Maxillofacial Fractures and LeFort Classification

CATATANCATATAN
BEDAHBEDAH
dr.Syafwan Azharidr.Syafwan Azhari
Department of General SurgeryDepartment of General Surgery
Zainoel Abidin HospitalZainoel Abidin Hospital
Banda AcehBanda Aceh

Glasgow ComaGlasgow Coma
ScaleScale
Assesment areaAssesment area
ScoreScore
Motor response (M)Motor response (M)
 Obeys commandObeys command 66
 Localizes painLocalizes pain 55
 Normal flexionNormal flexion
(withdrawal to pain)(withdrawal to pain) 44
 Abnormal flexionAbnormal flexion
(decorticate)(decorticate) 33
 Abnormal extensionAbnormal extension
(decerebrate)(decerebrate) 22
 None (flaccid)None (flaccid) 11
ScoreScore
Verbal Response (V)Verbal Response (V)
 OrientedOriented 55
 Confused conversationConfused conversation 44
 Inappropriate wordsInappropriate words 33
 Incomprehensible soundsIncomprehensible sounds 22
 NoneNone 11
ScoreScore
Eye opening (E)Eye opening (E)
 SpontaneousSpontaneous 44
 To speechTo speech 33
 To painTo pain 22
 NoneNone 11
DecorticateDecorticate
DecerebrateDecerebrate

Figure 22-17
PosturingPosturing
Abnormal extensionAbnormal extension
(decerebrate posturing)(decerebrate posturing)
Abnormal flexionAbnormal flexion
(decorticate posturing)(decorticate posturing)

PERJALANAN KLINIKPERJALANAN KLINIK
EDHEDH

STONESTONE
INFECTIONINFECTION OBSTRUCTIONOBSTRUCTION
PYONEPHROSISPYONEPHROSIS
UROSEPSISUROSEPSIS
HYDRONEPHROSISHYDRONEPHROSIS
HYDROURETERHYDROURETER
RENAL FAILURERENAL FAILURE
(Relation with location, duration and size of stone)(Relation with location, duration and size of stone)

Grade traumaGrade trauma
ginjalginjal• Grade I:Grade I:
Kontusio ginjal/hematoma perirenal.Kontusio ginjal/hematoma perirenal.
• Grade II:Grade II:
Laserasi ginjal terbatas pada korteks.Laserasi ginjal terbatas pada korteks.
• Grade III:Grade III:
Laserasi ginjal sampai pada medullaLaserasi ginjal sampai pada medulla
ginjal, mungkin terdapat trombosisginjal, mungkin terdapat trombosis
arteri segmentalis.arteri segmentalis.
• Grade IV:Grade IV:
Laserasi sampai mengenai sistemLaserasi sampai mengenai sistem
kalises ginjal.kalises ginjal.
• Grade V:Grade V:
– Avulsi pedikel ginjal, mungkinAvulsi pedikel ginjal, mungkin
terjadi trombosis arteria renalis.terjadi trombosis arteria renalis.
– Ginjal terbelah (shatered).Ginjal terbelah (shatered).

Penilaian preoperatif &Penilaian preoperatif &
diagnosisdiagnosis
Trauma Tumpul GinjalTrauma Tumpul Ginjal
HematuriaHematuria
Gross / mikroskopik dengan syokGross / mikroskopik dengan syok
Stabil:Stabil:
IVPIVP
Tidak stabil:Tidak stabil:
LaparatomiLaparatomi
eksplorasieksplorasi
AbnormalAbnormal NormalNormal
E k s p l o r a s iE k s p l o r a s i ObservasiObservasi
Hematom retroperitonealHematom retroperitoneal
Meluas / berdenyutMeluas / berdenyut
ObservasiObservasiEksplorasiEksplorasi
Tidak meluasTidak meluas
HematuriaHematuria
mikroskopikmikroskopik
tanpa syoktanpa syok
Imajing (–) Kec:Imajing (–) Kec:
Trauma penyertaTrauma penyerta
Deselerasi cepatDeselerasi cepat
Tidak informatifTidak informatif
Trauma penyertaTrauma penyerta
(-)(-) (+)(+)
ObservasiObservasi

Staging Ca buli – buliStaging Ca buli – buli

Stadium Ca buli – buliStadium Ca buli – buli
sistem TNM & menurut Marshallsistem TNM & menurut Marshall
TNMTNM MarshallMarshall UraianUraian
TisTis 00 Carsinoma in situCarsinoma in situ
TaTa 00 Tumor papilari non invasifTumor papilari non invasif
T1T1 AA Invasi submukosaInvasi submukosa
T2T2 B1B1 Invasi otot superfisialInvasi otot superfisial
T3aT3a B2B2 Invasi otot profundaInvasi otot profunda
T3bT3b CC Invasi jaringan lemak prevesikaInvasi jaringan lemak prevesika
T4T4 D1D1 Invasi ke organ sekitarInvasi ke organ sekitar
N1 – 3N1 – 3 D1D1 Matestase ke limfonudi regionalMatestase ke limfonudi regional
M1M1 D2D2 Metastase hematogenMetastase hematogen

frontal views of LeFort complex fractures I - IIIfrontal views of LeFort complex fractures I - III
lateral views of LeFort complex fractures I - IIIlateral views of LeFort complex fractures I - III

Maxillary fracture
• The LeFort IThe LeFort I, or transmaxillary fracture runs between the maxillary floor and the orbital, or transmaxillary fracture runs between the maxillary floor and the orbital
floor. It may involve the medial and lateral walls of the maxillary sinuses and invariablyfloor. It may involve the medial and lateral walls of the maxillary sinuses and invariably
involves the pterygoid processes of the sphenoid. Clinically, the floating fragment will be theinvolves the pterygoid processes of the sphenoid. Clinically, the floating fragment will be the
lower maxilla with the maxillary teeth.lower maxilla with the maxillary teeth.
• The LeFort IIThe LeFort II occurs along yet another weak zone in the face, and is sometimes called aoccurs along yet another weak zone in the face, and is sometimes called a
pyramidal fracture because of its shape. A common mechanism is a downward blow to thepyramidal fracture because of its shape. A common mechanism is a downward blow to the
nasal area.nasal area.
• The most severe of the classic LeFort fracture complexes is theThe most severe of the classic LeFort fracture complexes is the LeFort IIILeFort III. I suppose that. I suppose that
this is pretty obvious, given a three-part grading system. In this case, the large unstablethis is pretty obvious, given a three-part grading system. In this case, the large unstable
(floating) fragment is virtually the entire face! Thus, this fracture is also referred to as(floating) fragment is virtually the entire face! Thus, this fracture is also referred to as
craniofacial disassociation. This is a very severe injury, and is often associated withcraniofacial disassociation. This is a very severe injury, and is often associated with
significant injury to many of the soft tissue structures along the fracture lines. Generally,significant injury to many of the soft tissue structures along the fracture lines. Generally,
considerable force is necessary to produce this injury, and it is uncommon as an isolatedconsiderable force is necessary to produce this injury, and it is uncommon as an isolated
injury. It may also occur in association with severe skull and brain injuries.injury. It may also occur in association with severe skull and brain injuries.

