FRACTURE AND

DISLOCATION

• MUHAMMAD ARETHUSA ANANTA • ELIZABETH MARGARETH

• REZA KHADAFY NUGROHO • RANI SEPTIKASARI
• HAVEZ KLEIB • CAHYONO YUDIANTO
• TEGUH SETIAWANTO • AYU VIDYA PUTRI
• ANDI KUSNAWAN
FRACTURE DEFINITION
A fracture is a break in the structural continuity of bone
• Open fracture: if the skin or one of the body cavities is
breached If the overlying skin remains intact
• Closed fracture: If the overlying skin remains intact

HOW FRACTURES OCCUR

• Injury: sudden and excessive force. May be direct or indirect.
• Stress fracture: repeated heavy loading
• Pathological fractures: weakened bone due to a change in its
structure or through a lytic lesion
TYPES OF FRACTURE
 Complete fractures
 Incomplete fractures
HOW FRACTURES ARE DISPLACED

Translation (Shift)
Angulation (tilt)
Rotation (twist)
Length – distracted and seperated
Fracture Management
Patient’s age Mechanism of injury

Symptoms : pain and swelling elsewhere

beside the main site of injury , numbness,
loss of movemenrt, skin pallor/cyanosis,
General medical history
blood in urine, abdominal pain, difficulty
with breathing or transient loss of
consciousness

History Taking
Local signs A systematic
approach is Examine the most obviously
always
helpful:
injured part.
Test for artery and nerve damage.

Look for associated injuries in the

region.
Look for associated injuries in
distant parts.
Local signs
Look : swelling, bruising, deformity, posture of the distal
extremity, and the colour of the skin

Feel : gently palpated for - localized tenderness. -the common and

characteristic associated injuries should also be felt for, even if
the patient does not complain of them. – vascular and peripheral
nerve abnormalities

Move : ask if the patient can move the joint distal to the injury
X-RAYS – The rule of twos

Two views - at least two views must be taken

Two joints – Joints above and below the fracture
must be included
Two limbs – Especially in children
Two injuries – Severe forces often causes injuries at
more than one level
Two occasions
Special Imaging
Computed Tomography (CT) : for the lesions of the spine or for
complex joint fractures

Magnetic Resonance Imaging (MRI) : the only way of showing

whether a fractured vertebra is threatening to compress the spinal
cord

Radioisotope Scanning : for suspected stress (fatigue ) fracture or

other undisplaced fractures

Ultrasound : an be used in children to diagnose fracture (imaging

fracture line or haematoma is possible).
Treatment of REDUCE

Closed HOLD
EXERCISE

Fractures
TSCHERNE CLASSIFICATION OF CLOSED FRACTURE
Grade O: • Injury from indirect forces with negligible soft tissue damage

• Closed fracture caused by low-to-moderate energy mechanisms, with

Grade I:
superficial abrasions or contusions of soft tissues overlying the fracture

• Closed fracture with significant muscle contusion, with possible deep,

Grade II: contaminated skin abrasions associated with moderate-to-severe energy
mechanisms and skeletal injury; high risk for compartment syndrome

• Extensive crushing of soft tissues, with subcutaneous degloving or

Grade III:
avulsion, and arterial disruption or established compartment syndrome
 Reduction should aim for adequate apposition and normal alignment of
the bone fragments. The greater the contact surface area between

Reduce fragments, the more likely healing is to occur .

Two types of
reduction:
- Closed Reduction Situations in which reduction is unnecessary:
- Open Reduction
when displacement when reduction is
does not matter unlikely to succeed
when there is little or
initially (e.g. in frac- (e.g. with
no displacement;
tures of the clavicle); compression fractures
and of the vertebrae).
Closed Reduction
Under appropriate anaesthesia and muscle relaxation, the
fracture is reduced by a three-fold maneuver:

• the distal part of the limb is pulled in the line of the bone;
• as the fragments disengage, they are repositioned (by reversing the
original direction of force if this can be deduced); and
• alignment is adjusted in each plane.

