pp unstable pelvis
TRANSCRIPT
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UNSTABLE PELVISUNSTABLE PELVIS
Ahmad Salimi JauhariAhmad Salimi Jauhari
PembimbingPembimbingDr.Ismail Mariyanto,SpOTDr.Ismail Mariyanto,SpOT
PPDS-I Orthopaedi & TraumatologiPPDS-I Orthopaedi & TraumatologiFK UNS/RSDM/RSOSFK UNS/RSDM/RSOS
SurakartaSurakarta
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PendahuluanPendahuluan
Fraktur Pelvis Fraktur Pelvis 1,5% total fraktur 1,5% total fraktur Ratio Wanita : Laki-laki = 2 : 1Ratio Wanita : Laki-laki = 2 : 1 Mortalitas akibat fraktur pelvisMortalitas akibat fraktur pelvis 3% pada pasien yang MRS dengan 3% pada pasien yang MRS dengan
hemodinamik stabilhemodinamik stabil 38% pada pasien dengan 38% pada pasien dengan
hemodinamik tidak stabilhemodinamik tidak stabil
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PendahuluanPendahuluan
Fraktur dg displacement >> usia Fraktur dg displacement >> usia mudamuda
~ High Energy Trauma ~ High Energy Trauma 47% penumpang mobil47% penumpang mobil 31% pejalan kaki31% pejalan kaki 12% pengendara sepeda motor12% pengendara sepeda motor 10% pengendara sepeda10% pengendara sepeda
Mortalitas fraktur berat 10-50%Mortalitas fraktur berat 10-50%
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PelvisPelvis Stabilitas pelvis tergantung dari Stabilitas pelvis tergantung dari
integritas ligamen dan tulangintegritas ligamen dan tulang Ligamen yang terpenting dan Ligamen yang terpenting dan
terkuat adalah ligamen pada bagian terkuat adalah ligamen pada bagian posterior yaitu lig. sacroiliac dan posterior yaitu lig. sacroiliac dan iliolumbariliolumbar
Pada trauma pelvis yang tidak stabil Pada trauma pelvis yang tidak stabil dapat terjadi kehilangan darah yang dapat terjadi kehilangan darah yang sangat besar dan dapat terjadi sangat besar dan dapat terjadi komplikasi pada organ viscera pada komplikasi pada organ viscera pada rongga pelvisrongga pelvis
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AnatomiAnatomi
Pelvis Pelvis penghubung vertebra dg penghubung vertebra dg ekstremitas inferiorekstremitas inferior
Pelvic ring : sacrum & 2 tulang Pelvic ring : sacrum & 2 tulang inominatainominata– Anterior Anterior : simfisis pubis: simfisis pubis– Posterior Posterior : sacroiliac joint: sacroiliac joint
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AnatomiAnatomi
LigamentumLigamentum
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AnatomiAnatomi
LigamentumLigamentum
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Biomechanics of the Biomechanics of the Pelvic RingPelvic Ring
A stable pelvis can withstand A stable pelvis can withstand normal vertical and rotational normal vertical and rotational physiological forces. Disruption of physiological forces. Disruption of the anterior pelvic ligaments the anterior pelvic ligaments creates rotational instability , creates rotational instability , whereas posterior ligaments whereas posterior ligaments injury creates both rotational and injury creates both rotational and vertical instabilityvertical instability
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Biomechanics of the Pelvic Biomechanics of the Pelvic RingRing
FracturesFractures Pelvic fractures typically Pelvic fractures typically
occurred in patients who have occurred in patients who have suffered high-energy traumasuffered high-energy trauma
The fractures is often The fractures is often associated with other injuries associated with other injuries ( multiple trauma )( multiple trauma )
( Marvin Tile, Fractures of the Pelvic and Acetabulum, 2003 )
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Pemeriksaan FisikPemeriksaan Fisik
Nyeri panggul, pembengkakan perut Nyeri panggul, pembengkakan perut bawah, paha perineum, bawah, paha perineum, skrotum/vulvaskrotum/vulva
Prioritas : KU pasien, cari tanda-Prioritas : KU pasien, cari tanda-tanda perdarahan tanda perdarahan resusitasi !!! resusitasi !!!
Abdomen : tanda perdarahan Abdomen : tanda perdarahan intraperitonealintraperitoneal
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Pemeriksaan FisikPemeriksaan Fisik
AP Compression & Lateral CompressionAP Compression & Lateral Compression
Compression-Distraction TestCompression-Distraction Test
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Pemeriksaan FisikPemeriksaan Fisik
Rectal Toucher Rectal Toucher prostat prostat melayang,Bloody discharge melayang,Bloody discharge Ruptur Ruptur urethra?urethra? jangan pasang kateter jangan pasang kateter uretrografi retrograduretrografi retrograd
Gagal miksi/tidak teraba vesika stl Gagal miksi/tidak teraba vesika stl resusitasi cairan resusitasi cairan ruptur vesika ? ruptur vesika ?
