refrat rsop repaired)

31
REFRAT RSOP FRAKTUR TERBUKA Oleh: Intannuari Paringga G0006 Rizqinia Sheila Mar’ah G0007147 Yoni Frista Vendarani G0008039 Pembimbing: Iwan Budiwan Anwar, dr., Sp.OT

Upload: venda-rani

Post on 30-Aug-2014

133 views

Category:

Documents


7 download

TRANSCRIPT

Page 1: Refrat Rsop Repaired)

REFRAT RSOP

FRAKTUR TERBUKA

Oleh:

Intannuari Paringga G0006

Rizqinia Sheila Mar’ah G0007147

Yoni Frista Vendarani G0008039

Pembimbing:

Iwan Budiwan Anwar, dr., Sp.OT

KEPANITERAAN KLINIK SMF ORTHOPAEDI DAN TRAUMATOLOGI

FAKULTAS KEDOKTERAN UNS / RSOP PROF. DR. R. SOEHARSO

SURAKARTA

2012

Page 2: Refrat Rsop Repaired)

HALAMAN PENGESAHAN

Refrat ini disusun untuk memenuhi persyaratan kepaniteraan klinik Ilmu Bedah

Fakultas Kedokteran Universitas Sebelas Maret Surakarta.

Refrat dengan judul:

FRAKTUR TERBUKA

Oleh :

Intannuari Paringga G0006

Rizqinia Sheila Mar’ah G0007147

Yoni Frista Vendarani G0008039

Pembimbing

Iwan Budiwan Anwar, dr., Sp.OT

2

Page 3: Refrat Rsop Repaired)

BAB I.

PENDAHULUAN

Salah satu trauma muskuloskeletal yang menyebabkan morbiditas yang

tinggi adalah patah tulang panjang terbuka (Bedah UGM, 2009). Epidemiologi

dari patah tulang terbuka masih belum banyak diketahui. Kejadiannya bervariasi

di tempat dan institusi yang berbeda, tergantung pada kejadian kecelakaan lalu

lintas dan luka tembak. Level satu trauma center biasanya mendapatkan lebih

banyak kasus patah tulang terbuka dari pada rumah sakit kecil di daerah terpencil

(Court-Brown, McQueen, & Tornetta, 2006). Insidens patah tulang terbuka 4%

dari semua kasus patah tulang. Pada penelitian Grecco et al tahun 2002 yang

berjudul “Epidemiology of Tibial Shaft Fractures” di Brazil, mendapatkan dari

179 patah tulang pada tibia, 120-nya merupakan patah tulang terbuka. Sedangkan

penelitian yang dilakukan oleh Ibeanusi dan Ekere (2007) tentang patah tulang

tibia terbuka di rumah sakit pendidikan Universitas Port Hartcourt, di Nigeria

menemukan dari 72 pasien, 70 merupakan patah tulang terbuka.

BAB II

ISI

A. DEFINISI

Fraktur terbuka adalah putusnya kontinuitas jaringan tulang dimana terjadi

kerusakan kulit dan jaringan dibawahnya berhubungan langsung dengan

dunia luar. Compound fracture merupakan nama lain dari fraktur terbuka

namun istilah tersebut sudah tidak digunakan lagi (Koval & Zuckerman,

2006).

Cedera jaringan lunak dalam fraktur terbuka mungkin memiliki tiga

konsekuensi penting:

- Kontaminasi dari luka dan patah tulang oleh paparan lingkungan.

3

Page 4: Refrat Rsop Repaired)

- Peremukan, pengelupasan, dan devaskularisasi menyebabkan jaringan

lunak rentan terhadap infeksi.

- Kerusakan atau kehilangan jaringan lunak dapat mempengaruhi

metode imobilisasi fraktur, membahayakan kontribusi dari jaringan

lunak di atasnya untuk penyembuhan (misalnya, kontribusi sel

osteoprogenitor), dan mengakibatkan hilangnya fungsi dari otot, saraf

tendon, pembuluh darah , ligamen, atau kerusakan kulit.

B. MEKANISME

Fraktur terbuka terjadi karena suatu kekuatan yang keras. Energi kinetik

(.5 mv2) didisipasikan oleh jaringan lunak dan struktur tulang (Tabel 3.1) 

Jumlah tulang yang berpindah dan kominusi dapat menandakan tingkat

cedera dan gaya yang diterapkan.

Table 3.1. Energy transmitted by injury mechanism

Injury

Energy (Foot-

Pounds)

Fall from curb 100

Skiing injury 300–500

High-velocity gunshot wound (single missile) 2,000

20-mph bumper injury (assumes bumper strikes fixed

target)

100,000

Sumber: Bucholz et al, 2006.