In general, closed reduction can be used for all minimally

displaced fractures, for most fractures in children and for
fractures that are not unstable after reduction and can be
held in some form of splint or cast .
Open Reduction

Indication :
(1) when closed reduction fails, either because of difficulty in
controlling the fragments or because soft tissues are interposed
between them;
(2) when there is a large articular fragment that needs accurate
positioning;
(3) for traction (avulsion) fractures in which the fragments are held
apart
Holding (Retaining) Reduction

1. Continuous Traction
• To maintain accurate reduction
• Traction methods include :
• Traction by gravity – this applies only to upper limb injuries.. For
comfort and stability, especially with a transverse fracture, a u-slab
of plaster may be bandaged on or, better, a removable plastic sleeve
from the axilla to just above the elbow is held on with velcro.
Holding (Retaining) Reduction

 Skin traction – Skin traction will sustain a pull of no more than 4–5
kg. Holland strapping or one- way-stretch Elastoplast is stuck to the
shaved skin and held on with a bandage. The malleoli are protected
by Gamgee tissue, and cords or tapes are used for traction.
 Skeletal traction – A stiff wire or pin is inserted – usually behind the
tibial tubercle for hip, thigh and knee injuries, or through the
calcaneum for tibial fractures – and cords tied to them for applying
trac-ion.
Holding (Retaining) Reduction
2. Cast Splintage

3. Functional Bracing

• Is one way of preventing joint stiffness while

still permitting fracture splintage and loading.
Functional bracing is commonly used in
fracture-dislocations.
Holding (Retaining) Reduction
4. Internal Fixation
• Indication :
• Fractures that cannot be reduced except by operation
• Fractures that are inherently unstable and prone to redisplace
after reduction (e.G. Midshaft fractures of the forearm and some
displaced ankle fractures) plus those fractures liable to be pulled
apart by muscle action (e.G. Transverse fracture of the patella or
olecranon)
• Pathological fractures in which bone disease may inhibit healing
• Multiple fractures where early fixation (by either internal or
external fixation) reduces the risk of general complications and
late multisystem organ failure
• Fractures in patients who present nursing difficulties (e.G.
Paraplegics, those with multiple injuries and the very elderly).
Holding (Retaining) Reduction

5. External Fixation
• Indication :
• Fractures associated with severe soft-tissue dam- age
(including open fractures) or those that are contaminated,
where internal fixation is risky and repeated access is
needed for wound inspection, dressing or plastic surgery
• Fractures around joints that are potentially suitable for
internal fixation but the soft tissues are too swollen to
allow safe surgery – a spanning external fixator provides
stability until soft-tissue conditions improve
• Patients with severe multiple injuries, especially if there
are bilateral femoral fractures, pelvic fractures with
severe bleeding, and those with limb and associated
chest or head injuries
 Indication (Cont):
 Ununited fractures, which can be excised and compressed;
sometimes this is combined with bone lengthening to replace the
excised segment
 Infected fractures, for which internal fixation might not be suitable.
 Prevention of Oedema : Persistent oedema is an important cause of
Exercise joint stiffness, especially in the hand; it should be prevented if possible,
and treated energetically if it is already present, by a combination of
elevation and exercise.

Elevation : In order to reduce swelling, the limb should be elevated to

the same level as the heart or above. The patient is allowed and
encouraged to exercise the limb actively, but not to let it dangle. When
the plaster is finally removed, a similar routine of activity, punctuated
by elevation, is practised until circulatory control is fully restored.

Active Exercise : helps to pump away oedema fluid, stimulates the

circulation, prevents soft-tissue adhesion and promotes fracture healing

Assisted Movement :to retain function or regain movement after fractures

involving the articular surfaces.

Functional Activity
Specific Method of Treatment for Closed
Fracture
1.Protection Alone (without Reduction or
Immobilization)