Pemeriksaan Neurologis pleksus Pemeriksaan Neurologis pleksus lumbosakrallumbosakral
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CLINICALCLINICAL The lower extr should be examined for The lower extr should be examined for
shortening and rotational deformity. In shortening and rotational deformity. In the absence of long bone fracture, the absence of long bone fracture, shortening and ext or int rotation must shortening and ext or int rotation must be due to pelvic displacementbe due to pelvic displacement
The traction maneuver usually requires The traction maneuver usually requires two individuals, one palpating the crest two individuals, one palpating the crest and the other applying traction the and the other applying traction the limb. limb.
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Physical examinationPhysical examination
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DiagnosisDiagnosisPada setiap trauma abdomen bawah dan tungkai Pada setiap trauma abdomen bawah dan tungkai selalu pikirkan kemungkinan fraktur pelvisselalu pikirkan kemungkinan fraktur pelvis
Perhatikan mekanisme traumaPerhatikan mekanisme traumaPemeriksaan klinis :Pemeriksaan klinis :
–Jejas pada pelvis/abdomen bagian bawahJejas pada pelvis/abdomen bagian bawah–Nyeri tekan pada pelvisNyeri tekan pada pelvis–Ketidakstabilan pada perabaanKetidakstabilan pada perabaan–Perbedaan panjang kedua tungkaiPerbedaan panjang kedua tungkai–Rectal examination & darah pada mueRectal examination & darah pada mue–Hipotensi & tachycardia (bila disertai gangguan hemodinamik)Hipotensi & tachycardia (bila disertai gangguan hemodinamik)
Radiologis : foto pelvis AP, CT scanRadiologis : foto pelvis AP, CT scan
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Pemeriksaan RadiologiPemeriksaan Radiologi
AP ViewAP View Inlet viewInlet view Outlet viewOutlet view CT ScanCT Scan
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KlasifikasiKlasifikasi
Tile’s ClassificationTile’s Classification– A : StabilA : Stabil– B : Rotational unstable, B : Rotational unstable,
vertical stable vertical stable– C : Rotational & vertical C : Rotational & vertical
unstable unstable
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Klasifikasi Klasifikasi
Young-BurgessYoung-Burgess– AP CompressionAP Compression
– AP I :AP I : Diastasis simfisis < 2.5 cm atau Diastasis simfisis < 2.5 cm atau
fraktur rami vertikal dan fraktur rami vertikal dan peregangan ligamentum anterior SI.peregangan ligamentum anterior SI.
Daya kompresi rendah-sedangDaya kompresi rendah-sedang Stabil Stabil
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Klasifikasi Klasifikasi
AP CompressionAP Compression– AP II :AP II :
Diasthasis simfisis > 2.5 cm atau Diasthasis simfisis > 2.5 cm atau fraktur rami dan robekan fraktur rami dan robekan ligamentum SI, robekan ligamentum SI, robekan ligamentum sacrotuberous/ ligamentum sacrotuberous/ sacrospinoussacrospinous
High-energy “open-book”High-energy “open-book” Tidak stabilTidak stabil
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Klasifikasi Klasifikasi
AP CompressionAP Compression– AP III :AP III :
Diasthasis simfisis atau fraktur Diasthasis simfisis atau fraktur rami, robekan ligamentum SI rami, robekan ligamentum SI posterior dan anteriorposterior dan anterior
Sangat tidak stabilSangat tidak stabil High-energy traumaHigh-energy trauma, terjadi rotasi , terjadi rotasi
eksternal pelvis sampai iliac wing eksternal pelvis sampai iliac wing posterior menyentuh bagian posterior menyentuh bagian posterior sacrum, sangat berisiko posterior sacrum, sangat berisiko terjadi perdarahanterjadi perdarahan
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Klasifikasi Klasifikasi
Lateral CompressionLateral Compression– LC I :LC I :
Kompresi rami unilateral dan sacral Kompresi rami unilateral dan sacral ipsilateralipsilateral
Kompresi dari sisi lateral menekan Kompresi dari sisi lateral menekan sacrumsacrum
Biasanya stabilBiasanya stabil
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Klasifikasi Klasifikasi
Lateral CompressionLateral Compression– LC II :LC II :
Rami unilateral dan posterior iliaca Rami unilateral dan posterior iliaca ipsilateralipsilateral
Terjadi kompresi lateral terhadal Terjadi kompresi lateral terhadal iliumilium
Biasanya stabilBiasanya stabil
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Klasifikasi Klasifikasi
Lateral CompressionLateral Compression– LC III :LC III :
LC I atau II disertai APC LC I atau II disertai APC kontralateralkontralateral
Bisa menimbulkan rotasiBisa menimbulkan rotasi Tidak stabil Tidak stabil
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Klasifikasi Klasifikasi
Vertical ShearVertical Shear– Pergeseran (Pergeseran (displacementdisplacement) anterio dan ) anterio dan