C. DERAJAT

Tujuan dari sistem klasifikasi patah tulang terbuka manapun adalah

untuk mengira keadaan fraktur dan parameter penatalaksanaan (Cross and

Swiontkowski, 2008). Walau banyak sistem klasifikasi untuk patah tulang

terbuka, sistem klasifikasi Gustillo-Anderson-lah yang paling sering

digunakan di seluruh dunia. Sistem ini menilai patah tulang terbuka

berdasarkan ukuran luka, derajat kerusakan jaringan lunak dan

kontaminasi, dan derajat fraktur (Gustillo et al, 1990). Hal-hal lain yang

4

Page 5: Refrat Rsop Repaired)

juga diperhatikan antara lain adalah ada atau tidaknya kerusakan pada

saraf, energy transfer (derajat comminution dan periosteal stripping ), dan

wound dimension . Terdapat tiga macam patah tulang terbuka pada sistem

klasifikasi Gustillo-Anderson, dengan derajat yang ke tiga dibagi ke

dalam tiga subtype lagi berdasarkan kerusakan periosteal, Ada

tidaknya kontaminasi dan derajat kerusakan pembuluh darah (Gustillo et

al, 1990). Pengklasifikasian patah tulang terbuka menurut Gustillo-

Anderson adalah sebagai berikut:

1. Derajat I: Luka biasanya berupa tusukan kecil dan

bersih berukuran kurang dari 1 cm. Terdapat tulang yang

muncul dari luka tersebut. Sedikit kerusakan jaringan

lunak tanpa adanya crushing dan patah tulang tidak

kominutif. Patah tulang biasanya berupa sederhana,

melintang, atau oblik pendek. Biasanya berupa patah

tulang energi rendah.

Gambar 1: Fraktur Terbuka Gustilo-Anderson derajat 1(http://eorif.com/General/Open%20Fx%20Class.html)

2. Derajat II: Luka lebih besar dari 1 cm, tanpa adanya skin flap

ataupun avulsion. Kerusakan pada jaringan lunak tidak begitu

banyak. Kominusi dan crushing injury terjadi hanya

sedang. Juga terdapat kontaminasi sedang. Bisanya juga

berupa patah tulang energi rendah.

5

Page 6: Refrat Rsop Repaired)

Gambar 2: Fraktur Terbuka Gustilo-Anderson derajat 2(http://eorif.com/General/Open%20Fx%20Class.html)

3. Derajat III: Terdapat kerusakan yang luas pada kulit, jaringan

lunak, struktur neurovaskuler, dengan adanya kontaminasi

pada luka. Dapat juga terjadi kehilangan jaringan lunak. Luka

yang berat dengan adanya high-energy transfer ke

tulang dan jaringan lunak. Biasanya disebabkan oleh

trauma kecepatan tinggi sehingga fraktur tidak stabil

dan banyak komunisi. Amputasi traumatik, patah

tulang segemental terbuka, luka tembak kecepatan tinggi,

patah tulang terbuka lebih dari 8 jam, patah tulang terbuka

yang memerlukan perbaikan vaskuler juga termasuk dalam

derajat ini. derajat III ini dibagi lagi menjadi tiga

subtype:

a. Derajat IIIA : Tulang yang patah dapat

ditutupi oleh jaringan lunak, atau terdapat penutup

periosteal yang cukup pada tulang yang patah.

Gambar 3: Fraktur Terbuka Gustilo-Anderson derajat 3a(http://eorif.com/General/Open%20Fx%20Class.html)

6

Page 7: Refrat Rsop Repaired)

b. Derajat IIIB : Kerusakan atau kehilangan

jaringan lunak yang luas disertai dengan

pengelupasan periosteum dan komunisi yang

berat dari patahan tulang tersebut. Tulang

terekspos dengan kontaminasi yang massif.

Gambar 4: Fraktur Terbuka Gustilo-Anderson derajat 3b(http://eorif.com/General/Open%20Fx%20Class.html)

c. Derajat IIIC : Semua patah tulang terbuka

dengan kerusakan vaskuler yang perlu diberbaiki,

tanpa meilhat kerusakan jaringan lunak yang terjadi

(Apley dan Solomon, 2001 dan Gustillo et al, 1990).

Gambar 5: Fraktur Terbuka Gustilo-Anderson derajat 3c(http://eorif.com/General/Open%20Fx%20Class.html)

Klasifikasi ini menjadi sangat penting untuk menentukan

terapi. Klasifikasi ini juga menunjukkan resiko terjadinya

infeksi, dilihat dari derajat kontaminasi, derajat kerusakan 7

Page 8: Refrat Rsop Repaired)

jaringan lunak, dan tindakan operatif pada patah tulang. Resiko

infeksi semakin meningkat seiring dengan derajat yang terjadi.

