Lecture

Soft tissue injury Vascular injury Peripheral nerve injury Spine injury

Tujuannya apa sih???

Umum: Dapat mengetahui dan mendiagnosa Memberikan informasi tentang penyakit kepada pasien dan keluarga Khusus Mengetahui tindakan yg akan diambil

Primary Survey
Airway Breathing Circulation Disability

Secondary Survey
Look:

Wound description
Feel :

Vascular disturbance???
Move: Active and passive movement

Soft Tissue Injury

Soft tissue: Muscle Tendon Ligament Vascular Nerve

Soft Tissue Injury

Strain: muscle or ligament tear Sprain: ligament tear Neuropraxia Axonotmesis Neurotmesis Compartment Syndrome

COMPARTMENT SYNDROME

COMPARTMENT SYNDROME
Definition:
Elevation of the interstitial pressure in a closed osseofascial compartment that results microvascular compromise

Compartment Syndrome
Occurs when pressure w/i soft tissues in a fixed body compartment increases to level that exceeds venous pressure, compromising venous blood flow, and limiting capillary perfusion.
Leads to muscle ischemia and necrosis. TRUE ORTHOPEDIC EMERGENCY

Compartment Syndrome
Contributing Factors External:
Conditions that reduced size of muscle compartment (casts/splints); occlusive dressing; eschar of burns

Internal:
Conditions that increase compartment volume: bleeding, swelling, fluid extravasation into tissue

Compartment Syndrome
The Five Ps Paindisproportionate to the apparent injury
Especially with passive motion or stretch of the involved muscles

ParesthesiaOccurring in the distribution of the sensory nerve traveling in the involved compartment Pallor PulselessnessNot specific; Pulses remain normal in most cases unless arterial injury has occurred ParalysisIf one waits until this sign appears, then full function rarely returns after treatment

Compartment Syndrome

CS-Recognition
Suspect with long bone fx, crush injuries Presents as pain out of proportion to physical findings, +/- hypoesthesia, pulselessness (late).

Measure intra-compartmental pressure when considering compartment syndrome

Pressures >40mmHg considered dangerous

Compartment Syndrome

Compartment Syndrome
Compartment syndrome should be suspected in long bone Fxs and Fxs associated w/ significant vascular injuries or pronounced swelling. Intra-compartment pressures must be measured once the issue of compartment syndrome is raised.

PERIPHERAL NERVE INJURY ANATOMY

Pathophysiology
Types of injury:
Traction, stretch and contusion Missiles (gunshot wounds) Compression and ischemia Thermal and electrical injuries

Pathophysiology

Pathophysiology

Seddon grade ( 1943 ) Sunderland grade ( 1951 )

Nerve Injury Classification

Seddon Sunderland Pathophysiologic Basis Neuropraxia I Local myelin damage. Axons preserved. No degeneration.

Axonotmesis

II

Endoneural tube preserved. Axon degeneration.

III

Loss of endoneural tube continuity. Perineurium intact. Axon degeneration.

IV

Endoneural tube and perineurium disrupted. Epineurium intact. Axon degeneration.

Neurotmesis

Complete loss of neural continuity.

Neuropraxia
Dysfunction and/or paralysis without loss of nerve sheath continuity and peripheral wallerian degeneration (Ristic, 2000; Schwartz, 1999).

Axonotmesis
Result of damage to the axons with preservation of the neural connective tissue sheath (endoneurium), epineurium, Schwann cell tubes, and other supporting structures (Colohan, 1996; Trumble, 2000; Grant, 1999).

Neurotmesis
Axon, myelin, and connective tissue components are damaged and disrupted or transected (Greenfield, 1997; Ristic, 2000; Schwartz, 1999). Recovery axonal regeneration ( - )

Selected Muscle Evaluation for Diagnosis of Motor Nerve Injury

I. Median nerve: intrinsic A. Thumb-palmar abduction (abductor pollicis brevis) II. Median nerve: extrinsic A. All flexor digitorum sublimi B. Flexor profundus digitorum to index C. Flexor pollicis longus D. Flexor carpi radialis III. Ulnar nerve: intrinsic A. First dorsal interosseous muscle B. Muscles of the hypothenar eminence IV. Ulnar nerve: extrinsic

A. Flexor digitorum profundus, small finger

B. Flexor carpi ulnaris

V.