posterio-vertikalposterio-vertikal– Akibat jatuh dari ketinggian atau Akibat jatuh dari ketinggian atau
kecelakaan lalu lintaskecelakaan lalu lintas– Tidak stabil Tidak stabil
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Klasifikasi Klasifikasi
ComplexComplex Kombinasi dari beberapa Kombinasi dari beberapa
trauma dan faktor kompresitrauma dan faktor kompresi Tidak stabilTidak stabil
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ManajemenManajemen
1.1. AirwayAirway
2.2. BreathingBreathing
3.3. CirculationCirculation
4.4. Perdarahan IntraabdominalPerdarahan Intraabdominal
5.5. Trauma Buli-buli atau uretraTrauma Buli-buli atau uretra
6.6. Fraktur pelvis stabil atau tidak Fraktur pelvis stabil atau tidak stabilstabil
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Angiography Angiography
Source of the Source of the bleedingbleeding
EmbolizationEmbolization Guide for Guide for
surgical surgical procedureprocedure
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Stabilisasi PelvisStabilisasi PelvisMengecilkan Mengecilkan rongga pelvis : rongga pelvis : berfungsi sebagai berfungsi sebagai tampon, tampon, mengurangi nyerimengurangi nyeri
Pelvic sling, Pelvic sling, stagenstagen
Fiksasi eksternaFiksasi eksternaFiksasi internaFiksasi interna
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C-ClampC-Clamp
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C-ClampC-Clamp
Technique : Technique : With the patients supine, palpate the With the patients supine, palpate the posterosuperior iliac spine and draw imaginary posterosuperior iliac spine and draw imaginary line between it and the anterosuperior ilac spine. line between it and the anterosuperior ilac spine. Insert the nail on this line approximately 3 – 4 Insert the nail on this line approximately 3 – 4 fingerbreadths anterolateral to the fingerbreadths anterolateral to the posterosuperior iliac spine. Don’t make the entry posterosuperior iliac spine. Don’t make the entry point too distal, to avoid the point too distal, to avoid the gluteal vessels or the gluteal vessels or the sciatic nervesciatic nerve. Advanced the pins until bone is . Advanced the pins until bone is contacted and then use a hammer to drive the contacted and then use a hammer to drive the pins approximately 1 cm into the bone.pins approximately 1 cm into the bone.Correct cranial displacement of the hemipelvis by Correct cranial displacement of the hemipelvis by placing traction on the ipsilateral leg before placing traction on the ipsilateral leg before applying compression applying compression
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Pelvic C clampPelvic C clamp
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Pelvic C clampPelvic C clamp
C clamp will compress the SI joint’s gapC clamp will compress the SI joint’s gap Apply traction before tightening the C clampApply traction before tightening the C clamp
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C clampC clamp
TractionTraction of of the afected leg first the afected leg first beforebefore tightening tightening the C clamp in vertical shearing pelvic injurythe C clamp in vertical shearing pelvic injury !!
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PenangananPenanganan
AP I : SimptomatisAP I : Simptomatis AP II : Plate / external fiksasiAP II : Plate / external fiksasi
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PenangananPenanganan
AP IIIAP III– Fiksasi Anterior : External fiksasiFiksasi Anterior : External fiksasi– Fiksasi Posterior : Percutaneus Iliac Fiksasi Posterior : Percutaneus Iliac
Screw Screw
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PenangananPenanganan
LC IILC II– Anterior : External Fiksasi / ORIFAnterior : External Fiksasi / ORIF– Posterior : ORIF lag screw dan platePosterior : ORIF lag screw dan plate
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PenangananPenanganan
LC IIILC III– Anterior : External Fiksasi / ORIFAnterior : External Fiksasi / ORIF– Posterior : Ilium : Plate dan screwPosterior : Ilium : Plate dan screw
Sacrum dg Sacrum dg displacement : displacement : percutaneus iliac screwpercutaneus iliac screw
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PenangananPenanganan
VSVS– Anterior : External Fiksasi / ORIFAnterior : External Fiksasi / ORIF– Posterior : percutaneus iliac screwPosterior : percutaneus iliac screw– Displaced comminutifDisplaced comminutif
Iliosacral screw + transiliac barIliosacral screw + transiliac bar ORIF plate ilium kontralateralORIF plate ilium kontralateral
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KomplikasiKomplikasi
InfeksiInfeksi TromboembolisTromboembolis
mm MalunionMalunion NonunionNonunion
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TERIMA KASIHTERIMA KASIH