o Protection of a fracture from the usual forces applied to

the particular bone as well as from further injury can be
accomplished in the upper limb by means of a simple
sling and in the lower limb by relief of weightbearing
with crutches, at least for older children and adult
2. Immobilization by External
Splinting
 Only relative immobilization as opposed to rigid
fixation, in as much as some motion can still occur inside
the limb or trunk at the fracture site during early phase of
healing.
 Relative immobilization is usually achieved by the use of
plaster-of-Paris casts of varyng design and occasionally
by metallic or plastic spilnts
3. Close Reduction by
Manipulation Followed
by Immobilization
o Closed reduction of fracture
which is a form of surgical
manipulation is by far the most
common method of treatment
for majority of displaced
fracture
o Imobilization of fracture by a
plester-of-paris cast is the most
common method of maintaining
the reduction
4. Closed Reduction by Continuous
Traction Followed by Immobilization
 For fracture in young children, continuous traction can
be applied through the skin by means of extension tape.
(skin traction)
 For older children and adult best applied though
transverse rigid wire or pin. (skeletal traction)
5. Closed Reduction Followed
by Functional Fracture-Bracing
 The principle is
 Rigid mobilization of fracture fragment is not only
unnecessary but also undesirable for fracture healing
 Function and resultant controlled motion at the fracture site
actually stimulate healing
 Function prevent iatrogenic joint stiffness
 Somewhat less than perfect (anatomical) reduction of a
fracture of the shaft of long bone doesn’t create significant
problem
6. Closed Reduction by Manipulation
Followed by External Skeletal Fixation

 Two or three metal pins are inserted percutaneously

through the bone above and below the fracture site, and
held together by external bars to provide firm fixation of
the fracture
7. Closed Reduction by Manipulation
Followed by Internal Skeletal Fixation

 After accurate manipulative reduction, the reduction can

be maintained by the percutaneous insertion of metallic
nails or intramedullary rods across the fracture site
8. Open Reduction Followed by
Internal Skeletal Fixation

 Open reduction has an important place in

the treatment of uncomplicated closd
fractures, but should never be undertaken
lightly
 The fracture site is exposed surgically so
that the fracture fragments may be reduced
perfectly under direct vision
9. Excision of Fracture Fragment
and Replacement by Endoprosthesis
 For certain fractures of the hip and elbow the result of
internal fixation are relatively unsatisfactory
 Under these circumstances, the articular fragment may be
excised and replaced by suitable endoprosthesis to
provide a prosthetic joint replacement
Treatment of Open Fractures
GUSTILO-ANDERSON
CLASSIFICATION OF OPEN
FRACTURES
ATLS

Perform a careful clinical and radiographic evaluation as

outlined earlier.

Wound hemorrhage should be addressed with direct pressure

rather than limb tourniquets or blind clamping.

Initiate parenteral antibiotic Assess skin and soft tissue

damage; place a moist sterile dressing on the wound.

Perform provisional reduction of fracture and place in a

splint, brace, or traction
Antibiotic Coverage
for Open Fractures

Antibiotic Coverage for Open

Fractures
• Types I and II: First-
generation cephalosporin
• Type III: Add an
aminoglycoside.
• Farm injuries: Add penicillin
and an aminoglycoside.
Tetanus Prophylaxis
 Wound extension :: The safest extensions are to follow
Wound excision : The wound margins are
the line of fasciot- omy incisions; these avoid damaging
excised, but only enough to leave healthy skin
important per- forator vessels that can be used to raise

Debridement edges. skin flaps for eventual fracture cover

Aims to render the wound free

from foreign material and of Delivery of the fracture : The simplest (and gentlest) Removal of devitalized tissue : Devitalized tissue pro-
method is to bend the limb in the manner in which it vides a nutrient medium for bacteria.. All doubtfully
dead tissue (for example,
was forced at the moment of injury; the fracture surfaces viable tissue, whether soft or bony, should be removed.
avascular bone fragments),
will be exposed through the wound without any The fracture ends can becurette or nibbled away until
leaving a clean surgical field and
additional damage to the soft tissues seen to bleed.
tissues with a good blood supply

Wound cleansing : All foreign material and

tissue debris is removed by excision or
through a wash with copious quantities of
saline
 Wound Closure
• A small, uncontaminated wound in a type I or II fracture may be sutured (after debridement)

• In more severe injuries, immediate fracture stabilization and wound cover using split-skin grafts, local or distant flaps
are ideal

• It should be done within 48–72 hours, and not later than 5 days.

Stabilizing the Fractures

• Stabilizing the fracture is important in reducing the likelihood of infection and assisting recovery of the soft tissues.