Common sites ofCommon sites of
Mandibular FracturesMandibular Fractures
FractureFracture TypeType
PrevalencePrevalence
BodyBody 30 - 40 %30 - 40 %
AngleAngle 25 - 31 %25 - 31 %
CondyleCondyle 15 - 17 %15 - 17 %
SymphysisSymphysis 7 - 15 %7 - 15 %
RamusRamus 3 - 9 %3 - 9 %
AlveolarAlveolar 2 - 4 %2 - 4 %
CoronoidCoronoid
processprocess
1 - 2 %1 - 2 %

Figure 22-11
Evaluation of the NeckEvaluation of the Neck
3 zones defined by3 zones defined by
horizontal planeshorizontal planes
• Zone IZone I
– Injuries carry highestInjuries carry highest
mortality ratemortality rate
• Zone IIZone II
– Most common injuries butMost common injuries but
lower mortality rate thanlower mortality rate than
zone I injurieszone I injuries
• Zone IIIZone III
– Greatest risk of injury toGreatest risk of injury to
distal carotid artery,distal carotid artery,
salivary glands, andsalivary glands, and
pharynxpharynx

KLASIFIKASI STADIUM TNM PADAKLASIFIKASI STADIUM TNM PADA
KANKER PAYUDARAKANKER PAYUDARA

TxTx Tumor primer tdk dpt dinilaiTumor primer tdk dpt dinilai
CATATAN:CATATAN:
Ukuran T secara klinis, radiologis, dan mikroskopis adalah sama.Ukuran T secara klinis, radiologis, dan mikroskopis adalah sama.
Nilai T dalam cm, nilai paling kecil dibulatkan ke angka 0,1 cm.Nilai T dalam cm, nilai paling kecil dibulatkan ke angka 0,1 cm.
T0T0 Tdk t’dpt tumor primerTdk t’dpt tumor primer
TisTis
•Tis(DCIS)Tis(DCIS)
•Tis(LCIS)Tis(LCIS)
•Tis(paget)Tis(paget)
Karsinoma in situKarsinoma in situ
•Ductal carcinoma in situDuctal carcinoma in situ
•Lobular carcinoma in situLobular carcinoma in situ
•Penyakit Paget pd putting tanpa adanya tumorPenyakit Paget pd putting tanpa adanya tumor
CATATAN:CATATAN:
Penyakit Paget dgn adanya tumor dikelompokkan sesuai dgn ukuran tumornyaPenyakit Paget dgn adanya tumor dikelompokkan sesuai dgn ukuran tumornya
T1T1
•T1micT1mic
•T1aT1a
•T1bT1b
•T1cT1c
Tumor dgn ukuran diameterTumor dgn ukuran diameter ≤ 2 cm≤ 2 cm
•Adanya micro invasi ukuran 0,1 cm at kurangAdanya micro invasi ukuran 0,1 cm at kurang
•Tumor dgn ukuran lebih dari 0,1 cm sampai 0,5 cmTumor dgn ukuran lebih dari 0,1 cm sampai 0,5 cm
•Tumor dgn ukuran lebih dari 0,5 cm sampai 1 cmTumor dgn ukuran lebih dari 0,5 cm sampai 1 cm
•Tumor dgn ukuran lebih dari 1 cm sampai 5 cmTumor dgn ukuran lebih dari 1 cm sampai 5 cm
T2T2 Tumor dgn ukuran diameter terbesarnya lebih dari 2 cm sampai 5 cmTumor dgn ukuran diameter terbesarnya lebih dari 2 cm sampai 5 cm
T3T3 Tumor dgn ukuran diameter terbesarnya lebih dari 5 cmTumor dgn ukuran diameter terbesarnya lebih dari 5 cm
T4T4
•T4aT4a
•T4bT4b
•T4cT4c
•T4dT4d
Ukuran tumor berapapun dgn ekstensi langsung ke dinding dada atau kulitUkuran tumor berapapun dgn ekstensi langsung ke dinding dada atau kulit
•Ekstensi kedinding dada (tdk t’masuk otot pectoralis)Ekstensi kedinding dada (tdk t’masuk otot pectoralis)
•Edema (t’masuk peau d’orange), ulcerasi, nodul satelit pd kulit yg t’batas pd 1 payudaraEdema (t’masuk peau d’orange), ulcerasi, nodul satelit pd kulit yg t’batas pd 1 payudara
•Mencakup kedua hal diatasMencakup kedua hal diatas
•Mastitis karsinomatosaMastitis karsinomatosa
CATATAN:CATATAN:
Dinding dada adalah t’masuk iga, otot intercostalis dan otot serratus anterior tapi tidak t’masukDinding dada adalah t’masuk iga, otot intercostalis dan otot serratus anterior tapi tidak t’masuk
otot pectoralisotot pectoralis

NxNx KGB regional tdk dpt dinilai (telah diangkat sebelumnya)KGB regional tdk dpt dinilai (telah diangkat sebelumnya)
N0N0 Tidak terdapat metastase KGBTidak terdapat metastase KGB
N1N1 Metastase ke KGB axilla ipsilateral yg mobileMetastase ke KGB axilla ipsilateral yg mobile
N2N2
•N2aN2a
•N2bN2b
Metastase ke KGB axilla ipsilateral t’fiksir, b’konglomerasi at adanya pembesaran KGB mamariaMetastase ke KGB axilla ipsilateral t’fiksir, b’konglomerasi at adanya pembesaran KGB mamaria
interna ipsilateral (klinisinterna ipsilateral (klinis**) tanpa adanya metastase ke KGB axilla.) tanpa adanya metastase ke KGB axilla.
•Metastase pd KGB axilla t’fiksir at b’konglomerasi at melekat pd struktur lainMetastase pd KGB axilla t’fiksir at b’konglomerasi at melekat pd struktur lain
•Metastase hanya pd KBG mamaria interna ipsilateral secara klinisMetastase hanya pd KBG mamaria interna ipsilateral secara klinis** dan tdk t’dpt metastase pddan tdk t’dpt metastase pd
KGB axillaKGB axilla
N3N3
•N3aN3a
•N3bN3b
•N3cN3c
Metastase pd KGB infraklavikular ipsilateral dgn at tanpa metastase KGB axilla at klinis t’dptMetastase pd KGB infraklavikular ipsilateral dgn at tanpa metastase KGB axilla at klinis t’dpt
metastase pd KGB mamaria interna ipsilateral klinis dan metastase pd KGB axillametastase pd KGB mamaria interna ipsilateral klinis dan metastase pd KGB axilla
at metastase pd KGB supraklavikular ipsilateral dgn at tanpa metastase KGB axilla/mamariaat metastase pd KGB supraklavikular ipsilateral dgn at tanpa metastase KGB axilla/mamaria
internainterna
•Metastase ke KGB infraklavikular ipsilateralMetastase ke KGB infraklavikular ipsilateral
•Metastase ke KGB mamaria interna dan KGB axillaMetastase ke KGB mamaria interna dan KGB axilla
•Metastase ke KGB supraklavikularMetastase ke KGB supraklavikular
CATATAN:CATATAN:
*t’deteksi secara klinis : t’deteksi dgn pemeriksaan fisik at secara imaging (diluar*t’deteksi secara klinis : t’deteksi dgn pemeriksaan fisik at secara imaging (diluar
limfoscintigrafi)limfoscintigrafi)MxMx Metastase jauh belum dapat dinilaiMetastase jauh belum dapat dinilai
M0M0 Tidak terdapat metastase jauhTidak terdapat metastase jauh
M1M1 Terdapat metastase jauhTerdapat metastase jauh