Resiko terjadinya infeksi pada derajat I adalah 0-12%, pada derajat II 2-

12%, dan pada derajat III 9-55%. Derajat patah tulang terbuka ini juga

sangat erat kaitannya dengan kejadian amputasi, delayed union

dan non-union, dan kecacatan atau penurunan fungsi

ekstermitas. Penentuan derajat patah tulang terbuka secara

definitive dilakukan setelah debridement yang adekuat telah

dilakukan (Gustillo et al, 1990).

D. TATALAKSANA

1. Evaluasi Klinis

Nilai ABCDE:airway, breathing, circulation, disability, and

exposure.

Lakukan resusitasi dan penanganan cedera yang mengancam jiwa.

Evaluasi cedera dari kepala, thorak, abdomen, pelvis dan vertebra.

Identifikasi semua cedera hingga ekstremitas.

Nilai status neurovascular di sepanjang cedera.

Nilai kerusakan kulit dan jaringan lunak: eksplorasi luka dalam

keadaan darurat tidak diindikasikan jika intervensi operatif

direncanakan karena risiko kontaminasi lebih lanjut dandapat

menimbulkan perdarahan lebih lanjut.

Benda asing yang jelas mudah dibersihkan di ruang gawat

darurat dalam kondisi steril.

Irigasi luka dengan salin normal steril dapat dilakukan

dalamruang gawat darurat jika tindakan bedah ditunda.

Injeksi steril sendi dengan salin dapat dilakukan untuk

menentukan jalan keluar dari sisi luka untuk mengevaluasi

kemungkinan kontinuitas.

8

Page 9: Refrat Rsop Repaired)

Identifikasi cedera tulang; memerlukan pemeriksaan radiografi.

2. Emergency Room Management

Table 3.3. Factors that modify open fracture classification regardless of initial skin defect

Contamination

A. Exposure to soil

B. Exposure to water (pools, lakes/streams)

C. Exposure to fecal matter (barnyard)

D. Exposure to oral flora (bite)

E. Gross contamination on inspection

F. Delay in treatment >12 hours

Signs of high-energy mechanism

A. Segmental fracture

B. Bone loss

C. Compartment syndrome

D. Crush mechanism

E. Extensive degloving of subcutaneous fat and skin

F. Requires flap coverage (any size defect)

From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and

Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams &

Wilkins, 2006.

After initial trauma survey and resuscitation for life-threatening injuries (see

Chapter 2):

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.

9

Page 10: Refrat Rsop Repaired)

Initiate parenteral antibiosis (see later).

Assess skin and soft tissue damage; place a saline-soaked sterile dressing

on the wound.

Perform provisional reduction of fracture and place a splint.

Operative intervention: open fractures constitute orthopaedic emergencies,

because intervention less than 8 hours after injury has been reported to

result in a lower incidence of wound infection and osteomyelitis. In certain

centers, there has been a move to delay operating on lower-energy open

fractures in the middle of the night and to treat the injury as the first case

of the morning. The patient should undergo formal wound exploration,

irrigation, and debridement before definitive fracture fixation, with the

understanding that the wound may require multiple debridements.

Important

Do not irrigate, debride, or probe the wound in the emergency room if

immediate operative intervention is planned: this may further contaminate

the tissues and force debris deeper into the wound. If a surgical delay is

anticipated, gentle irrigation with normal saline may be performed. Only

obvious foreign bodies that are easily accessible should be removed.

Bone fragments should not be removed in the emergency room, no matter

how seemingly nonviable they may be.

Antibiotic Coverage for Open Fractures (Table 3.4)

Table 3.4. Intravenous antibiotic therapy for open fracturesa

Type

I

Type

II

Type

III

Organic

Contamination

Cefazolin, 1 g every 8 hours X X X

Aminoglycoside, 3–5 mg/kg/dayb X

Penicillin, 2,000,000 units every 4 hours

(or metronidazole, 500 mg every 6

X

10

Page 11: Refrat Rsop Repaired)

hours)aAntibiotic doses for adult patients.bVaries with renal function of patient.

From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and

Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams &

Wilkins, 2006.

Grade I, II: First-generation cephalosporin

Grade III: Add an aminoglycoside

Farm injuries: Add penicillin and an aminoglycoside

Tetanus prophylaxis should also be given in the emergency room (see later). The

current dose of toxoid is 0.5 mL regardless of age; for immune globulin, the dose

is 75 U for patients <5 years of age, 125 U for those 5 to 10 years old, and 250 U

for those >10 years old. Both shots are administered intramuscularly, each from a

different syringe and into a different site.