Radial nerve: extrinsic

A. Wrist extension (extensor carpi radialis brevis and longus, extensor carpi ulnaris) B. Extension of fingers at metacarpophalangeal joint (extensor digitorum communis, extensor indicis proprius, extensor digiti minimi)

Sensory Evaluation for Specific Peripheral Nerve Injury

I. Median nerve -- Pulp of thumb and index finger

II.

Palmar cutaneous branch of median nerve -- Proximal palm over thenar eminence

III.

Ulnar nerve -- Pulp of small finger

IV.

Dorsal cutaneous branch of ulnar nerve -- Dorsal ulnar surface of hand

V.

Radial nerve -- Dorsal radial hand over first web space

VI.

Digital nerve -- Area of the distal phalangeal joint flexion crease

Therapeutic Management
Acute Phase
Immobilization period Post immobilization period

Recovery Phase
Motor retraining Desensitization Sensory reeducation

Chronic Phase
Surgical approach

Acute Phase
Immobilization period ( splinting period )
Goals : minimize tension at repair site protect the nerve from disruption resolution of inflammatory reaction

Acute Phase
Plaster cast or removable plastic splint Positioning : avoid tension at the repair site Monitoring pressure sores
Post immobilization period :
Increase of range of motion Enhancement of function Patient education

Post immobilization period

Increase ROM Gradually Begin from active ROM If progress slow : passive ROM exercise may begin Serial adjusted of the splint

Post immobilization period

Enhancement of function : Splinting Radial nerve palsy :simple wrist cock up splint,phoenix outriggers splint Median nerve injury : hand base splint, web space splinting Ulnar nerve injury : dorsal hand base splint

Post immobilization period

Patient education: Inform concern Simple, realistic Communication between therapist and surgeon

Recovery Phase
Motor retraining :
Control strengthening Electrical stimulation Nerve radial lesion : key exercise :wrist, finger and thumb extension Nerve median lesion : key exercise : thenar intrinsic muscle Nerve ulnar lesion : key exercise : fingers abduction and adduction.

Recovery Phase
Desensitization
Use of modalities and procedure designed to reduce the symptom of hypersensitivity 5-10 minutes, 3-4 times per day Technique :
Barbers approach texture Contac particle Vibration Massage TENS Fluid therapy

Recovery Phase
Sensory reeducation:
A method by which the patient learns to interpret the pattern of abnormal sensory impulse generated after an interruption in the peripheral nervous system Dellon : recovery : pain,vibration 30 cps,moving touch,constant touch, vibration 256 cps.

Sensory reeducation
First phase : perception vibration 30 cps , moving touch : begin sensory reeducation Second phase : moving touch,constant touch good at fingertips ,tactile recognition : texture,shape and size object

Chronic Phase
Functionally limiting residual deficit. Surgical approach:
Nerve exploration and grafting Joint fusion Tendon transfer

Tendon transfer
Low injury (wrist) High injury (elbow)

MEDIAN NERVE: Thumb Opposition (loss of FBP) (note thumb opposition is combination of flexion and adduction) 1.Ring finger FDS transfer to APB via a pulley made in the FCU tendon at the level of the pisiform. 2.MCP +/or IP joint fusion

For index and middle finger flexion FDP of index and middle finger sutured side to side to FDP of ring and little fingers, +/- ECRL tendon transfer to FDP for extra strength For flexion of IP joint of thumb -Brachioradialis transfer to FPL For thumb opposition -Extensor indices transfer to Abductor pollicis brevis

Tendon transfer
ULNAR NERVE: For Adductor pollicis and FPB (thumb opposition) 1. Absent FPB = Ring finger FDS transfer to APB via a pulley made in the FCU tendon at the level of the pisiform. 2.If FPB working and adductor not = use extensor indices transfer through interosseous membrane to adductor pollicis For loss of action of interrosei and ulnar 2 lumbricals 1.Split tendon transfers of FDS + /- EIP & EDQ, to radial dorsal extensor apparatus (tenodesis procedures) 2.Or stabilise MCP joint with Zancolli capsulodesis where the volar capsule is tightened to produce slight flexion of MCP joint (not very successful). +For loss of FCU - Use ECRL transfer for power

Tendon transfer
COMBINED MEDIAN & ULNAR NERVES: For function of the interrossei and lumbricals, to restore flexion of MCP joint and extension of IP joints - Brands ECRB graft with a plantaris graft to increase length, attached to insertion of intrinsics Thumb opposition - FDS (ring finger) via FCU pulley to EPL Thumb adduction (pinch) EIP to Adductor pollicis very difficult problem For function of the long flexors & interrossei and lumbricals, to restore flexion of MCP joint and extension of IP joints - Zancolli Capsulodesis of MCP joints, ECRL to FDP, BR to FPL, ECU (with free graft) to EPL Thumb fusions

