CATATAN

BEDAH

dr.Syafwan Azhari

Department of General Surgery

Zainoel Abidin Hospital
Banda Aceh

Glasgow Coma
Scale
Assesment area
Score

Assesment area
Score

Eye opening (E)

Motor response (M)

Spontaneous
4

To speech

To pain
Assesment
None area
Score1

3
2

Verbal Response (V)

Oriented
5
Confused conversation 4
Inappropriate words
3
Incomprehensible sounds
None
1

Decerebrate

Obeys command 6
Localizes pain
5
Normal flexion
(withdrawal to pain)
Abnormal flexion
(decorticate)
3
Abnormal extension
(decerebrate)
2
None (flaccid)
1

Decorticate

Posturing
Abnormal flexion
(decorticate posturing)

Abnormal extension
(decerebrate posturing)
Figure 22-17

PERJALANAN KLINIK
EDH

STONE
INFECTION

OBSTRUCTION

PYONEPHROSIS

HYDRONEPHROSIS

UROSEPSIS

HYDROURETER

RENAL FAILURE

(Relation with location, duration and size of stone)

Grade trauma
ginjal
Grade I:
Kontusio ginjal/hematoma
perirenal.

Grade II:
Laserasi ginjal terbatas pada
korteks.

Grade III:
Laserasi ginjal sampai pada
medulla ginjal, mungkin terdapat
trombosis arteri segmentalis.

Grade IV:
Laserasi sampai mengenai sistem
kalises ginjal.

Grade V:
Avulsi pedikel ginjal, mungkin
terjadi trombosis arteria
renalis.
Ginjal terbelah (shatered).

Penilaian preoperatif &

diagnosis
Hematuria
mikroskopik
tanpa syok

Trauma Tumpul
Ginjal

Hematuria
Gross / mikroskopik dengan syo

Imajing () Kec:
Trauma penyerta
Stabil:
Deselerasi cepat
IVP

Tidak stabil:
Laparatomi
eksplorasi

Tidak informatif AbnormalNormal

Hematom retroperitoneal

Trauma penyerta
(-)

(+)

Meluas / berdenyut Tidak meluas

Observasi E k s p l o r a s Observasi
i

Eksplorasi

Observasi

Staging Ca buli buli

Stadium Ca buli buli

sistem TNM & menurut Marshall

TNM

Marshall

Uraian

Tis

Carsinoma in situ

Ta

Tumor papilari non invasif

T1

Invasi submukosa

T2

B1

Invasi otot superfisial

T3a

B2

Invasi otot profunda

T3b

Invasi jaringan lemak

prevesika

T4

D1

Invasi ke organ sekitar

N1 3

D1

Matestase ke limfonudi
regional

M1

D2

Metastase hematogen

frontal views of LeFort complex fractures I - III

lateral views of LeFort complex fractures I - III

Maxillary fracture
The LeFort I, 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 invariably involves the pterygoid processes of the sphenoid.
Clinically, the floating fragment will be the lower maxilla with the maxillary
teeth.

The LeFort II occurs 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 the nasal area.

The most severe of the classic LeFort fracture complexes is the LeFort III. I
suppose that this 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 craniofacial 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, considerable 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.

Common sites of
Mandibular Fractures
Fracture

Type
Prevalence

Body

30 - 40 %

Angle

25 - 31 %

Condyle

15 - 17 %

Symphysis

7 - 15 %

Ramus

3-9%

Alveolar

2-4%

Coronoid
process

1-2%

Evaluation of the Neck

3 zones defined by
horizontal planes
Zone I

Injuries carry highest

mortality rate

Zone II

Most common injuries but

lower mortality rate than
zone I injuries

Zone III

Greatest risk of injury to

distal carotid artery,
salivary glands, and
pharynx

Figure 22-11

KLASIFIKASI STADIUM TNM PADA

KANKER PAYUDARA

Tx

Tumor primer tdk dpt dinilai

CATATAN:
Ukuran T secara klinis, radiologis, dan mikroskopis adalah sama.