GROUP STADIUM KANKER PAYUDARAGROUP STADIUM KANKER PAYUDARA
STADIUM 0STADIUM 0 TisTis N0N0 M0M0
STADIUM ISTADIUM I T1*T1* N0N0 M0M0
STADIUM IIASTADIUM IIA T0T0
T1*T1*
T2T2
N1N1
N1N1
N0N0
M0M0
M0M0
M0M0
STADIUM IIBSTADIUM IIB T2T2
T3T3
N1N1
N0N0
M0M0
M0M0
STADIUM IIIASTADIUM IIIA T0T0
T1T1
T2T2
T3T3
T3T3
N2N2
N2N2
N2N2
N1N1
N2N2
M0M0
M0M0
M0M0
M0M0
M0M0
STADIUM IIIBSTADIUM IIIB T4T4
T4T4
T4T4
N0N0
N1N1
N2N2
M0M0
M0M0
M0M0
STADIUM IIICSTADIUM IIIC Tiap TTiap T N3N3 M0M0
STADIUM IVSTADIUM IV Tiap TTiap T Tiap NTiap N M1M1

Mammogram normalMammogram normal
Usia lanjut <------------------- usia muda

MechanismMechanism
ofof
InjuryInjury

KLASIFIKASI STADIUM TNM PADA KANKER KELENJARKLASIFIKASI STADIUM TNM PADA KANKER KELENJAR
LIUR (AJCC 2002)LIUR (AJCC 2002)
TxTx Tumor primer tdk dpt dinilaiTumor primer tdk dpt dinilai
T0T0 Tdk t’dpt tumor primerTdk t’dpt tumor primer
T1T1 Tumor dgn ukuran diameterTumor dgn ukuran diameter ≤ 2 cm≤ 2 cm
Tidak ada ekstensi ekstraparenkimTidak ada ekstensi ekstraparenkim
T2T2 Tumor dgn ukuran diameter > 2 cmTumor dgn ukuran diameter > 2 cm
sampai 4 cmsampai 4 cm
Tidak ada ekstensi ekstraparenkimTidak ada ekstensi ekstraparenkim
sampai 6 cmsampai 6 cm
Atau adaAtau ada ekstensi ekstraparenkimekstensi ekstraparenkim
tanpa terlibat n.VIItanpa terlibat n.VII
Atau ada invasi ke n.VII / dasarAtau ada invasi ke n.VII / dasar
tengkoraktengkorak
NxNx KGB regional tdk dpt dinilaiKGB regional tdk dpt dinilai
N0N0 Tidak terdapat metastase KGBTidak terdapat metastase KGB
N1N1 Metastase ke KGB tunggal < 3 cmMetastase ke KGB tunggal < 3 cm
IpsilateralIpsilateral
N2N2
•N2aN2a
•N2bN2b
•N2cN2c
Metastase ke KGB tunggal / multipleMetastase ke KGB tunggal / multiple
>3 cm – 6 cm>3 cm – 6 cm
Ipsilateral / bilateral / kontralateralIpsilateral / bilateral / kontralateral
Metastase ke KGB tunggal >3 cm – 6Metastase ke KGB tunggal >3 cm – 6
cmcm
IpsilateralIpsilateral
Metastase ke KGB multipleMetastase ke KGB multiple ≥≥ 6 cm6 cm
ipsilateralipsilateral
Metastase ke KGBMetastase ke KGB ≥≥ 6 cm6 cm
bilateral / kontralateralbilateral / kontralateral
N3N3 Metastase ke KGBMetastase ke KGB >> 6 cm6 cmMxMx Metastase jauh belum dapat dinilaiMetastase jauh belum dapat dinilai
M0M0 Tidak terdapat metastase jauhTidak terdapat metastase jauh
M1M1 Terdapat metastase jauhTerdapat metastase jauh

GROUP STADIUM KANKER KELENJAR LIURGROUP STADIUM KANKER KELENJAR LIUR
STADIUM ISTADIUM I T1T1
T2T2
N0N0
N0N0
M0M0
M0M0
STADIUM IISTADIUM II T3T3 N0N0 M0M0
STADIUM IIISTADIUM III T1T1
T2T2
N1N1
N1N1
M0M0
M0M0
STADIUM IVSTADIUM IV T4T4
T3T3
T4T4
Tiap TTiap T
Tiap TTiap T
Tiap TTiap T
N0N0
N1N1
N1N1
N2N2
N3N3
Tiap NTiap N
M0M0
M0M0
M0M0
M0M0
M0M0
M1M1

Lymph node stationsLymph node stations
1 = jugular chain1 = jugular chain
2 = spinal chain2 = spinal chain
3 = supraclavicular chain3 = supraclavicular chain
4 = occipital lymph nodes4 = occipital lymph nodes
5 = mastoid lymph nodes5 = mastoid lymph nodes
6 = parotid lymph nodes6 = parotid lymph nodes
7 = submandibular lymph nodes7 = submandibular lymph nodes
8 = submental lymph nodes8 = submental lymph nodes
9 = retropharyngeal lymph nodes9 = retropharyngeal lymph nodes
10 = recurrent lymph nodes10 = recurrent lymph nodes
11 = pretracheal lymph nodes11 = pretracheal lymph nodes
12 = prethyroidean lymph nodes12 = prethyroidean lymph nodes

Superficial surgical trianglesSuperficial surgical triangles
m = mandiblem = mandible
c = claviclec = clavicle
i = hyoid bonei = hyoid bone
1 = angle of mandible1 = angle of mandible
2 = posterior belly of digastric muscle2 = posterior belly of digastric muscle
3 = hyoglossus muscle3 = hyoglossus muscle
4 = mylohyoid muscle4 = mylohyoid muscle
5 = anterior belly of digastric muscle5 = anterior belly of digastric muscle
6 = sternocleidomastoid muscle6 = sternocleidomastoid muscle
7 = superior belly of omohyoid muscle7 = superior belly of omohyoid muscle
8 = sternohyoid muscle8 = sternohyoid muscle
9 = trapezius muscle9 = trapezius muscle
10 = inferior belly of omohyoid muscle10 = inferior belly of omohyoid muscle

PembagianPembagian
ZonaZona
RetroperitoneRetroperitone
alal
Clasification
de Kuds y Sheldon 1982.
 Zona I (central)
 Zona II (lateral)
 Zona III (pelvic)

Schematic lateralSchematic lateral
view of the cervical spineview of the cervical spine
Note the odontoid (dens),Note the odontoid (dens),
the predental space and thethe predental space and the
spinal canal.spinal canal.
 A=anterior spinal line.A=anterior spinal line.
 B=posterior spinal line.B=posterior spinal line.
 C=spinolaminar line.C=spinolaminar line.
 D=clivus base line.D=clivus base line.

RetroperitonealRetroperitoneal
hematomahematoma
• Zone 1:Zone 1:
Explore regardless ofExplore regardless of
mechanism.mechanism.
• Zone 2:Zone 2:
Explore penetrating trauma.Explore penetrating trauma.
Observe blunt trauma:Observe blunt trauma:
non expandingnon expanding
non pulsatilenon pulsatile
no urologic indicationsno urologic indications
•Zone 3:Zone 3:
Explore penetrating.Explore penetrating.
Observe blunt.Observe blunt.