Tendon transfer
RADIAL NERVE: (Radial wrist extensors functioning:) wrist extension Pronator Teres to ECRB MCP joint extension FCR / FCU to EDC or FDS to EDC extension and abduction of the thumb - PL rerouted to EPL If radial nerve might still recover keep EPL in continuity and bring palmaris longus upward

SPINAL INJURY

The Spine
Composed of 33 vertebrae 7 cervical 12 thoracic 5 lumbar 5 sacral + 4 coccyx (fused) Act to support the trunk and transfer muscular load
42

Spinal Injuries
>80% occur in young males Motor vehicle accidents, falls from height, gunshot wound Worrisome presentations:
pain over spine in setting of trauma loss of motor function incontinence priapism

Spinal Injuries
Additional risk factors for spinal PAIN:
Metastatic cancer Osteoporosis, rheumatic dz, steroid use (compression fracture) IV drug use (epidural abscess) Spinal hardware

Cervical Spine Injuries (CSI)

The cervical spinal column is extremely vulnerable to injury. The seven cervical vertebrae, whose specific facet joint articulations allow movement in the planes of flexion, extension, lateral bending, and rotation, have attached at the cephalic aspect the skull and its contents.

Spinal Injury
Assessment
ABCs Immobilize neck and back GCS, motor/sensory/sphincter tone exam

Imaging
Plain c-spine films (lateral only detects >85% of cervical spine injuries) CT/MRI for injuries with neuro deficits and identifiable spine fractures.

CLASSIFICATION
Compressive Flexion (CF) Vertical Compression (VC) Distractive Flexion (DF) Compression Extension (CE) Distractive Extension (DE) Lateral Flexion (LF)

TREATMENT
(1) (2)
(3) (4) (5) The goals of treatment of CSI are To realign the spine, To prevent loss of function of undamaged neurological tissue, To improve neurological recovery, To obtain and maintain spinal stability, To obtain early functional recovery

Nonoperative Treatment
Management involves treating the multiple traumas and, more specifically, treating concomitant neurologic injury The use of steroids for neurologic injury has become the standard to prevent secondary causes of spinal cord damage Doses

within 3 hours: methylprednisolone of 30 mg/kg over an hour intravenously followed by 5.4 mg/kg/h for the next 23 hours more than 3 hours but less than 8 hours postinjury, the 5.4 mg/kg/h is extended for 48 hours

Nonoperative Treatment
For a stable CSI with no compression of the neural elements, a rigid cervical brace or halo for 8 to 12 weeks usually produces a stable, painless spine without residual deformity. Stable compression fractures of the vertebral bodies and undisplaced fractures of the laminae, lateral masses, or spinous processes also can be treated with immobilization in a cervical orthosis.

Nonoperative Treatment
skeletal traction through spring-loaded Gardner-Wells tongs or a halo ring.
Unilateral facet dislocations that are reduced in traction may be immobilized in a halo vest for 8 to 12 weeks

Halo Vest Immobilization (Perry and Nickels in 1959)

Many trauma patients with unstable CSI are initially managed with cervical traction through a halo ring

 observed closely. Because subacute instability may occur despite adequate initial physical and roentgenographic examinations, a second complete evaluation should be performed within 3 weeks of injury. Serial roentgenograms weekly for the first 3, 6 weeks,and 1 year

 Complications of halo immobilization have been reported to occur in as many as 30% of patients

Operative Treatment
Unstable injuries of the CSI, with or without neurological deficit, generally require operative treatment. In most patients early open reduction and internal fixation are indicated to obtain stability and allow early functional rehabilitation.

 Cervical spine fractures may be stabilized through an anterior, posterior, or combined approach. This allows rapid mobilization of the patient in a cervical orthosis, and healing usually occurs within 8 to 12 weeks.

PITFALLS AND COMPLICATIONS

NEUROLOGIC Ascending paralysis SPINAL DEFORMITYlate instability and deformity PULMONARYAtelectasis and pneumonia GASTROINTESTINALgastrointestinal hemorrhage OPERATIVE wound infections massive hemorrhage. dysphagia, fistula formation dysphagia, fistula formation increased neurologic deficit retropulsion of a ruptured disc causing spinal cord compression nonunions 6. BRACINGskin breakdown 1. 2. 3. 4. 5.