T0

Nilai T dalam cm, nilai paling kecil dibulatkan ke angka 0,1 cm.
Tdk tdpt tumor primer

Tis

Karsinoma in situ

Tis(DCIS)

Ductal carcinoma in situ

Tis(LCIS)

Lobular carcinoma in situ

Tis(paget)

Penyakit Paget pd putting tanpa adanya tumor

CATATAN:

T1
T1mic

Penyakit Paget dgn adanya tumor dikelompokkan sesuai dgn ukuran tumornya
Tumor dgn ukuran diameter 2 cm
Adanya micro invasi ukuran 0,1 cm at kurang

T1a

Tumor dgn ukuran lebih dari 0,1 cm sampai 0,5 cm

T1b

Tumor dgn ukuran lebih dari 0,5 cm sampai 1 cm

T1c
T2

Tumor dgn ukuran lebih dari 1 cm sampai 5 cm

Tumor dgn ukuran diameter terbesarnya lebih dari 2 cm sampai 5 cm

T3

Tumor dgn ukuran diameter terbesarnya lebih dari 5 cm

T4

Ukuran tumor berapapun dgn ekstensi langsung ke dinding dada atau kulit

T4a

Ekstensi kedinding dada (tdk tmasuk otot pectoralis)

T4b

Edema (tmasuk peau dorange), ulcerasi, nodul satelit pd kulit yg tbatas pd 1 payudara

T4c

Mencakup kedua hal diatas

T4d

Mastitis karsinomatosa
CATATAN:
Dinding dada adalah tmasuk iga, otot intercostalis dan otot serratus anterior tapi tidak tmasuk
otot pectoralis

Nx

KGB regional tdk dpt dinilai (telah diangkat sebelumnya)

N0

Tidak terdapat metastase KGB

N1

Metastase ke KGB axilla ipsilateral yg mobile

N2

Metastase ke KGB axilla ipsilateral tfiksir, bkonglomerasi at adanya pembesaran KGB mamaria
interna ipsilateral (klinis*) tanpa adanya metastase ke KGB axilla.
Metastase pd KGB axilla tfiksir at bkonglomerasi at melekat pd struktur lain
N2a

Metastase hanya pd KBG mamaria interna ipsilateral secara klinis * dan tdk tdpt metastase pd
KGB axilla

N2b

N3

Metastase pd KGB infraklavikular ipsilateral dgn at tanpa metastase KGB axilla at klinis tdpt
metastase pd KGB mamaria interna ipsilateral klinis dan metastase pd KGB axilla
at metastase pd KGB supraklavikular ipsilateral dgn at tanpa metastase KGB axilla/mamaria
interna

N3a
N3b
N3c

Mx

Metastase ke KGB infraklavikular ipsilateral

Metastase ke KGB mamaria interna dan KGB axilla
Metastase ke KGB supraklavikular
CATATAN:
*tdeteksi secara klinis : tdeteksi dgn pemeriksaan fisik at secara imaging (diluar
limfoscintigrafi)
Metastase jauh belum dapat dinilai