Systemic inflammatory resposeSystemic inflammatory respose
syndromesyndrome
SIRSSIRS
Two or more ofTwo or more of
1.Temperature >38 C or <36 C1.Temperature >38 C or <36 C
2.Tachycardia >90/min2.Tachycardia >90/min
3.RR >20/min or PaCO2 ,4.3kPa3.RR >20/min or PaCO2 ,4.3kPa
4.WBC>12X10 or < 4X10 or 10% immature form4.WBC>12X10 or < 4X10 or 10% immature form
SepsisSepsis SIRS due to infectionSIRS due to infection
Severe sepsisSevere sepsis Sepsis with evidence of organ hypoperfusionSepsis with evidence of organ hypoperfusion
Septic shockSeptic shock
Severe sepsis with hypotension (SBP,90) despiteSevere sepsis with hypotension (SBP,90) despite
adequate fluid resuscitation or the requirementadequate fluid resuscitation or the requirement
for vasopressors/inotropes to maintain bloodfor vasopressors/inotropes to maintain blood
pressurepressure

Metabolisme pigmen empedu danMetabolisme pigmen empedu dan
proses eksresinyaproses eksresinyaHaemoglobinHaemoglobin
FerumFerum Cincin porfirinCincin porfirin
Bilirubin – GlobinBilirubin – Globin
(larut lemak/nonkonyugasi)(larut lemak/nonkonyugasi)
BilirubinBilirubin
(larut air/terkonyugasi)(larut air/terkonyugasi)
UrobilinogenUrobilinogen
StarkobilinStarkobilin
FecesFeces
BilirubinBilirubin
(sistemik)(sistemik)
BilirubinBilirubin
(urin)(urin)
UrobilinogenUrobilinogen
(sistemik)(sistemik)
UrobilinUrobilin
(urin)(urin)
HeparHepar
(faal?)(faal?)
EmpeduEmpedu
(obstruksi?)(obstruksi?)
LimpaLimpa
UsusUsus

An anterior view of segmental anatomy.An anterior view of segmental anatomy.
HV, hepatic vein; IVC, inferior vena cava; PV, portal vein.HV, hepatic vein; IVC, inferior vena cava; PV, portal vein.

Segmental anatomy viewed from the inferior surface.Segmental anatomy viewed from the inferior surface.

Grading of LiverGrading of Liver
InjuriesInjuries

Grading of SplenicGrading of Splenic
InjuriesInjuries

Clasifikasi fraktur pelvisClasifikasi fraktur pelvis
Clasifikasi menurut Tile
Tipe A
Stable
Tipe B
Rotationally unstable
Vertically stable
(open book type)
Tipe C
Rotationally and
Vertically Unstable

Tile ClassificationTile Classification
• Type A: StableType A: Stable
– Type A1: Fractures of the pelvis not involving the ring; avulsionType A1: Fractures of the pelvis not involving the ring; avulsion
injuries.injuries.
– Type A2: Stable, minimally displaced fractures of the ring.Type A2: Stable, minimally displaced fractures of the ring.
• Type B: Rotationally unstable, vertically stable.Type B: Rotationally unstable, vertically stable.
– Type B1: Open-book.Type B1: Open-book.
– Type B2: Lateral compression; ipsilateral.Type B2: Lateral compression; ipsilateral.
– Type B3: Lateral compression; contralateral (bucket handle).Type B3: Lateral compression; contralateral (bucket handle).
• Type C: Rotationally and vertically unstable.Type C: Rotationally and vertically unstable.
– Type C1: Unilateral.Type C1: Unilateral.
– Type C2: Bilateral; one side rotationally unstable, withType C2: Bilateral; one side rotationally unstable, with contralateralcontralateral
side vertically Unstable.side vertically Unstable.
– Type C3: Associated acetabular fracture.Type C3: Associated acetabular fracture.

Pathophysiology compartment syndromaPathophysiology compartment syndroma
InjuryInjury
Arterial injuryArterial injury
TraumaticTraumatic
InflammatoryInflammatory
ResponseResponse
HemorrhageHemorrhage
““Vicious cycle”Vicious cycle”
IschemiaIschemia
ICPICP
PerfusionPerfusionEdemaEdema

Classification of open fractureClassification of open fracture
by Gustilo - Andersonby Gustilo - Anderson

Gustilo and Anderson Classification of AllGustilo and Anderson Classification of All
Open FracturesOpen Fractures
Type IType I
• Wound less than 1cm longWound less than 1cm long
• Moderately clean puncture,Moderately clean puncture,
where spike of bone has piercedwhere spike of bone has pierced
the skinthe skin
• Little soft tissue damageLittle soft tissue damage
• No crushingNo crushing
• Fracture usually simpleFracture usually simple
transverse or oblique with littletransverse or oblique with little
comminutioncomminution
Type IIType II
• Laceration more than 1cm longLaceration more than 1cm long
• No extensive soft tissueNo extensive soft tissue
damage, flap or contusiondamage, flap or contusion
• Slight to moderate crushingSlight to moderate crushing
injuryinjury
• Moderate comminutionModerate comminution
• Moderate contaminationModerate contamination
Type IIIType III
• Extensive damage to softExtensive damage to soft
tissuestissues
• High degree of contaminationHigh degree of contamination
• Fracture caused by highFracture caused by high
velocity traumavelocity trauma
IIIA: Adequate soft tissue coverIIIA: Adequate soft tissue cover
IIIB: Inadequate soft tissueIIIB: Inadequate soft tissue
cover,a local or free flap iscover,a local or free flap is
requiredrequired
IIIC: Any fracture with an arterialIIIC: Any fracture with an arterial
injury which requiresinjury which requires
repairrepair

MM angledangled
EE xtremityxtremity
SS everityeverity
SS corecore

Applying Skeletal TractionApplying Skeletal Traction

Fracture DeformitiesFracture Deformities
A: Angulation is describedA: Angulation is described
by the direction in which theby the direction in which the
apex of the fracture isapex of the fracture is
pointing.pointing.
B: Displacement is definedB: Displacement is defined
as the position of thedistalas the position of thedistal
fragment in relation to thefragment in relation to the
proximal fragment.proximal fragment.
(Netter images reprinted with permission(Netter images reprinted with permission
from Elsevier. All rights reserved.)from Elsevier. All rights reserved.)
Valgus angulationValgus angulation Varus angulationVarus angulation Anterior angulationAnterior angulation Posterior angulationPosterior angulation
ShorteningShortening
TranslationTranslation

Fracture patternsFracture patterns
Transverse fractureTransverse fracture
Oblique fractureOblique fracture
Comminuted fractureComminuted fractureButterfly fragmentButterfly fragment
Segmental fractureSegmental fractureSpiral fractureSpiral fracture

Descriptive terms forDescriptive terms for
typical fracture patterns.typical fracture patterns.
Avulsion (greater tuberosityAvulsion (greater tuberosity
of humerus avulsed byof humerus avulsed by
supraspinatus m.)supraspinatus m.)
Greenstick fractureGreenstick fracture
Torus (buckle) fractureTorus (buckle) fracturePathologic fracturePathologic fracture
(tumor or bone disease)(tumor or bone disease)
Compression fractureCompression fracture
impresion fractureimpresion fracture
Segmental fractureSegmental fracture

