Fraktur Tibia Plateu.pptx

JAGA MALAM
SPV Incharge :
dr. Liana Karliasari, SpRad(K)
SPV Advisor :
dr. Dini Rachma Erawati, SpRad(K)
Residents : dr. Han, dr. Zul, dr. Wan, dr. Son

VISI & MISI
VISI :
“Menjadi Institusi Pendidikan Dokter Spesialis Radiologi, Pelopor, Dan Pembaharu,
Dengan Reputasi Internasional Untuk Menghasilkan Lulusan Unggul Di Bidang Deteksi
Dini Penyakit Dan Komplikasinya”
MISI:
1. Menyelenggarakan Pendidikan, Penelitian, Pengabdian Kepada Masyarakat Di Bidang
Radiologi Terintegrasi Berstandar Internasional Yang Menghasilkan Lulusan Yang
Beriman Dan Bertakwa Kepada Tuhan Yang Maha Esa, Serta Memiliki Moral Dan Budi
Pekerti Yang Luhur, Mandiri, Profesional, Dan Inovatif.
2. Menyelenggarakan Program Studi Sebagai Agen Pengembang Dan Penyebar Ilmu
Radiologi Dengan Berdasar Nilai Kearifan Lokal Yang Luhur Untuk Perbaikan Kualitas
Hidup
3. Menyelenggarakan Tata Kelola Program Studi Di Perguruan Tinggi Yang Unggul,
Berkeadilan, Dan Berkelanjutan.
4. Merintis Dan Menjadi Pioner Pendidikan, Penelitian, Dan Pengabdian Masyarakat Di
Bidang Radiologi Terkini Dan Bermutu Dengan Keunggulan Bidang Deteksi Dini Penyakit

RESUME JAGA
FNK : 63 CT SCAN : 8
USG : 1
RESPONSE
TIME : 90%

IDENTITAS PASIEN
Tn. AN/
20 tahun
11577315
CF Tibia
Fibula L
Genu D AP/ Lat
Cruris D AP/ Lat
Pedis D AP/ Oblique
CTA Ekstremitas Inferior
ANAMNESIS
• Pasien datang dengan keluhan nyeri dan luka terbuka pada tungkai bawah kiri, luka
babras pada kaki kiri, disertai rasa kebas pada bagian belakang tungkai bawah dan
telapak kaki setelah tungkai bawah terjepit mesin cor.
• Riwayat pingsan (-), muntah (-), kejang (-)

PEMERIKSAAN FISIK
• GCS 456, TD : 136/ 87 mmHg, HR : 98 x/m, RR : 20x/m, SpO2 : 98%
• Lateralisasi (-)
• Status Lokalis Regio Left Lower Leg :
 L : swelling (+), rotational deformity (+), bruise (+), open wound (+) at posterolateral
side, size 2x2 cm, bone based
 F : tenderness (+), parasthesia no posterior side lower leg (+)
 M : ROM limited
• Status Lokalis Regio Left Foot :
 L : multiple vulnus abrasion (+), dorsal side, size 3 x 0,4 cm, 0,6 x 0,6 cm, 2 x 0,4 cm
with nail loss
 F : tenderness (+), parasthesia on plantar side foot (+)
 M : ROM limited
• Pulsasi a. Tibialis Posterior (-), a. Dorsalis Pedis (-)
• Saturation of all L toes (-)

Pedis S
AP/ Oblique
25-05-2023

KESIMPULAN
• Split fraktur pada medial tibial plateu melibatkan intraartiular os tibia
kiri sesuai Fraktur Tibial Plateu tipe IV (Schatzer classification)
• Fraktur avulsi head os fibula sinistra
• Fraktur oblique komplit pada 1/3 distal os tibia dan os fibula sinistra
dengan displacement dan shortening
• Tidak tampak fraktur pada radiografi pedis sinistra
• Soft tissue swelling regio genu, cruris (dengan defek), dan pedis
sinistra
• Lipohemarthrosis suprapatellar recess kiri

CTA EKSTREMITAS INFERIOR D/S
25-05-2023

Dekstra Sinistra
Kaliber ± 8 mm. Tidak tampak
stenosis/ kalsifikasi/ trombus
A. Illiaca Communis Kaliber ± 8 mm. Tidak tampak
A. Illiaca Eksterna Kaliber ± 8 mm. Tidak tampak
stenosis/ kalsifikasi/ thrombus
A. Illiaca Interna Kaliber ± 8 mm. Tidak tampak
A. Communis Femoralis Kaliber ± 8 mm. Tidak tampak
A. Superfisialis Femoralis Kaliber ± 5 mm. Tidak tampak
A. Profunda Femoralis Kaliber ± 4 mm. Tidak tampak
A. Poplitea Kaliber ± 4 mm. Tampak cut off
pada distal a. poplitea setinggi
metafisis os tibia sepanjang 3,4 cm
A. Tibialis Anterior Kaliber ± 5 mm. Tidak tampak
A. Tibialis Posterior Kaliber ± 1,5 mm. Tampak cut off
pada 1/3 tengah PTA sepanjang 10
cm. Tampak opasifikasi kontras
pada 1/3 distal PTA (mendapat dari
kolateral)
A. Peroneal Kaliber ± 2,0 mm. Tidak tampak
A. Dorsalis Kaliber ± 1,5 mm. Tidak tampak
A. Plantaris Kaliber ± 1 mm. Tidak tampak