M0

Tidak terdapat metastase jauh

M1

Terdapat metastase jauh

GROUP STADIUM KANKER PAYUDARA

STADIUM 0

Tis

N0

M0

STADIUM I

T1*

N0

M0

STADIUM IIA

T0
T1*
T2

N1
N1
N0

M0
M0
M0

STADIUM IIB

T2
T3

N1
N0

M0
M0

STADIUM IIIA

T0
T1
T2
T3
T3

N2
N2
N2
N1
N2

M0
M0
M0
M0
M0

STADIUM IIIB

T4
T4
T4

N0
N1
N2

M0
M0
M0

STADIUM IIIC

Tiap T

N3

M0

STADIUM IV

Tiap T

Tiap N

M1

Mammogram normal

Usia lanjut <------------------- usia muda

Mechanism
of
Injury

KLASIFIKASI STADIUM TNM PADA KANKER KELENJAR

LIUR (AJCC 2002)
Tx

Tumor primer tdk dpt dinilai

Nx

KGB regional tdk dpt dinilai

T0

Tdk tdpt tumor primer

N0

Tidak terdapat metastase KGB

N1

Metastase ke KGB tunggal < 3 cm

T1

Tumor dgn ukuran diameter 2 cm

Tidak ada ekstensi ekstraparenkim

T2

T3

N2

Metastase ke KGB tunggal / multiple

>3 cm 6 cm

Tumor dgn ukuran diameter > 2 cm

sampai 4 cm

Ipsilateral / bilateral / kontralateral

Tidak ada ekstensi ekstraparenkim

Metastase ke KGB tunggal >3 cm 6

cm

Tumor dgn ukuran diameter > 4 cm

sampai 6 cm
Atau ada ekstensi ekstraparenkim
tanpa terlibat n.VII

T4

Ipsilateral

Tumor dgn ukuran diameter > 6 cm

Atau ada invasi ke n.VII / dasar
tengkorak

N2a

Ipsilateral
Metastase ke KGB multiple 6 cm

N2b

ipsilateral
Metastase ke KGB 6 cm

N2c

bilateral / kontralateral

N3
Mx

Metastase
KGB
> 6 dapat
cm
Metastase ke
jauh
belum
dinilai

M0

Tidak terdapat metastase jauh

M1

Terdapat metastase jauh

GROUP STADIUM KANKER KELENJAR LIUR

STADIUM I

T1

N0

M0

T2

N0

M0

STADIUM II

T3

N0

M0

STADIUM III

T1

N1

M0

T2

N1

M0

T4

N0

M0

T3

N1

M0

T4

N1

M0

Tiap T

N2

M0

Tiap T

N3

M0

Tiap T

Tiap N

M1

STADIUM IV

Lymph node stations

1 = jugular chain
2 = spinal chain
3 = supraclavicular chain
4 = occipital lymph nodes
5 = mastoid lymph nodes
6 = parotid lymph nodes
7 = submandibular lymph nodes
8 = submental lymph nodes
9 = retropharyngeal lymph nodes
10 = recurrent lymph nodes
11 = pretracheal lymph nodes
12 = prethyroidean lymph nodes

Superficial surgical triangles

m = mandible
c = clavicle
i = hyoid bone
1 = angle of mandible
2 = posterior belly of digastric muscle
3 = hyoglossus muscle
4 = mylohyoid muscle
5 = anterior belly of digastric muscle
6 = sternocleidomastoid muscle
7 = superior belly of omohyoid muscle
8 = sternohyoid muscle
9 = trapezius muscle
10 = inferior belly of omohyoid muscle

Pembagian
Zona
Retroperitone
al
Clasification
de Kuds y Sheldon 1982.
Zona I (central)
Zona II (lateral)
Zona III (pelvic)

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

Retroperitoneal
hematoma
Zone 1:
Explore regardless of
mechanism.
Zone 2:
Explore penetrating trauma.
Observe blunt trauma:
non expanding
non pulsatile
no urologic indications
Zone 3:
Explore penetrating.
Observe blunt.

Systemic inflammatory respose

syndrome
Two or more of

1.Temperature >38 C or <36 C

SIRS

2.Tachycardia >90/min
3.RR >20/min or PaCO2 ,4.3kPa
4.WBC>12X10 or < 4X10 or 10% immature form

Sepsis

SIRS due to infection

Severe sepsis

Sepsis with evidence of organ hypoperfusion

Septic shock

Severe sepsis with hypotension (SBP,90) despite

adequate fluid resuscitation or the requirement
for vasopressors/inotropes to maintain blood
pressure

Haemoglobin

Metabolisme pigmen empedu

dan proses eksresinya
Limpa

Ferum

Cincin porfirin
Bilirubin Globin
(larut lemak/nonkonyugasi)

Hepar
(faal?)

Bilirubin
(larut air/terkonyugasi)

Empedu
(obstruksi?)
Usus

Urobilinogen
Urobilinogen
(sistemik)

Starkobilin

Bilirubin
(sistemik)

Urobilin
(urin)

Feces

Bilirubin
(urin)

An anterior view of segmental anatomy.

HV, hepatic vein; IVC, inferior vena cava; PV, portal

Segmental anatomy viewed from the inferior

surface.

Grading of Liver
Injuries

Grading of Splenic
Injuries

Clasifikasi fraktur pelvis

Clasifikasi menurut Tile

Tipe A
Stable

Tipe B
Rotationally unstable
Vertically stable
(open book type)

Tipe C
Rotationally and
Vertically Unstable

Tile Classification
Type A: Stable

Type A1: Fractures of the pelvis not involving the ring; avulsion
injuries.
Type A2: Stable, minimally displaced fractures of the ring.

Type B: Rotationally unstable, vertically stable.

Type B1: Open-book.

Type B2: Lateral compression; ipsilateral.
Type B3: Lateral compression; contralateral (bucket handle).

Type C: Rotationally and vertically unstable.

Type C1: Unilateral.

Type C2: Bilateral; one side rotationally unstable, with contralateral
side vertically Unstable.
Type C3: Associated acetabular fracture.