Three ColumnsThree Columns
of theof the
ThoracolumbarThoracolumbar
SpineSpine

Schatzker classification of tibialSchatzker classification of tibial
plateau fractures.plateau fractures.
Schatzker Classification:Schatzker Classification:
Type I: Lateral plateau, splitType I: Lateral plateau, split
fracture.fracture.
Type II: Lateral plateau, splitType II: Lateral plateau, split
depression fracture.depression fracture.
Type III: Lateral plateau,Type III: Lateral plateau,
depression fracture.depression fracture.
Type IV: Medial plateauType IV: Medial plateau
fracture.fracture.
Type V: Bicondylar plateauType V: Bicondylar plateau
fracture.fracture.
Type VI: Plateau fractureType VI: Plateau fracture
with metaphyseal-diaphysealwith metaphyseal-diaphyseal
dissociation.dissociation.
Type IType I Type IIType II Type IIIType III
Type IVType IV Type VType V Type VIType VI

classification ofclassification of
distal femurdistal femur
fractures.fractures.
AO Classification:AO Classification:
Type A: Extra articularType A: Extra articular
• Type A1: Simple, two-partType A1: Simple, two-part
supracondylar fracturesupracondylar fracture
• Type A2: Metaphyseal wedgeType A2: Metaphyseal wedge
• Type A3: Comminuted supracondylarType A3: Comminuted supracondylar
fracturefracture
Type B: UnicondylarType B: Unicondylar
• Type B1: Lateral condyle, sagittalType B1: Lateral condyle, sagittal
• Type B2: Medial condyle, sagittalType B2: Medial condyle, sagittal
• Type B3: CoronalType B3: Coronal
Type C: BicondylarType C: Bicondylar
• Type C1: Noncomminuted supracondylarType C1: Noncomminuted supracondylar
“T” or “Y”“T” or “Y”
• fracturefracture
• Type C2: Comminuted supracondylarType C2: Comminuted supracondylar
fracturefracture
• Type C3: Comminuted supracondylar andType C3: Comminuted supracondylar and
intercondylarintercondylar
• fracturefracture

The deformity of theThe deformity of the
humeral shaft fracture ishumeral shaft fracture is
dependent on the musclesdependent on the muscles
that insert above and belowthat insert above and below
the fracturethe fracture

Fractures of the Radius
with Distal Radioulnar Subluxation
(Galeazzi)
Anteroposterior and lateralAnteroposterior and lateral
radiographs of a fracture of theradiographs of a fracture of the
radius with a distal radioulnarradius with a distal radioulnar
subluxation.subluxation.
Note the small intra-articularNote the small intra-articular
fracture from the distal ulnafracture from the distal ulna
(arrow)(arrow)..
Open reduction and internal fixationOpen reduction and internal fixation
of this fracture are essentialof this fracture are essential

Fracture of the ulna with dislocation of theFracture of the ulna with dislocation of the
proximal radioulnar joint (Monteggia fracture)proximal radioulnar joint (Monteggia fracture)
Radiograph showing a displaced fracture of the ulnaRadiograph showing a displaced fracture of the ulna
with a dislocated radial head.with a dislocated radial head.
Bado ClassificationBado Classification
• Type I: Anterior dislocation of the radialType I: Anterior dislocation of the radial
head with fracture of the ulnarhead with fracture of the ulnar
diaphysis at any level with anteriordiaphysis at any level with anterior
angulation.angulation.
• Type II: Posterior/posterolateralType II: Posterior/posterolateral
dislocation of the radial head withdislocation of the radial head with
fracture of the ulnar diaphysis withfracture of the ulnar diaphysis with
posterior angulation.posterior angulation.
• Type III: Pateral/anterolateral dislocationType III: Pateral/anterolateral dislocation
of the radial head with fractureof the radial head with fracture
of the ulnar metaphysic.of the ulnar metaphysic.
• Type IV: Anterior dislocation of the radialType IV: Anterior dislocation of the radial
head with fractures of both thehead with fractures of both the
radius and ulna within proximalradius and ulna within proximal
third at the same level.third at the same level.

Hirschsprung’s DiseaseHirschsprung’s Disease
DefinisiDefinisi
Suatu kelainan bawaan yang ditandai dengan tidakSuatu kelainan bawaan yang ditandai dengan tidak
ditemukannya sel-sel ganglion (syaraf simpatis dan paraditemukannya sel-sel ganglion (syaraf simpatis dan para
simpatis) di kedua lapisan yaitu lapisan ototsimpatis) di kedua lapisan yaitu lapisan otot
(Auerbach’s) dan submukosa (meissner’s) pada kolon(Auerbach’s) dan submukosa (meissner’s) pada kolon
sehingga menyebabkan hilangnya peristaltic padasehingga menyebabkan hilangnya peristaltic pada
segmen tersebut yang berakibat terjadinya obstruksisegmen tersebut yang berakibat terjadinya obstruksi
fungsional.fungsional.
→→ Paling sering di rectosigmoid.Paling sering di rectosigmoid.
Differensial diagnosis:Differensial diagnosis:
– Atresia Ileum.Atresia Ileum.
– Meconeum Plug Syndroma (MPS).Meconeum Plug Syndroma (MPS).
– Stenosis/Atresia Recti.Stenosis/Atresia Recti.
– N E C stadium Awal (Stadium 1 – 2a ).N E C stadium Awal (Stadium 1 – 2a ).

Tipe-tipe Hirschsprung’s DiseaseTipe-tipe Hirschsprung’s Disease
SUBCLASSIFIED ACCORDINGSUBCLASSIFIED ACCORDING
TO THE RELATIVE LENGTHTO THE RELATIVE LENGTH
OF THE AGANGLIONICOF THE AGANGLIONIC
REGION :REGION :
• SHORT –SEGMENT DISEASESHORT –SEGMENT DISEASE
(RECTO-SIGMOID ) : 75 –80 %.(RECTO-SIGMOID ) : 75 –80 %.
• LONG – SEGMENT DISEASELONG – SEGMENT DISEASE
(SPLENIC FLEXURE): 10 %.(SPLENIC FLEXURE): 10 %.
• TOTAL COLONIC – AGANGLIONIC :TOTAL COLONIC – AGANGLIONIC :
LESS 5 %.LESS 5 %.
• ULTRA SHORT – SEGMENT IS AULTRA SHORT – SEGMENT IS A
CONTROVERSIAL ENTITYCONTROVERSIAL ENTITY
(Achalasia Recti )(Achalasia Recti )

Pullthrough
(swenson’96 ; Leappe,96 ; Aschraft’00 ; fitgerald’05 ; Orvas’05)
Swenson 1
Duhamel
Swenson 2
Soave Rehbein

3 zones of the neck3 zones of the neck
Zone IZone I
From the clavicles to theFrom the clavicles to the
cricoidcricoid
Zone IIZone II
From cricoid to angle ofFrom cricoid to angle of
mandiblemandible
Zone IIIZone III
Angle of mandible to baseAngle of mandible to base
of skullof skull
• Trachea.Trachea.
• Lungs.Lungs.
• Proximal carotid andProximal carotid and
vertebral arteries.vertebral arteries.
• Jugular veins.Jugular veins.
• Thoracic Vessels.Thoracic Vessels.
• Esophagus.Esophagus.
• Superior Mediastinum.Superior Mediastinum.
• Thoracic Duct.Thoracic Duct.
• Spinal Cord.Spinal Cord.
• Brachial Plexus.Brachial Plexus.
• Trachea.Trachea.
• Larynx.Larynx.
• Carotid and vertebralCarotid and vertebral
arteries.arteries.
• Jugular Vein.Jugular Vein.
• Esophagus.Esophagus.
• Spinal Corda.Spinal Corda.
• Distal carotid andDistal carotid and
vertebral arteries.vertebral arteries.
• Pharynx.Pharynx.
• Spinal cord.Spinal cord.