Observasi General :
● Tampak split fraktur pada lateral
tibial plateu hingga metafisis
melibatkan intraarticular tibial
plateru sisi lateral-media pada os
tibia kiri dengan displace fragmen
fraktur ke lateral sejuah 5 mm, dan
ke inferior sejauh 9 mm
● Tampak fraktur avulsi pada head os
fibula kiri dengan displace fragmen
fraktur ke superior sejauh 6 mm

● Tampak fraktur transverse komplit pada 1/3 distal os tibia sinistra dengan
displace fragmen fraktur ke anterior sejauh 1,8 cm, dan shortening 3 cm,
disertai hematome pada m. gastrocnemius kiri dan vaskular injury
disekitarnya
● Tampak fraktur transverse komplit pada 1/3 distal os fibula sinistra dengan
displace fragmen fraktut ke posterior sejauh 2,7 cm dan shortening 2.5 cm,
dengan muskular hematome dan defek soft tissue pada distal regio cruris
kiri sisi posterior. Tidak tampak injury pada tendon achiles

• Tampak fluid collection pada suprapatelar recess kiri
membentuk gambaran triple layer densitas darah,
cairan dan densitas lemak.
• Tidak tampak injury pada ACL,PCL, MCL, LCL
• Tampak fat stranding luas dengan edema cutis subcutis
regio cruris kiri

KESIMPULAN
• Multifokal vascular injury extremities inferior sinistra regio cruris :
 Total oklusi a. poplitea sinistra sepanjang 3,4 cm
 Total oklusi pada 1/3 tengah PTA sinistra sepanjang 10 cm
 Total oklusi pada 1/3 proximal a. peroneal sepanjang 2 cm dan pada 1/3 distal a.
peroneal sinistra
• Split fraktur pada medial tibial plateu melibatkan intraartiular os tibia kiri sesuai Fraktur
Tibial Plateu tipe IV (Schatzer classification) dengan kecurigaan injury pada nervus
peroneus communis
• Fraktur oblique komplit pada 1/3 distal os tibia dan pada 1/3 distal os fibula sinistra
dengan displacement dan shortening
• Fraktur avulsi head os fibula sinistra
• Soft tissue swelling regio cruris sinistra dengan muskular hematome pada m.
gastrocnemius, m. tibialis anterior, dan defek soft tissue

Klasifikasi Schatzker membagi fraktur tibia plateau menjadi enam tipe :
• Type 1:
lateral plateau fracture tanpa depresi
• Type 2:
lateral plateau fracture dengan depresi
• Type 3:
fraktur kompresi dari tibia plateau lateral
(A) atau central (B).
• Type 4:
fraktur medial plateau
• Type 5:
fraktur bicondylar plateau
• Type 6:
fraktur plateau dengan diskontinuitas
diafisis

Type I fracture
A type I fracture is a wedge-shaped pure cleavage fracture of the lateral tibial plateau, with a
displacement or depression less than 4mm. They are caused by the lateral femoral condyle being driven
into the articular surface of the tibial plateau.

Type II
Type II is a fracture with a combined cleavage and compression of the lateral tibial plateau, a type I
fracture with a depressed component. There is a depression greater than 4mm.

Type III fracture
A Schatzker type III fracture is a pure compression fracture of the lateral tibial plateau in which the
articular surface of the tibial plateau is depressed and driven into the lateral tibial metaphysis by
axial forces.
Type III fractures are divided into two subgroups: those with lateral depression (type IIIA) and those
with central depression (type IIIB).[3]

Type IV
Type IV is a medial tibial plateau fracture with a split or depressed component. These fractures occur
as a result of varus forces combined with axial loading in a hyperflexed knee. Type IV fractures have the
worst prognosis.[3]

Type VI
Type VI is a tibial plateau fracture with a dislocation of the metaphysis from the diaphysis. This
pattern results from high-energy trauma and diverse combinations of forces.[1] [3]

► Penatalaksanaan fraktur tipe I, II, dan III berpusat
pada evaluasi dan perbaikan kartilago artikular.
► Mekanisme fraktur-dislokasi fraktur tipe IV
meningkatkan kemungkinan cedera pada saraf
peroneal atau pembuluh poplitea.
► Pada fraktur tipe V dan VI, lokasi cedera jaringan
lunak menentukan pendekatan pembedahan dan
derajat soft tissue swelling jaringan lunak
menentukan waktu operasi definitif dan kebutuhan
akan stabilisasi sementara dengan fiksator
eksternal.