Pelvic C clamp

Pathophysiology compartment syndroma

Arterial injury
Ischemia

Injury

Traumatic
Inflammatory
Response

Edema

Perfusion

Hemorrhage
ICP

Vicious

Classification of open fracture

by Gustilo - Anderson

Gustilo and Anderson Classification of All

Open Fractures
Type I
Wound less than 1cm long
Moderately clean puncture,
where spike of bone has pierced
the skin
Little soft tissue damage
No crushing
Fracture usually simple
transverse or oblique with little
comminution
Type II
Laceration more than 1cm long
No extensive soft tissue
damage, flap or contusion
Slight to moderate crushing
injury
Moderate comminution
Moderate contamination

Type III
Extensive damage to soft
tissues
High degree of contamination
Fracture caused by high
velocity trauma
IIIA: Adequate soft tissue cover
IIIB: Inadequate soft tissue
cover,a local or free flap is
required
IIIC: Any fracture with an arterial
injury which requires
repair

M angled
E xtremity
S everity
S core

Applying Skeletal Traction

Fracture Deformities

Valgus angulation

Shortening

Varus angulation

Anterior angulation

Translation

Posterior angulation

A: Angulation is described
by the direction in which the
apex of the fracture is
pointing.
B: Displacement is defined
as the position of thedistal
fragment in relation to the
proximal fragment.
(Netter images reprinted with permission
from Elsevier. All rights reserved.)

Fracture patterns

Spiral fracture

Oblique fracture
Transverse fracture

Butterfly fragment

Segmental fracture
Comminuted fracture

Descriptive terms for

typical fracture patterns.

Segmental fracture

Compression fracture

impresion fracture

Pathologic fracture
(tumor or bone disease)

Greenstick fracture

Avulsion (greater tuberosity

of humerus avulsed by
supraspinatus m.)

Torus (buckle) fracture

Three Columns
of the
Thoracolumbar
Spine

Schatzker classification of tibial

plateau fractures.
Schatzker Classification:
Type I: Lateral plateau, split
fracture.
Type II: Lateral plateau, split
depression fracture.
Type I

Type II

Type III

Type III: Lateral plateau,

depression fracture.
Type IV: Medial plateau
fracture.
Type V: Bicondylar plateau
fracture.

Type IV

Type V

Type VI

Type VI: Plateau fracture

with metaphyseal-diaphyseal
dissociation.

classification of
distal femur
fractures.

AO Classification:
Type A: Extra articular
Type A1: Simple, two-part
supracondylar fracture
Type A2: Metaphyseal wedge
Type A3: Comminuted supracondylar
fracture
Type B: Unicondylar
Type B1: Lateral condyle, sagittal
Type B2: Medial condyle, sagittal
Type B3: Coronal
Type C: Bicondylar
Type C1: Noncomminuted supracondylar
T or Y
fracture
Type C2: Comminuted supracondylar
fracture
Type C3: Comminuted supracondylar and
intercondylar
fracture

The deformity of the

humeral shaft fracture is
dependent on the muscles
that insert above and
below the fracture

Fractures of the Radius

with Distal Radioulnar Subluxation
(Galeazzi)
Anteroposterior and lateral
radiographs of a fracture of
the radius with a distal
radioulnar subluxation.
Note the small intra-articular
fracture from the distal ulna
(arrow).
Open reduction and internal
fixation of this fracture are
essential

Fracture of the ulna with dislocation of the

proximal radioulnar joint (Monteggia fracture)
Bado Classification
Type I: Anterior dislocation of the radial

head with fracture of the ulnar

diaphysis at any level with anterior
angulation.

Type II: Posterior/posterolateral

dislocation of the radial head with
fracture of the ulnar diaphysis with
posterior angulation.
Type III: Pateral/anterolateral dislocation
of the radial head with fracture
of the ulnar metaphysic.
Type IV: Anterior dislocation of the radial
head with fractures of both the
radius and ulna within proximal
third at the same level.

Radiograph showing a displaced

fracture of the ulna with a dislocated

Hirschsprungs Disease
Definisi
Suatu kelainan bawaan yang ditandai dengan
tidak ditemukannya sel-sel ganglion (syaraf
simpatis dan para simpatis) di kedua lapisan
yaitu lapisan otot (Auerbachs) dan submukosa
(meissners) pada kolon sehingga menyebabkan
hilangnya peristaltic pada segmen tersebut
yang berakibat terjadinya obstruksi fungsional.
Paling sering di rectosigmoid.
Differensial diagnosis:

Atresia Ileum.
Meconeum Plug Syndroma (MPS).
Stenosis/Atresia Recti.
N E C stadium Awal (Stadium 1 2a ).