Motor Function of spinal rootsMotor Function of spinal roots
UpperUpper
ExtremityExtremity
Nerve RootNerve Root MuscleMuscle MotorMotor
ExaminationExamination
C5C5 DeltoidDeltoid Shoulder abductionShoulder abduction
C6C6 BicepsBiceps Elbow flexionElbow flexion
C7C7 TricepsTriceps Elbow extensionElbow extension
C8C8 Flexor carpi ulnarisFlexor carpi ulnaris Wrist flexionWrist flexion
T1T1 LumbricalesLumbricales Finger abductionFinger abduction
LowerLower
ExtremityExtremity
L2L2 IliopsoasIliopsoas Hip flexionHip flexion
L3L3 QuadricepsQuadriceps Knee extensionKnee extension
L4L4 Tibialis anteriorTibialis anterior Ankle dorsiflexionAnkle dorsiflexion
L5-S1L5-S1 Extensor hallucis longusExtensor hallucis longus Great toe extensionGreat toe extension
S1S1 GastrocnemiusGastrocnemius Ankle plantarflexionAnkle plantarflexion
ScoreScore Functional AbilityFunctional Ability
00 No contraction of muscleNo contraction of muscle
11 Palpable muscle contraction, no limb movementPalpable muscle contraction, no limb movement
22 Able to move in gravity-neutral planeAble to move in gravity-neutral plane
33 Able to move against gravityAble to move against gravity
44 Diminished strengthDiminished strength
55 Normal strengthNormal strength

BacteremiaBacteremia
FungemiaFungemia
ParasitemiaParasitemia
ViremiaViremia
OtherOther
BurnsBurns
PancreatitisPancreatitis
SIRSSIRSSEPSISSEPSISINFECTIONINFECTION
OtherOther
TraumaTrauma
Beal et al, JAMA, 1994;271;226-233

The Lethal Triad of DeathThe Lethal Triad of Death

Severe Trauma Prolonged hypotensionSevere Trauma Prolonged hypotension
CoagulopathyCoagulopathy
Metabolic AcidosisMetabolic Acidosis
HypothermiaHypothermia
DEATDEAT
HH
The Lethal Triad of DeathThe Lethal Triad of Death
Rotondo MF, Zonies DH. Surg Clin North Am 1997; 77(4): 761-777Rotondo MF, Zonies DH. Surg Clin North Am 1997; 77(4): 761-777

SIRSSIRS Systemic Inflammatory Response SyndromeSystemic Inflammatory Response Syndrome
MODSMODS Multiple Organ Dysfunction SyndromeMultiple Organ Dysfunction Syndrome
MOFMOF Multiple Organ FailureMultiple Organ Failure
MSOFMSOF Multiple-Sytem Organ FailureMultiple-Sytem Organ Failure
ARDSARDS Acute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome
DICDIC Disseminated Intravascular CoagulationDisseminated Intravascular Coagulation
SIRSSIRS Systemic Inflammatory Response SyndromeSystemic Inflammatory Response Syndrome
MODSMODS Multiple Organ Dysfunction SyndromeMultiple Organ Dysfunction Syndrome
MOFMOF Multiple Organ FailureMultiple Organ Failure
MSOFMSOF Multiple-Sytem Organ FailureMultiple-Sytem Organ Failure
ARDSARDS Acute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome
DICDIC Disseminated Intravascular CoagulationDisseminated Intravascular Coagulation

Microcirculatory SystemMicrocirculatory System

A L IA L I
(Acute Lung Injury)(Acute Lung Injury)
A R D SA R D S
(Acute Respiratory Distress Syndrome)(Acute Respiratory Distress Syndrome)
ALIALI
ARDSARDS
SIRS /SIRS /
SEPSISSEPSIS

Penetrating abdominal InjuryPenetrating abdominal Injury
Explore woundExplore wound
under localunder local
anesthesiaanesthesia
LaparotomyLaparotomy
NONO
DPLDPL
Debride sutureDebride suture
Consider dischargeConsider discharge
NegativeNegative
Admit, observeAdmit, observe
IsIs peritoneumperitoneum intact ?intact ?
PositivePositive
Gun shot?Gun shot?
Evisceration?Evisceration?
Rigid silent abdomen?Rigid silent abdomen?
Free gas on radiography?Free gas on radiography?
NONO YESYES
YESYES

Trauma of the kidneyTrauma of the kidney
Stab wound of the kidneyStab wound of the kidney BluntBlunt
HematuriaHematuria
StableStable UnstableUnstable
Explore Retroperitoneal hematomeExplore Retroperitoneal hematome
Expand (+)Expand (+)
Bulging (+)Bulging (+)
Expand (-)Expand (-)
Bulging (-)Bulging (-)
KUB - IVPKUB - IVP
NormalNormal
ObserveObserve
Non VisualNon Visual
AbnormalAbnormal
ExploreExplore ObserveObserveFurther ExploreFurther Explore
CT scanCT scan

Blunt Trauma Of The KidneyBlunt Trauma Of The Kidney
HematuriaHematuria
Microscopic, shock (+)Microscopic, shock (+)
MacroscopicMacroscopic
Microscopic, Shock (-)Microscopic, Shock (-)
StableStable UnstableUnstable
KUB - IVPKUB - IVP
ExploreExplore
Retro-hematomaRetro-hematoma Retro-hematomaRetro-hematoma
Bulging (-)Bulging (-) Bulging (+)Bulging (+)
Expanding (-)Expanding (-) Expanding (+)Expanding (+)
ObserveObserve Explore furtherExplore further
AbnormalAbnormal NormalNormal
ExploreExplore ObserveObserve
Not InformativeNot Informative
ConcomitantConcomitantConcomitantConcomitant
Trauma (-)Trauma (-)TraumaTrauma (+)(+)
ExploreExplore ObserveObserve
Where is CT Scan functionWhere is CT Scan function
Imaging exam not necessaryImaging exam not necessary
Except:Except:
• Concomitant traumaConcomitant trauma
• DecelerationDeceleration
Trauma of the kidneyTrauma of the kidney
Stab woundStab wound

Approach to TraumaticApproach to Traumatic
Retroperitoneal HematomaRetroperitoneal Hematoma
Type - HematomaType - Hematoma Penetrating InjuryPenetrating Injury Blunt InjuryBlunt Injury
Central (Zone I)Central (Zone I) ExploreExplore ExploreExplore
Lateral (Zone II)Lateral (Zone II) Usually exploreUsually explore Usually do notUsually do not
exploreexplore
Pelvic (Zone III)Pelvic (Zone III) ExploreExplore Do not exploreDo not explore
Mosche Schein : Common Sense Emergency Abdominal Surgery, Thieme 2000Mosche Schein : Common Sense Emergency Abdominal Surgery, Thieme 2000
CATATAN:CATATAN:
Blunt injury pada Zona II biasanya akan dieksplorasi bila:Blunt injury pada Zona II biasanya akan dieksplorasi bila:
– Ukuran sangat luas.Ukuran sangat luas.
– Pulsating.Pulsating.
– Expanding.Expanding.

