekan tungkai,
exo/endorotasi
 Oedema
 Syok
 INJURY ASSESSMENT
 Initial Assessment - ABC’s
 History – SAMPLE
 Chief Complaint
 Mechanism of injury
 Onset of symptoms
 Focused Physical Assessment
 Observation
 Inspection
 Palpation
 5 P’s
9 Illinois EMSC
 INTERVENTIONS
 R - Rest/immobilize
 I - Ice
 C - Compression
 E - Elevation
 S - Support

10 Illinois EMSC
 IMMOBILIZATION/SPLINTING
KEY POINTS
 Immobilize joint above and  Minimize movement
below injury
of extremity during
 Assess neurovascular
status distal to injury prior splinting
to splint application and  Secure splint to
again right after splint
application
provide support and
 If angulation at fracture site
compression
without neurovascular  Reassess/monitor
compromise, immobilize as neurovascular status
presented
every 5-10 minutes

11 Illinois EMSC
 HIP DISLOCATION
- ORTHOPEDIC EMERGENCY!
- Biasanya disebabkan auto accident
- Paling sering bagian posterior
- HIP FLEXED AND LEG ROTATED
INTERNALLY
- Nyeri hebat TO STRAIGHTEN
 … continued
 Memerlukan intervensi bedah
 Mismanagement can cause sprain to
become strain
MUSCULOSKELETAL INJURIES
Sprains/Strains
Knowledge
• These injuries are painful with
swelling commonly present
• Usual mechanism of injury is
hyperextension of joint:twist
ankle, bend wrist or fingers
backward, twist knee
• Most common sites of Injury
Sprains/Strains : Ankle,
Elbow,Hand/fingers, Knees
Medical Management
• X-Ray
• Splint - may be used if injury
severe enough. Used more now in
place of casting to allow swelling to
go down & ROM exercises to be
done to avoid freezing of joint
• Elastic Wrap – most common
treatment
• Crutches used to prevent re-injury
& to take stress off joint
MUSCULOSKELETAL INJURIES
Sprains/Strains
Assesment
• Deformity, presence of swelling
• Sensory, motor, circulation Fx
• Pain
• Mechanism of injury
• 1st aid given – is it splinted? Has
area of injury been manipulated
since injury?
• Assume fracture until proven
otherwise
Interventions
• Assess for Fx
• Rest, ice, compression, elevation
• Application of elastic wrap
• Depending on type of splint, may
apply or assist with application Any
splint involving casting material
must be applied by MD
• Patient Education: splint
management, monitoring of
sensory, motor & circulation; crutch
walking, S/S to report.
 DISLOCATION
 Excessive stress in an abnormal direction
may produce a dislocation
 Common sites for dislocations
 Shoulder-may be a reoccurring problem,
(humeral head slips out of glenoid
cavity)
 Usually treated with closed reduction
and external immobilization
 Hip -femoral head forced from within the
acetabulum, orthopedic emergency !!
 FRACTURES
 Break in continuity of bone
 No difference between broken vs. fracture
 Always have injury to surrounding tissue
 Classified as
Complete vs. incomplete
Closed (Simple) vs. Open (Compound)
Complex
Communited
Impacted
Stress/Pathological
 SPLINTING INDICATIONS
 Prevention of  Stabilize fracture or
further injury dislocation

 Decrease pain  Relieve impaired

neurological function or
muscle spasms
 Decrease swelling
 Reduce blood and fluid
loss into tissues
18 Illinois EMSC
Klasifikasi Fraktur Gustilo,et.al. 1990
1. Derajat I : luka < 1 cm, bersih
2. Derajat II: luka > 1cm, avulsi, memar, fraktur
sederhana
3. Derajat III: trauma tumpul yang hebat, fraktur hebat
disertai kerusakan jaringan yang luas + gangguan
neurovaskular
IIIA: fragmedn tulang terbungkus jaringan lunak
IIIB  fragmen tak terbungkus jar lunak  kominutif
IIIC  terdapat trauma arteri + kerusakan jaringan
lunak hebat
 FRACTURES
All Fractures/Strain/Sprain
Assesment Interventions

• Deformity RICE
• X-Ray –human eyes R = Rest area (Limit
can’t see fracture or movement)
extent of obvious
fracture I = Ice (Not directly on skin)
C = Compression, Contain
• Pain, swelling,bruising
(Splinting)
• Sensory, motor,
circulation Fx E = Elevate (above level of
• Presence of Crepidus heart to ↓ swelling)
 Pengkajian Fracture
 Look, Feel, Move
 Radiologi
 Pengkajian neuromuskuler  P5
 P ain
 P ale
 P uls
 P araesthese
 P aralise
 Pengkajian
 Look  deformitas, luka, perdarahan
 Feel  Palpasi
 Move  don’t’n move if # sign
 Pengukuran
 Intervensi
 Splinting + spalk
 Traction  manual, continous t (closed,
open/pembedahan)
 Immobilisasi
 Femur Fractures
 DO NOT attempt to splint a fracture of femur
 May assist with splinting but requires more than
one person to splint and can do more damage to
splint
 Only splinted if failure to do so will interfere with
transport or compromise circulation distally
 Remember, splint in position found on arrival
 Get pain medicine on board fast!
 Remember that patient can bleed to death from
fractured femur
 Requires surgical intervention
Penatalaksanaan Fractur Femur
 Casting
 Splinting
 Repositions  traction, ORIF, closed
reductions
 Komplikasi
Schock
Assesment Interventions

• Tissue trauma assoc. with • Immobilisasi

fractures may rupture local • Monitor vital signs berkala
blood vessels • Check pulses distal to
• Pelvic, femur fractures can injury with vital signs
cause loss of excessive
blood
• Review s/s of schock
 Komplikasi
Fat Embolism
Assesment
• Gumpalan lemak dr
sumsum tulang ikut
sirkulasi
• menjadi embolus
• # tulang panjang
• Terjadi 24-48 jam paska #
• Pria (20-40), lansia
• S/S, respirasi, petesia di
bagian atas
Interventions
• Hati-hati menggerakan bag
fraktur
• Segera respon adanya
distres pernafasan
• Kaji suara nafas
• Fluid management of
pulmonary edema
• R/ Steroids
Kegawatan Muskuloskeletal
 Fraktur:
 Spinal
 Costa & sternum
 Pelvic
 Femur
 Dislokasi:
 Temporomandibula
 Humeroclavicula
 Hip
 Crush Syndrom  Rabdomiolisis traumatik (pd
femur & cruris)
Dislocation
 Trauma orthopedi
 Energi kinetik trauma muskuloskeletal
 Resuscitative orthopaedics” manajemen trauma
orthopedi, meliputi: assessment cepat, diagnosis,
treatment.
 Penatalaksanaan trauma orthopedi meliputi: kontrol
perdarahan, stabilisasi fraktur segera, manajemen
tissue defect
Penatalaksanaan
Sprain/ contusio RICE
Rest
Ice
Compression
 elevation
 Penatalaksanaan
Fraktur terbuka
 Evaluasi kegawatan kelangsungan hidup
 Antibiotik
 Debridemen dan irigasi
 Stabilisasi fraktur
 Penutupan luka
 rehabilitasi
Fraktur tertutup
 Hati-hati compartment syndrome! (jaringan
mati + amputasi
 Pemeriksaan neurovaskular perifer untuk
deteksi dini
 • fasciotomi
Dislokasi
 Reposisi segera
 Mobilisasi setelah 2-3 minggu
(penyembuhan jaringan lunak)