Hemarthrosis
● Hemarthrosis is hemorrhage into a joint space and can be regarded as a
subtype of a joint effusion.
● Trauma is by far the most common cause of a hemarthrosis. Other
causes include bleeding disorders, anticoagulation, neurological deficits,
arthritis, tumors and vascular damage.

Injury
Synovial
vessels
rupture
Blodd
accumulates
Tamponade
of synovial
vessels
Patophysiology of hemarthrosis

Radiographic features
● Hemarthrosis displaces normal
structures, for example in an elbow,
anterior and posterior fat pads may
be elevated or visible
respectively. In the knee, there may
be anterior displacement of the
patella and quadriceps tendon. In
the shoulder, the humerus may be
inferiorly displaced, mimicking a
dislocation.
Hemarthrosis in a 40-year-old woman; standing lateral radiograph of the
right knee. Fluid density is present behind the patellar tendon and around
patella tip (arrows); note patella tilting (arrowhead) due to abundant
effusion.

Hemarthrosis and Lipohemarthrosis (illustrations)

Lipohemarthosis
results from an intra-articular fracture with escape of fat and blood from the bone
marrow into the joint, and is most frequently seen in the knee, associated with
a tibial plateau fracture or distal femoral fracture; rarely a patellar fracture. They
have also been described in hip, shoulder, elbow and wrist fractures

4
2
Lipohemarthrosis
Plain radiograph
The fat-fluid level is seen on any horizontal beam radiograph, such that the beam is tangential to
the fat-blood interface. In the knee this is best achieved with a cross-table horizontal lateral view,
where a long horizontal line is seen in the suprapatellar pouch. Ideally the patient has been lying
in that position for ~5 minutes to allow the fat and blood to adequately separate
In patients with a prominent suprapatellar plica, a double fat-fluid level may be seen
It is important to remember that up to 64% of tibial plateau fractures do not have an x-ray visible
lipohemarthrosis, but rather a simple hemarthrosis 1, thus absence of the finding does not exclude
an intra-articular fracture.
It is also important to remember that a simple hemarthrosis can separate into serum and red cells
(hematocrit effect) and create a subtle fluid-fluid level. This should not be mistaken for a
lipohemarthrosis 2. In some cases, all three layers can be seen, a so-called
lipohydrohaemathrosis. This tri-level appearance is sometimes known as parfait sign.

4
3
Lipohemarthrosis
CT and MRI
CT and MRI having much higher
sensitivity to density differences are not
only very sensitive at identifying intra-
articular fat, but also identify a hematocrit
effect, with three layers visible
(fat above, serum/synovial fluid middle,
red blood cells below)
The upper layer will follow fat on all
sequences and saturate on fat-saturated
sequences

20XX 48
Schematic diagram of the arterial
and venous anatomy of the lower
extremity showing important
related anatomic landmarks.

Radiographic features
CT
◈ Another noninvasive technique is CTA, which utilizes intravenous contrast medium
injection to opacify the arterial lumen and detect any change in the caliber.
◈ Assessment of the stenosis, occlusion and collateral circulation can be done using
multislice thin axial cuts followed by multiplanar reconstruction. Maximum intensity
projections (MIP) and volume rendering techniques (VRT) can also be used in the
assessment of the vessels.
51

CTA of Lower Extremities Protocol
▪ The patient is placed feet first and supine on the scanner table, with feet and
ankle joints in neutral position.
▪ The typical field-of-view (FOV) extends from the lower thorax (diaphragm) to
the toes, with an average scan length of 110–130 cm.
▪ A scanning protocol for peripheral CTA should always include (1) a scout
image, (2) a test bolus or bolus triggering acquisition (based on the operator’s
preference), and (3) CTA acquisition during the arterial contrast phase.
▪ A second late CTA acquisition of the distal territories may be prescribed in case
of inadequate pedal opacification during the arterial CTA.
▪ An entire peripheral CTA study may be easily performed in 10–15 minutes.

Contrast Injection
◈ Intravenous contrast medium is injected by using a power injection into an
antecubital vein (20–22 gauge cannula).
◈ The time the contrast takes to travel from the injection site to the aorta (transit
time) is variable between patients.
◈ In addition, the transit time of intravenous contrast agents traveling from the aorta
to the popliteal artery has also been shown to vary significantly between patients
in relation to the severity of atherosclerotic disease.
◈ Empirically, a contrast bolus length of at least 30 s should be used to enable all
patients to be imaged.

Contrast Injection
◈ When the bolus chase technique is employed, 100–120 ml of contrast (with an
iodine concentration between 320 and 370 mg/ml) are administered at a rate of 4
ml/s.
◈ When an automated bolus detection algorithm is used, the region of interest is set
up in the aorta immediately below the level of the diaphragm.
◈ A repetitive monitor acquisition (120kV, 10 mAs, 1 s interscan delay) is started 10
s after contrast injection begins.
◈ The actual peripheral CTA acquisition is then started when the contrast
enhancement reaches a prespecified level (typically set between 150 and 200
Hounsfield units (HU).
◈ In general, the use of 370 mg/ml contrast agents yields excellent results.

Fraktur Tibia Plateu.pptx

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