Exposure Zone IExposure Zone I Exposure Zone IIExposure Zone II

Manuver KocherManuver Kocher
Trauma vena retrohepatik.Trauma vena retrohepatik.
Manuver PringleManuver Pringle + klem oklusi parsial+ klem oklusi parsial

Manuver MattoxManuver Mattox
untuk mengekspos aortauntuk mengekspos aorta
abdominalabdominal
Manuver CattellManuver Cattell
untuk mengekspos v.cavauntuk mengekspos v.cava
dan duodenumdan duodenum

PRINCIPLES OF MANAGEMENT OFPRINCIPLES OF MANAGEMENT OF
KIDNEY INJURIESKIDNEY INJURIES
• HISTORY.HISTORY.
• PHYSICAL EXAMINATION.PHYSICAL EXAMINATION.
• LABORATORY EXAMINATION.LABORATORY EXAMINATION.
• IMAGING.IMAGING.
DIAGNOSISDIAGNOSIS
MANAGEMENTMANAGEMENT
SUSPICION OF INJURY OF THESUSPICION OF INJURY OF THE
KIDNEYKIDNEY
1.1. Trauma, pain, lacerations on the flank area.Trauma, pain, lacerations on the flank area.
2.2. Fractures of T8 - T12 rib, a mass in the retroperitoneal area.Fractures of T8 - T12 rib, a mass in the retroperitoneal area.
3.3. Hematuria (bloody urine).Hematuria (bloody urine).
4.4. Shock.Shock.

IMAGING EXAMINATIONIMAGING EXAMINATION
IN KIDNEY TRAUMAIN KIDNEY TRAUMA
• KUB – IVP.KUB – IVP.
• CT – Scan.CT – Scan.
• Arteriography.Arteriography.
Very helpful in determining whether to do exploration or not.Very helpful in determining whether to do exploration or not.
• Done almost everywhere in Indonesia.Done almost everywhere in Indonesia.
• Relatively inexpensive.Relatively inexpensive.
• Double dose (2 cc/kg BW).Double dose (2 cc/kg BW).
• How to interpret:How to interpret:
• Psoas line or kidney shape in KUB is (-).Psoas line or kidney shape in KUB is (-).
• Decrease of the excretion of contrast.Decrease of the excretion of contrast.
• Scoliosis due to psoas muscle contraction.Scoliosis due to psoas muscle contraction.
• Contrast extravasation.Contrast extravasation.

Indication to do kidney explorationIndication to do kidney exploration
• Persistent hemorrhage believed from renal injury.Persistent hemorrhage believed from renal injury.
• Reccurent Shock.Reccurent Shock.
• During Laparotomy, there is expanding and bulging ofDuring Laparotomy, there is expanding and bulging of
retroperitoneal hematome.retroperitoneal hematome.
• IVP :IVP :
• Contrast extravasation.Contrast extravasation.
• Non visualized part of the kidneyNon visualized part of the kidney
(ideally continue with a CT Scan exam).(ideally continue with a CT Scan exam).
• Arteriography :Arteriography :
• Part of the kidney avascular.Part of the kidney avascular.
• Total obstruction of renal artery.Total obstruction of renal artery.
• Large extravasation.Large extravasation.

Isolasi pembuluh darah ginjal (prosedur Mc Anninch)Isolasi pembuluh darah ginjal (prosedur Mc Anninch)

Insisi retroperitoneal diatas aortaInsisi retroperitoneal diatas aorta
medial dari v. mesenterika inferiormedial dari v. mesenterika inferior
VENAVENA
MESENTERICA INFERIORMESENTERICA INFERIOR
AORTAAORTA
INSISIINSISI

• Hubungan anatomi dariHubungan anatomi dari
pembuluh darah ginjalpembuluh darah ginjal
• Insisi retroperitonealInsisi retroperitoneal
lateral dari kolonlateral dari kolon
memperlihatkan ginjalmemperlihatkan ginjal

Teknik Renorafi:Teknik Renorafi:
A.A. Cidera khas pada ginjal tengah.Cidera khas pada ginjal tengah.
B.B. Debridement, hemostasis dan penutupan sistem pengumpul.Debridement, hemostasis dan penutupan sistem pengumpul.
C.C. Aproksimasi tepi parenkim.Aproksimasi tepi parenkim.
D.D. Penjahitan dengan gelfoam.Penjahitan dengan gelfoam.

Cedera pembuluh darah:Cedera pembuluh darah:
KiriKiri : Cedera pada pembuluh darah utama / cabang segmental.: Cedera pada pembuluh darah utama / cabang segmental.
TengahTengah : Perbaikan pada vena utama ginjal.: Perbaikan pada vena utama ginjal.
KananKanan : Dilakukan ligasi pada cabang vena.: Dilakukan ligasi pada cabang vena.

PemotonganPemotongan
secara tajam untuksecara tajam untuk
jaringan yang nonjaringan yang non
viabelviabel

M – I – S – TM – I – S – T
•MMechanism of injuryechanism of injury
•IInjury sustainednjury sustained
•SSignsigns
•TTreatmentreatment

BEBERAPA JENIS IRISAN KULITBEBERAPA JENIS IRISAN KULIT
PADA OPERASI LEHERPADA OPERASI LEHER
MARTIN 1951MARTIN 1951 SCHOBINGER 1957SCHOBINGER 1957 LAMEY 1940LAMEY 1940
LATYSHEVSKYLATYSHEVSKY
FREUND 1960FREUND 1960
MAC FEE 1960MAC FEE 1960 CONLEY 1966CONLEY 1966

SLAUGHTER 1955SLAUGHTER 1955
SCHWEITZER 1965SCHWEITZER 1965
EDGERTON 1957EDGERTON 1957
FARR 1969FARR 1969

INDIKASI PEMBEDAHANINDIKASI PEMBEDAHAN
EKSPLORASI LEHER :EKSPLORASI LEHER :
1. Active bleeding.1. Active bleeding. 8. Hoarseness.8. Hoarseness.
2. Hematoma.2. Hematoma. 9. Stridor.9. Stridor.
3. Shock.3. Shock. 10.Dysphonia or voice change.10.Dysphonia or voice change.
4. Pulse defisit.4. Pulse defisit. 11. Hemoptysis.11. Hemoptysis.
5. Bruit.5. Bruit. 12. Subcutaneous emphysema.12. Subcutaneous emphysema.
6. Neurologic defisit.6. Neurologic defisit. 13. Dysphagia or odynaphagia.13. Dysphagia or odynaphagia.
7. Dispnea.7. Dispnea. 14. Hematemesis.14. Hematemesis.

PATOFISIOLOGI :PATOFISIOLOGI :
Gagal ventilasi, Gagal difusi, Gagal sirkulasiGagal ventilasi, Gagal difusi, Gagal sirkulasi
HIPOKSIA SELULERHIPOKSIA SELULER
CYTOKINESCYTOKINES
ARDS, SIRS, MOD/MOF, SEPSISARDS, SIRS, MOD/MOF, SEPSIS

Fraktur IgaFraktur Iga
FLAIL CHESTFLAIL CHEST

PARADOXAL RESPIRATION→ PARADOXAL RESPIRATION→
PARADOXAL RESPIRATION→ PARADOXAL RESPIRATION→

RUPTUR DIAFRAGMARUPTUR DIAFRAGMA
• Trauma tumpul kerasTrauma tumpul keras
• Sisi kiri terbanyakSisi kiri terbanyak
• !!! Cedera organ abdomen!!! Cedera organ abdomen
• Terapi :Terapi :
Operasi (cegah hernia)Operasi (cegah hernia)
• Ragu :Ragu :
Torakoskopi / Laparoskopi.Torakoskopi / Laparoskopi.