Requirements for Tetanus Prophylaxis

Immunization history dT TIG dT TIG

Incomplete (<3 doses) or not known + – + +

Complete/>10 years since last dose + – + –

Complete/<10 years since last dose – – –a –

Key: +, prophylaxis required; -, prophylaxis not required; dT, diphtheria and

tetanus toxoids; TIG, tetanus immune globulin; a, required if >5 years since last

dose.

3. Operative Treatment

- Irrigation and Debridement

Adequate irrigation and debridement are the most important steps in open fracture

treatment:

The wound should be extended proximally and distally to examine the

zone of injury.

11

Page 12: Refrat Rsop Repaired)

The clinical utility of intraoperative cultures has been highly debated and

remains controversial.

Meticulous debridement should be performed, starting with the skin and

subcutaneous fat (Table 3.5).

Table 3.5. Factors of muscle viability

Color Normally beefy red; rarely, carbon monoxide exposure

can be deceiving

Consistency Normally firm, not easily disrupted

Capacity to bleed Can be deceiving because arterioles in necrotic muscle

can bleed

Typically reliable

Contractility Responsive to forceps pinch or low cautery setting

Typically reliable

From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood

and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott

Williams & Wilkins, 2006.

o Large skin flaps should not be developed because this further

devitalizes tissues that receive vascular contributions from vessels

arising vertically from fascial attachments.

o A traumatic skin flap with a base-to-length ratio of 1:2 will

frequently have a devitalized tip, particularly if it is distally based.

o Tendons, unless severely damaged or contaminated, should be

preserved.

o Osseous fragments devoid of soft tissue may be discarded.

o Extension into adjacent joints mandates exploration, irrigation, and

debridement.

12

Page 13: Refrat Rsop Repaired)

The fracture surfaces should be exposed, with recreation of the injury

mechanism.

Pulsatile lavage irrigation, with or without antibiotic solution, should be

performed. Some authors have demonstrated decreased infection rates

with >10 L of irrigation under pulsatile lavage.

Meticulous hemostasis should be maintained, because blood loss may

already be significant and the generation of clot may contribute to dead

space and nonviable tissue.

Fasciotomy should be considered, especially in the forearm or leg.

Historically, it has been advocated that traumatic wounds should not be

closed. One should close the surgically extended part of the wound only.

More recently, certain centers have been closing the open wound after

debridement with close observation for signs or symptoms of sepsis.

The wound, if left open, should be dressed with saline-soaked gauze,

synthetic dressing, a vacuum assisted closure (VAC) sponge, or an

antibiotic bead pouch.

Serial debridement(s) should be performed every 24 to 48 hours as

necessary until there is no evidence of necrotic soft tissue or bone.

Foreign Bodies

Foreign bodies, especially organic ones, must be sought and removed because

they can lead to significant morbidity if they are left in the wound. (Note: Gunshot

injuries are discussed separately.)

Wood may become blood soaked and difficult to differentiate from

muscle.

Cloth and leather are usually found between tissue planes and may be

remote from the site of injury.

13

Page 14: Refrat Rsop Repaired)

The foreign material itself usually incites an inflammatory response,

whereas intrinsic crevices may harbor pathogenic organisms or spores.

Fracture Stabilization

In open fractures with extensive soft tissue injury, fracture stabilization (internal or

external fixation) provides protection from additional soft tissue injury, maximum access

for wound management, and maximum limb and patient mobilization. (See individual

chapters for specific fracture management) (Table 3.6).

Table 3.6. Relative indications for type of skeletal fixation in open fractures

External fixation

1. Severe contamination: any site

2. Periarticular fractures

A. Definitive

Distal radius

Elbow dislocation

Selected other sites

B. Temporizing

Knee

Ankle

Elbow

Wrist

Pelvis

3. Distraction osteogenesis

4. In combination with screw fixation for severe soft tissue injury

Internal fixation

14

Page 15: Refrat Rsop Repaired)

1. Periarticular fractures

A. Distal/proximal tibia

B. Distal/proximal femur

C. Distal/proximal humerus

D. Proximal ulnar radius

E. Selected distal radius/ulna

F. Acetabulum/pelvis

2. Diaphyseal fractures

A. Femur

B. Tibia

C. Humerus

D. Radius/ulna

From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and

Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams &

Wilkins, 2006.

Soft Tissue Coverage and Bone Grafting

Wound coverage is performed once there is no further evidence of

necrosis.