• If there is no obvious contamination and definitive wound cover can be achieved at the time of debridement, open
fractures of all types can be treated as for a closed injury; internal or external fixation may be appropriate depending
on the individual characteristics of the fracture and wound

Aftercare
• In the ward, the limb is elevated and its circulation carefully watched.
DISLOCATION
DISLOCATION

It is complete and persistent displacement

of a joint in which at least part of the
supporting joint capsule and some of its
ligaments are disrupted.
Types of dislocation
Congenital
Acquired

1.Traumatic
2.Pathological e.g. TB hip, Septic Arthritis
3.Paralytic e.g. Poliomyelitis, cerebral palsy, etc
4.Inflammatory disorders, rheumatoid arthritis,etc
DISLOCATION

Most commonly occur in the following joints.

 Shoulder
 Hip
 Elbow
 Metacarpophalengeal joint
 Facet joint dislocation in cervical spine.
 Acromiclavicular joint dislocation.
3 derajat instabilitas sendi:
1. Occult joint instability
2. Subluxation
3. Dislocation ( luxation )
Diagnosis trauma sendi
Pemeriksaan Fisik:
Edema
Deformitas(angulasi, rotasi,
kehilangankonturnormal,
pemendekan)
Gerakan abnormal
Nyeri lokal
Radiologi:
Gambaran khas suatu subluxasi
TYPE SPESIFIK TRAUMA SENDI

1.Kontusio:
 Hemarthrosis
 X-ray normal
2.Ligamentous Sprain:
 Sprain akut, strain →peregangan ligamen dengan
robeknya ligamen komplit → perdarahan lokal →
oedema lokal → NT⊕, Nyeri waktu digerakkan
 Radiologi: normal
 Terapi: strapping / splinting
3.Dislokasi
 Reposisi secara anatomis
 Immobilisasi
 Dislokasi Posterior Sendi Siku
 MEKANISME
 Jatuh dengan posisi siku sedikit
flexi
 Hiperekstensi injury pada siku
 KLINIS :
 Bengkak, posisi semi flexi
 Olecranon teraba pada bag
posterior
 RADIOLOGI : Dislokasi
 Dislokasi Posterior Sendi Siku

 TERAPI :
 Closed Reduction
 Immobilisasi dengan cast selama 3 mgg

 KOMPLIKASI :
 Stiffness siku
 Median nerve injury
Dislokasi Sendi Bahu

Dislokasi Anterior Sendi Bahu

 Predominan pada dewasa muda
 Disebabkan karena external rotasi & extensi dari sendi bahu
 Therapy
 Reduksi secepatnya, metode:
Kocher Method
Gravitasi
Hipocrates

 Kemudian immobilisasi dengan

 Velpeau Bandage
 Dislokasi Posterior Sendi Bahu
 Lebih jarang dibanding anterior
 Dislokasi posterior terjadi karena terjatuh dan mengenai
bagian depan bahu
 Klinis:
 Lengan penderita terkunci dalam posisi adduksi & rotasi internal
 Radiologi:
 Kelainan tidak jelas, perlu pemeriksaan khusus:
Superoinferior(axillary) projection dengan bahu abduksi
untuk melihat caput humerus terletak di bagian posterior
 Therapy: Closed reduction
 Dislokasi Acromioclavicular
Joint (AC Joint)
 Penderita mengeluh nyeri bahu
 NT (+) pada AC joint
 Radiologi:Penderita berdiri
dan mengangkat beban pada
tangannya
Therapy :
 Non operatif: Kenny-Howard Sling,untuk menekan
clavicula
 Bila gagal→ORIF, capsul repair, insersi K-wire
 K-wire dicabut setelah 6 minggu
Dislokasi Panggul
Dislokasi Posterior
 Posisi flexi, adduksi dan internal rotasi
 Biasa karena terkena dashboard injury
 Extremitas jadi lebih pendek
 Nyeri (+)
Therapy:
 Reduksi Tertutup
 Metode: Bigelow dan Stimson
 Komplikasi:
 Avascular necrosis caput femur
 Sciatic nerve lesion
 Post traumatic degenerative joint disease
Dislokasi Anterior
 Jarang
 Trauma yang
menyebabkan ekstensi
panggul
 Radiologi: Caput femoris
berada di bawah
acetabulum
Therapy :
 Reduksi tertutup sesegera mungkin dengan melakukan
traksi pada femur yang fleksi, kemudian dilakukan rotasi
internal& adduksi panggul
 Dilanjutkan immobilisasi dengan Hip Spica Cast dalam
posisi flexi, adduksi, dan rotasi internal
THANK YOU