Compartment :Compartment :
Closed anatomic space bound by relativelyClosed anatomic space bound by relatively
rigid wallsrigid walls of bone and fasciaof bone and fascia

DefinitionDefinition
Condition which is both limb and lifeCondition which is both limb and life
threateningthreatening  need prompt emergencyneed prompt emergency
actionaction
Acute Compartment Syndrome (ACS)Acute Compartment Syndrome (ACS)
Intra Compartment Pressure (ICP)Intra Compartment Pressure (ICP) ↑↑  tissue perfusiontissue perfusion ↓↓ 
compromise of circulation and function of tissuescompromise of circulation and function of tissues

EtiologyEtiology
-FracturesFractures
- Arterial injuryArterial injury
- BurnBurn
- Soft tissue injurySoft tissue injury
- Exertional sport injuryExertional sport injury
-Prolong limb compressionProlong limb compression

Symptom 5 P→Symptom 5 P→
EarlyEarly
 Pain, severe, pain out of proportion to severity injury.Pain, severe, pain out of proportion to severity injury.
 ParesthesiaParesthesia
LateLate
 ParesisParesis
 PallorPallor
 Pulselessness, last occur.Pulselessness, last occur.
SignsSigns
Decreased sensation of the involved nervesDecreased sensation of the involved nerves
Pain increases with passively streching the involvedPain increases with passively streching the involved
musclesmuscles
palpation : tense,palpation : tense, wooden signwooden sign

1872 : Richard van Volkmann1872 : Richard van Volkmann
Contracture of forearm and hand followingContracture of forearm and hand following
Supracondylar fracture of humerus.Supracondylar fracture of humerus.
Volkmann Ischemic contractureVolkmann Ischemic contracture

Anterior compartmentAnterior compartment
- Muscles- Muscles : Tib. Ant, Extensors (Dig & Hallucis): Tib. Ant, Extensors (Dig & Hallucis)
- Artery- Artery : Tib. Ant.: Tib. Ant.
- Nerve- Nerve : Deep Peroneal : sensation first dorsal web: Deep Peroneal : sensation first dorsal web
of footof foot
Lateral CompartmentLateral Compartment
- Muscle- Muscle : Peroneals (Longus et Brevis): Peroneals (Longus et Brevis)
- Nerve- Nerve : Superficial Peroneal : sensation dorsum foot: Superficial Peroneal : sensation dorsum foot

Deep Posterior compartmentDeep Posterior compartment
- Muscle- Muscle : Tib. Post, Flexors (Dig & Hallucis): Tib. Post, Flexors (Dig & Hallucis)
- Artery- Artery : Tib. Post.: Tib. Post.
- Nerve- Nerve : Tib Post.: Tib Post.  sensation sole of footsensation sole of foot
Superficial Posterior CompartmentSuperficial Posterior Compartment
- Muscle- Muscle : Gastroc, Soleus, Plantaris: Gastroc, Soleus, Plantaris
- Nerve- Nerve : Sural: Sural  sensation lateral aspect of foot andsensation lateral aspect of foot and
distal calfdistal calf

Treatment of choice for ACS in theTreatment of choice for ACS in the lower leglower leg
FasciotomyFasciotomy - Dermotomy- Dermotomy
Incision : the WHOLE length of compartment.Incision : the WHOLE length of compartment.

ACS in the lower legACS in the lower leg

Mubarak :Mubarak :
Two / Double incisions technique anterolateral & posteromedialTwo / Double incisions technique anterolateral & posteromedial
incisionsincisions
Safer access to all 4 compartment with good visualization of importantSafer access to all 4 compartment with good visualization of important
superficial and deep structuressuperficial and deep structures

Anterolateral IncisionAnterolateral Incision Posteromedial IncisionPosteromedial Incision

TIMETIME factor very important :factor very important :
-- Consensus : 12 hoursConsensus : 12 hours
> 12 hours : catastrophic clinical result> 12 hours : catastrophic clinical result
- Full recovery if within 6 hours- Full recovery if within 6 hours
- Exact time of onset : difficult- Exact time of onset : difficult

ACS in the ThighACS in the Thigh

ContraindicationContraindication : If ACS in late diagnosed: If ACS in late diagnosed
fasciotomy little benefit – probablyfasciotomy little benefit – probably
contraindicated after 3 – 4 days.contraindicated after 3 – 4 days.
If performed late severe infection may develops in theIf performed late severe infection may develops in the
necrotic muscle, even death.necrotic muscle, even death.
Painlessness / Paralysis (+) no use of fasciotomy.Painlessness / Paralysis (+) no use of fasciotomy.
Post fasciotomyPost fasciotomy
-- Leave the woundLeave the wound OPENOPEN
-- Skin graft performed after 1 – 3 weeksSkin graft performed after 1 – 3 weeks
-- Avoid skin graft : silicone sheet coverageAvoid skin graft : silicone sheet coverage
-- Do not elevate the limbelevate the limb  arterial flowarterial flow ↓↓  av. Pressureav. Pressure
gradientgradient ↓↓  ischemiaischemia ↑↑

DiagnosisDiagnosis
• Pada setiap trauma abdomen bawah dan tungkai selalu pikirkanPada setiap trauma abdomen bawah dan tungkai selalu pikirkan
kemungkinan fraktur pelvis.kemungkinan fraktur pelvis.
• Perhatikan mekanisme cedera.Perhatikan mekanisme cedera.
• Pemeriksaan klinis :Pemeriksaan klinis :
–Jejas pada pelvis/abdomen bagian bawah.Jejas pada pelvis/abdomen bagian bawah.
–Nyeri tekan pada pelvis.Nyeri tekan pada pelvis.
–Ketidakstabilan pada perabaan.Ketidakstabilan pada perabaan.
–Perbedaan panjang kedua tungkai.Perbedaan panjang kedua tungkai.
–Rectal examination & darah pada MUE.Rectal 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

Physical examinationPhysical examination

Pemeriksaan fraktur pelvisPemeriksaan fraktur pelvis
•Tekan kearah posteriorTekan kearah posterior
dan anterior pada kristadan anterior pada krista
iliaka (stabilitasiliaka (stabilitas
anteroposterior).anteroposterior).
•Lakukan traksi padaLakukan traksi pada
salah satu tungkaisalah satu tungkai
dengan memfiksasidengan memfiksasi
pelvis (stabilitaspelvis (stabilitas
vertikal).vertikal).

Outlet and inlet viewOutlet and inlet view
I
O

Fraktur PelvisFraktur Pelvis
Pelvic ring
Cedera pada urethra
Cedera vaskuler

Klasifikasi fraktur pelvisKlasifikasi fraktur pelvis
KlasifikasiKlasifikasi
TileTile
Tipe ATipe A
StableStable
Tipe BTipe B
Rotationally unstableRotationally unstable
Vertically stableVertically stable
(open book type)(open book type)
Tipe CTipe C
Rotationally andRotationally and
Vertically UnstableVertically Unstable

Pelvic ligamentsPelvic ligaments

Pelvic Ring AnatomyPelvic Ring Anatomy

Stabilisasi pelvisStabilisasi pelvis
•MengecilkanMengecilkan
rongga pelvis :rongga pelvis :
berfungsiberfungsi
sebagaisebagai
tampon.tampon.
•Pelvic sling,Pelvic sling,
stagen.stagen.
•FiksasiFiksasi
eksterna.eksterna.
•Fiksasi interna.Fiksasi interna.

ARTICULATIO GENUARTICULATIO GENU

Penetrating abdominal traumaPenetrating abdominal trauma..

Maxillofacial Fractures and LeFort Classification

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Editor's Notes