Tipe-tipe Hirschsprungs Disease

SUBCLASSIFIED
ACCORDING TO THE
RELATIVE LENGTH OF THE
AGANGLIONIC REGION :
SHORT SEGMENT DISEASE
(RECTO-SIGMOID ) : 75 80
%.
LONG SEGMENT DISEASE
(SPLENIC FLEXURE): 10 %.
TOTAL COLONIC
AGANGLIONIC : LESS 5 %.
ULTRA SHORT SEGMENT
IS A CONTROVERSIAL
ENTITY (Achalasia Recti )

Pullthrough
(swenson96 ; Leappe,96 ; Aschraft00 ; fitgerald05 ; Orvas05)

Swenson
1
Duhamel
Swenson
2

Soave

Rehbein

SOAVE

3 zones of the neck

Zone I

Zone II

Zone III

From the clavicles to From cricoid to angle Angle of mandible to

the cricoid
of mandible
base of skull
Trachea.
Lungs.
Proximal carotid
and vertebral
arteries.
Jugular veins.
Thoracic Vessels.
Esophagus.
Superior
Mediastinum.
Thoracic Duct.
Spinal Cord.

Trachea.
Larynx.
Carotid and
vertebral arteries.
Jugular Vein.
Esophagus.
Spinal Corda.

Distal carotid and

vertebral arteries.
Pharynx.
Spinal cord.

Motor Function of spinal

roots

Upper
Extremit
y

Nerve Root

Muscle

Motor
Examination

C5

Deltoid

Shoulder abduction

C6

Biceps

Elbow flexion

C7

Triceps

Elbow extension

C8

Flexor carpi ulnaris

Wrist flexion

T1

Lumbricales

Finger abduction

L2

Functional Ability
Iliopsoas
No contraction
of muscle

Hip flexion

Score
0
1
Lower
2
Extremit
y3
4
5

L3
Quadricepsno limb movement
Knee extension
Palpable
muscle contraction,
L4 Able to move
Tibialis
anterior
Ankle dorsiflexion
in gravity-neutral
plane
L5-S1
S1

hallucis
Able toExtensor
move against
gravity Great toe extension
longus
Diminished strength
Gastrocnemius
Ankle plantarflexion
Normal strength

Bacteremia

Other

Fungemia

INFECTION

SEPSIS

SIRS

Trauma

Parasitemia

Viremia

Burns

Other
Pancreatitis

Beal et al, JAMA, 1994;271;226-233

The Lethal Triad of Death

The Lethal Triad of Death

Severe Trauma
Prolonged
hypotension
Metabolic Acidosis

DEAT
H

Coagulopath
Hypotherm
ia761-777
Rotondo MF, ZoniesyDH. Surg Clin North Am 1997; 77(4):

SIRS

Systemic

Inflammatory

Response

Syndrome
MODS

Multiple

Organ

Dysfunction

Syndrome
MOF
MSOF

Multiple Organ Failure

Multiple-Sytem Organ Failure

Microcirculatory System

ALI
(Acute Lung Injury)

SIRS /
SEPSIS

ALI

ARDS

ARDS

(Acute Respiratory Distress

Syndrome)

Penetrating abdominal Injury

Gun shot?
Evisceration?
Rigid silent abdomen?
Free gas on radiography?

NO

Explore
wound
under local
anesthesia

Is peritoneum
intact ?

YES

Positive
Negativ
e

Laparotom

Admit,
observe

DP
L

NO

YES

Debride suture
Consider
discharge

Trauma of the kidney

Stab wound of the

kidney

Blunt
Hematuri
a

Stable
KUB - IVP
Non
Visual
Abnorma
l
Explor
e

Norm
al

Observ
e
CT scan

Unstabl
e
Explore Retroperitoneal
hematome
Expand
(+)
Bulging
(+)
Further
Explore

Expand (-)
Bulging (-)
Obser
ve

Trauma of the kidney

Blunt Trauma Of The Kidney
Stab wound

Microscopic, Shock
(-) exam not necessary
Imaging
Except:
Concomitant trauma
Deceleration