Thoracic and Lumbosacral Fractures

The most frequent causes are:
motor vehicle accidents (45%), falls (20%), sports (15%), acts of violence (15%)

In older patients (i.e., age 75 years and older), falls account for 60% of spinal fractures Males are injured four times more frequently than females.

Introduction
A few very minor cases can be treated with bed rest and physiotherapy; 60 % of lesions can be managed with closed treatment; Only 30 % will require surgery.

Classification of Thoracolumbar Fracture

COMPRESSION FRACTURES BURST FRACTURES FLEXION-DISTRACTION FRACTURES FRACTUREDISLOCATIONS

Dennis Fracture Classification

Burst Fractures

Burst fractures, according to Denis. A

type A burst fracture (A) involves both end plates, type B (B) involves only the superior end plate. type C fracture (C) includes the inferior end plate, type D (D) injury entails rotation. type E fracture (E) is characterized by lateral wedging of the vertebral body

Flexion Distraction Fractures (Seat Belts)

Seat belt-fractures.
A: Injury to soft-tissues only. B: Bony chance fracture. C: Mixed injury.

Fractures Dislocation

Fracture dislocations.
A: Flexion-rotation. B: Shear. C: Flexion-distraction.

Three-column model of Denis. A: Anterior column. B: Middle column. C: Posterior column.

Algorithm for Treatment Thoracolumbar Fracture

The goals of treatment, operative or otherwise are:

1. Protect neural elements, restore/maintain neurological function 2. Prevent or correct segmental collapse and deformity 3. Prevent spinal instability and pain 4. Permit early ambulation and return to function 5. Restore normal spinal mechanics

Non Operative Treatment

Only 20% to 30% of spine fractures require surgery. Nonoperative management may consist
bed rest, casting, application of an orthosis, often some combination of these

Indication for Non Operative Tretment:

Non Operative Treatment

Single-column injuries (e.g., compression fracture, laminar fracture, spinous process fracture) are treated in an off-the-shelf brace that encourages normal spinal alignment and limits extreme motion More significant compression fractures may be treated in molded orthosis. Two-column injuries, including severe compression fractures, mild to moderate burst fractures, and bony Chance fractures, are too unstable to be braced but may well be reduced and maintained at bed rest or in a hyperextension cast

Surgery
Indication
1. 2. 3. 4. Greater than 50% axial compression. Greater than 20 angular deformity. Multiple contiguous fractures. Neurologic injurycomplete, incomplete, or root. 5. Three-column injuries and dislocations. 6. Patients with extensive associated injuries. 7. Greater than 50% canal compromise at L-1 and 80% compromise at L-5.

Surgery
1. Timing Still controversial. Most authors agree that in the presence of a progressive neurological deficit, emergency decompression is indicated Complete spinal cord injuries or static incomplete spinal cord injuries, some authors advocate delaying surgery for several days to allow resolution of cord edema, whereas others favor early surgical stabilization

2. DECOMPRESSION
The role of decompression also is controversial. Compression of the neural elements by retropulsed bone fragments can be relieved indirectly by the insertion of posterior instrumentation or directly by exploration of the spinal canal through a posterolateral or anterior approach.

 The indirect approach to decompression of the spinal canal generally involves insertion of posterior Instrumentation (Harrington, Edwards, Cotrell-Dubousset, or Texas Scottish Rite Hospital implants)

PITFALLS AND COMPLICATIONS

Stretch the spinal cord, causing serious neurological injury. Posterior reconstruction of severe burst fractures without restoring the anterior weight-bearing column exposes instrumentation systems to excessive cantilever-bending forces, resulting in acute pedicle screw-bending failure, or late collapse and fatigue failure. If the normal thoracolumbar lordosis is not restored at the time of surgery, the forces of weight bearing will fall anterior to the lumbar spine and pelvis, imparting an exaggerated flexion moment on the fracture and fixation construct, predisposing to instrumentation failure. Finally, failure to expose the thecal sack completelyfrom pedicle to pedicle and endplate to endplateduring an anterior decompression may result in persistent neurologic impairment.

Endoscopic Techniques for the Management of Spinal Trauma

The possibilities of endoscopic spinal surgery have been developed continuously during the past few years, today nearly all operations in spinal traumatology can be performed endoscopically.

 Endoscopic splitting of the diaphragm also made it possible to open up the upper sections of the lumbar spine that the area between the third thoracic vertebra and the third lumbar vertebra is now accessible to endoscopic surgery

Technical Requirements
1. Image Transmission
The image transmission system consists of a rigid 30 angled optic linked to a threechip camera with remote release of the digitally recorded image