The type of coverage—delayed primary closure, split-thickness skin

graft, rotational or free muscle flaps—is dependent on the severity and

location of the soft tissue injury.

Bone grafting can be performed when the wound is clean, closed, and dry.

The timing of bone grafting after free flap coverage is controversial. Some

15

Page 16: Refrat Rsop Repaired)

advocate bone grafting at the time of coverage; others wait until the flap

has healed (normally 6 weeks).

Limb Salvage

Choice of limb salvage versus amputation in Gustilo Grade III injuries is

controversial. Immediate or early amputation may be indicated if:

The limb is nonviable: irreparable vascular injury, warm ischemia time >8

hours, or severe crush with minimal remaining viable tissue.

Even after revascularization the limb remains so severely damaged that

function will be less satisfactory than that afforded by a prosthesis.

The severely damaged limb may constitute a threat to the patient’s life,

especially in patients with severe, debilitating, chronic disease.

The severity of the injury would demand multiple operative procedures

and prolonged reconstruction time that is incompatible with the personal,

sociologic, and economic consequences the patient is willing to withstand.

The patient presents with an injury severity score (ISS; see Chapter 2) of

>20 in whom salvage of a marginal extremity may result in a high

metabolic cost or large necrotic/ inflammatory load that could precipitate

pulmonary or multiple organ failure.

The expected postsalvage function does not justify limb salvage.

The Mangled Extremity Severity Score (MESS) was designed to predict the

likelihood of amputation based on four criteria. A

score of >7 has been reported to predict amputation accurately in both retrospective

and prospective studies (Table 3.7).

Table 3.7. Mangled extremity severity score (MESS) for prediction of amputation

A.Skeletal/soft tissue injury Pointsa

1.Low energy (stab, simple fracture, low-velocity gunshot wound) 1

2.Medium energy (open/multiple fractures or dislocations) 2

3.High energy (close-range shotgun, high-velocity gunshot, crush) 316

Page 17: Refrat Rsop Repaired)

4.Very high energy (above plus gross contamination, soft tissue

avulsion)

4

B.Limb ischemia

1.Pulse reduced or absent but perfusion normal 1b

2.Pulseless, paresthesias, diminished capillary refill 2b

3.Cool, paralyzed, insensate, numb 3b

C.Shock

1.Systolic blood pressure always >90 mm Hg 0

2.Hypotensive transiently 1

3.Persistent hypotension 2

D.Age (Years)

1.<30 0

2.30–50 1

3.>50 2aMESS = total points.bScore doubles for ischemia >6 hours.

COMPLICATIONS

Infection: Open fractures may result in cellulitis or osteomyelitis, despite

aggressive, serial debridements, copious lavage, appropriate antibiosis,

and meticulous wound care. Gross contamination at the time of injury is

causative, although retained foreign bodies, soft tissue compromise, and

multisystem injury are risk factors for infection.

Compartment syndrome: This devastating complication results in severe

loss of function, especially in tight fascial compartments including the

forearm and leg. It may be avoided by a high index of suspicion with serial

neurovascular examinations accompanied by compartment pressure

monitoring, prompt recognition of impending compartment syndrome, and

fascial release at the time of surgery.

17

Page 18: Refrat Rsop Repaired)

18

Page 19: Refrat Rsop Repaired)

BAB III.

KESIMPULAN

19

Page 20: Refrat Rsop Repaired)

DAFTAR PUSTAKA

Apley, A.G., Nagayam S., Solomon, L., Warwick, D. (2001). Apley’s System of Orthopaedics and Fractures. :Arnold

Bedah UGM.(2009). Fraktur Terbuka. Retrieved from http://www.bedahugm.net/tag/fraktur-terbuka/ ( 3 April 2012).

Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.

Court-Brown, C. M., McQueen, M.M., Tornetta, P.(2006).Open Fractures in P. Tornetta (Eds) Trauma. Baltimore: Lipincott Williams & Wilkins.

Cross & Swiontkowski. (2008). Treatment Principles in the Management of Open Fractures. Indian Journal of Orthopaedics. 42(4). 377-386.

Gustillo, R. B., Merkow, R. L., Templeman, D.(1990).The Management of Open Fractures. The Journal of Bone and Joints Surgery.72-A(2).299-304

http://eorif.com/General/Open%20Fx%20Class.html

Ibeanusi, S.E.B. & Ekere, A.U.(2007).Epidemiology of Open Tibial fractures in a Teaching Hospital. Port Harcourt Medical Journal.1.156-160.

Koval, K.J. & Zuckerman, J. D. 2006. Handbook of Fractures, 3rd Edition. Lippincott Williams & Wilkins. Pp: 20-29.

20