Hematuri
a

Microscopic, shock
(+)
Macroscopic
Unstable

Stable

Unstable

KUB IVP

Not
Informative

Concomitant
Trauma
(+)
Explor
e

Explore

Abnormal Normal
Explor
Observe
e
Concomitant
Trauma (-)

Observe

Retro-hematoma
Bulging
Expanding
(-)
(-)
Observe

Where is CT Scan

RetroBulging
hematoma
Expanding
(+)
(+)
Explore
further

Approach to Traumatic
Retroperitoneal Hematoma
Type Penetrating
Hematoma
Injury
Central (Zone I)
Explore
Lateral (Zone II)
Usually explore
Pelvic (Zone III)

Explore

Blunt Injury
Explore
Usually do not
explore
Do not explore

Mosche Schein : Common Sense Emergency Abdominal Surgery, Thieme 2000

CATATAN:
Blunt injury pada Zona II biasanya akan dieksplorasi bila:
Ukuran sangat luas.
Pulsating.
Expanding.

Exposure Zone I

Exposure Zone II

Trauma vena retrohepatik.

Manuver Pringle + klem oklusi
parsial

Manuver Kocher

Manuver Mattox

Manuver Cattell

untuk mengekspos aorta

abdominal

untuk mengekspos v.cava

dan duodenum

PRINCIPLES OF MANAGEMENT OF
KIDNEY INJURIES

HISTORY.
PHYSICAL EXAMINATION.
LABORATORY EXAMINATION.
IMAGING.
DIAGNOSIS
MANAGEMENT
SUSPICION OF INJURY OF THE
KIDNEY

1.
2.
3.

Trauma, pain, lacerations on the flank area.

Fractures of T8 - T12 rib, a mass in the
retroperitoneal area.
Hematuria (bloody urine).

IMAGING EXAMINATION
IN KIDNEY TRAUMA
KUB IVP.
CT Scan.
Arteriography.
Very helpful in determining whether to do exploration or
not.

Done almost everywhere in

Indonesia.
Relatively inexpensive.
Double dose (2 cc/kg BW).
How to interpret:
Psoas line or kidney shape in KUB is
(-).
Decrease of the excretion of contrast.

Indication to do kidney exploration

Persistent hemorrhage believed from renal injury.
Reccurent Shock.
During Laparotomy, there is expanding and
bulging of retroperitoneal hematome.
IVP :
Contrast extravasation.
Non visualized part of the kidney
(ideally continue with a CT Scan exam).

Arteriography :
Part of the kidney avascular.
Total obstruction of renal artery.
Large extravasation.

Isolasi pembuluh darah ginjal (prosedur Mc Anninch)

VENA
MESENTERICA INFERIOR

AORTA

INSISI

Insisi retroperitoneal diatas

aorta

 Hubungan anatomi
dari pembuluh
darah ginjal

Insisi retroperitoneal
lateral dari kolon
memperlihatkan
ginjal

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

Cedera pembuluh darah:

Kiri
: Cedera pada pembuluh darah utama / cabang
segmental.
Tengah: Perbaikan pada vena utama ginjal.

Pemotongan
secara tajam
untuk jaringan
yang non
viabel

MIST

Mechanism of injury
Injury sustained
Signs
Treatment

BEBERAPA JENIS IRISAN

KULIT
PADA OPERASI LEHER
MARTIN 1951

LATYSHEVSKY
FREUND 1960

SCHOBINGER 1957

MAC FEE 1960

LAMEY 1940

CONLEY 1966

SLAUGHTER 1955

SCHWEITZER 1965

EDGERTON
1957
FARR 1969

INDIKASI PEMBEDAHAN
EKSPLORASI LEHER :
1. Active bleeding. 8. Hoarseness.
2. Hematoma. 9. Stridor.
3. Shock.
4. Pulse defisit.
5. Bruit.

10.Dysphonia or voice change.

11. Hemoptysis.
12. Subcutaneous emphysema.

6. Neurologic defisit.
odynaphagia.
7. Dispnea.

13. Dysphagia or

14. Hematemesis.

PATOFISIOLOGI :
Gagal ventilasi, Gagal difusi, Gagal
sirkulasi

HIPOKSIA SELULER
CYTOKINES
ARDS, SIRS, MOD/MOF, SEPSIS

Fraktur Iga
FLAIL CHEST

FLAIL
FLAIL CHEST
CHEST

PARADOXAL
PARADOXAL RESPIRATION
RESPIRATION

RUPTUR DIAFRAGMA

Trauma tumpul keras

Sisi kiri terbanyak
!!! Cedera organ
abdomen
Terapi :
Operasi (cegah hernia)
Ragu :
Torakoskopi /
Laparoskopi.

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

Definition
Condition which is both limb and life
threatening need prompt emergency
action

Acute Compartment Syndrome (ACS)

Intra Compartment Pressure (ICP) tissue perfusion
compromise of circulation and function of tissues

Etiology
-Fractures
- Arterial injury

- Burn
- Soft tissue injury
- Exertional sport injury

-Prolong limb compression

Symptom 5 P

Early
Pain, severe, pain out of proportion to severity
injury.
Paresthesia
Late
Paresis
Pallor
Pulselessness, last occur.
Signs
Decreased sensation of the involved nerves
Pain increases with passively streching the involved
muscles
palpation : tense, wooden

Volkmann Ischemic
contracture

1872 : Richard van

Volkmann

Contracture of forearm and hand following

Supracondylar fracture of humerus.

Anterior compartment
- Muscles : Tib. Ant, Extensors (Dig & Hallucis)
- Artery
: Tib. Ant.
- Nerve
: Deep Peroneal : sensation first dorsal web
of foot

Lateral Compartment
- Muscle : Peroneals (Longus et Brevis)
- Nerve
: Superficial Peroneal : sensation dorsum foot

Deep Posterior compartment

- Muscle : Tib. Post, Flexors (Dig & Hallucis)
- Artery : Tib. Post.
- Nerve : Tib Post. sensation sole of foot

Superficial Posterior Compartment

- Muscle : Gastroc, Soleus, Plantaris
- Nerve : Sural sensation lateral aspect of foot and
distal calf

Treatment of choice for ACS in the lower leg

Fasciotomy - Dermotomy
Incision : the WHOLE length of compartment.

ACS in the lower leg

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

Anterolateral Incision

Posteromedial Incision

TIME factor very important :

- Consensus : 12 hours

> 12 hours : catastrophic clinical result

- Full recovery if within 6 hours
- Exact time of onset : difficult

ACS in the Thigh

Forearm

Contraindication : If ACS in late diagnosed

fasciotomy little benefit probably
contraindicated after 3 4 days.
If performed late severe infection may develops in the
necrotic muscle, even death.
Painlessness / Paralysis (+) no use of fasciotomy.
Post fasciotomy
- Leave the wound OPEN
- Skin graft performed after 1 3 weeks
- Avoid skin graft : silicone sheet coverage
- Do not elevate the limb arterial flow av.
Pressure
gradient

Sepsis

Morfologi TV

LOKASI TREPANASI

LOKASI TREPANASI

LOKASI TREPANASI

Diagnosis
Pada setiap trauma abdomen bawah dan tungkai selalu pikirkan
kemungkinan fraktur pelvis.
Perhatikan mekanisme cedera.
Pemeriksaan klinis :
Jejas pada pelvis/abdomen bagian bawah.
Nyeri tekan pada pelvis.
Ketidakstabilan pada perabaan.
Perbedaan panjang kedua tungkai.
Rectal examination & darah pada MUE.
Hipotensi & tachycardia (bila disertai gangguan hemodinamik).
Radiologis : foto pelvis AP, CT scan

Physical examination

Pemeriksaan fraktur pelvis

Tekan kearah posterior dan
anterior pada krista iliaka
(stabilitas anteroposterior).
Lakukan traksi pada salah
satu tungkai dengan
memfiksasi pelvis (stabilitas
vertikal).

Outlet and inlet view

Pelvic ring

Fraktur Pelvis

Cedera vaskuler
Cedera pada urethra

Klasifikasi fraktur pelvis

Klasifikasi Tile

Tipe A
Stable

Tipe B
Rotationally unstable
Vertically stable
(open book type)

Tipe C
Rotationally and
Vertically Unstable

Pelvic ligaments

Pelvic Ring Anatomy

Stabilisasi pelvis
Mengecilkan
rongga pelvis :
berfungsi
sebagai tampon.
Pelvic sling,
stagen.
Fiksasi eksterna.
Fiksasi interna.

ARTICULATIO GENU

ARTICULATIO GENU

Fraktur pelvis

Fraktur pelvis

Fraktur pelvis

Blunt abdominal trauma

Penetrating abdominal trauma.