Surgery
BIMBEL UKDI MANTAP
SURGERY
dr. Andreas W Wicaksono dr. Anindya K Zahra
• Kehr’s sign : pain in
the left tip shoulder
cause by irritation of
peritoneum that
covers inferior
surface of left
diaphragm >> a sign
of rupture spleen
Kehr’s sign
History & Physical:
Grey Turner Sign: Flank
echymosis
Cullen sign: Periumbilical
echymosis
Abdomen 3 Posisi
Plain Abdomen LLD:
Subdiaphragmatic Air
Ruptur
Uretra
Anterior
Hematom penis
Butterfly
Hematome
Straddle
Injury
Ruptur Uretra Posterior
0 1 2 3 4 Eritem (dalam 12jam) < 3cm 3-12cm >12-25cm >25cm > ekstremitas Gejala Sistemik - - Mual, pusing Shock, Petechie, echymosis Gagal ginjal akut, coma, perdarahan
Migrating pain–
appendicitis
Periumbilical pain(colicky pain,
visceral) referred by N. Thoracal X
Mc. Burney pain (irritative
peritoneal pain, somatic)
Clinical Sign
Obturator sign
• Rovsing’s sign :
palpation in the left
lower quadrant of
abdomen increase the
pain in the right lower
quadrant
Radiology– Ileus
Stepladder pattern Herring bone Coil spring
How Does Colorectal Cancer Develop?
CRC Risk Factor
• >60 yo
• Family history (+): mutasi gen
• Familial adenomatous polyposis
• Low fiber diet
• IBD
Screening Test:
• FOBT
• Colonoscopy
• CEA
(Carcinoembryonic Antigen). Normal <2,5ng/ml
Hemorrhoid
External Hemorrhoids Internal Hemorrhoids
Outside anal canal, around sphincter Inside anal canal
Symptoms due to thrombosis Symtomps due to bleeding and/or irritation of mucosa
Painless, bleeding
Prolapse associated with defecation
Can not be inserted to anal canal Can be inserted to anal canal up to grade III
• Internal Hemorrhoids →
Internal hemorrhoidal plexus
– V. Rectus Inferior – V. Rectus Media
• External Hemorrhoids →
external hemrroidal plexus
• Tx:
– Non Farmakologis
• Changing lifestyle
(menghindari risk
factor)
• Diet tinggi serat
• Endoskopi (Rubber
band & Sclerotherapy)
– Farmakologis
• Fecal softener
• Fiber supplement
• NSAID
– Surgery
• Electrocautery &
Cryosurgery
• Hemorrhoidectomy
(excision or stapled)
Biliary Tract Disorders
• 4F: Female, forty, fat, fertile • Seringkali asimptomatik
• Simptomatik: biliary colic (terutama stlh makan berlemak) pd epigastrium atau RUQ
Gallstone disease
(cholelithiasis)
• Trias dx: Fever, Leukositosis, RUQ Tenderness • Murphy sign (+)
• Biliary colic > memburuk secara progresif, radiasi ke interscapular area, scapula & bahu dextra
Acute Cholecystitis
• Asymptomatic • Biliary colic • Obstructive jaundiceGallstone in CBD
(choledocholithiasis)
• Trias Charcot: 1. jaundice, 2. fever, usually with rigors,
3. RUQ abdominal pain.
• Severe: hypotension, altered mental status
Cholangitis
• Cholestasis jaundice with increase of direct bilirubin • 80% pd bile duct di atas level porta hepatis
Congenital : Atresia
bilier
Gallstone Disease / Cholelithiasis
• Terbentuk di gallbladder. Bisa bermigrasi ke distal : ductus cysticus, ductus choledocus, ductus pancreaticus atau Ampula vater.
• Tipe :
– 80% cholesterol & mixed stone – 20% pigmented stone
• Cholesterol & mixed stone
– Konten : kolesterol monohidrat, garam Ca, bile pigment, protein & fatty acid
– Mekanisme penting : increased biliary secretion of cholesterol, biasa pada pasien obese atau
diet tinggi kolesterol
• Pigmented stone
– Konten : kalsium bilirubinat (dominan) – Biasa pd pasien chronic hemolytic disease
atau alcoholic cirrhosis
• Dx :
– Plain film > deteksi radiopaque kalsium (kasus: 10-15% kolesterol & 50% pigmented stone)
• Sign & symptom :
– Seringkali asymptomatik (terutama di dlm gall bladder)
– Symptomatis jika sudah menimbulkan inflamasi atau obstruksi
– Gejala plg spesifik & khas: biliary colic. Yaitu severe pain (akibat
biliary contraction, terutama stlh makan berlemak) pd
epigastrium atau RUQ yg sering radiasi ke daerah interscapular,
scapula dextra dan bahu dextra
– Nausea & vomit sering menyertai biliary colic
• Temuan Klinis :
– Fever (biasanya sdh komplikasi / peradangan)
– Serum bilirubin (++)
– Alkaline phospatase (++)
• Lokasi tersering terjadi sumbatan / inflamasi :
– Ductus cysticus
Cholecystitis
• Berdasar penyebab :
– Calculous cholecystitis (90-95%) :
terutama akibat obstruksi gallstone pada ductus cysticus
– Acalculous cholecystitis (5-10%) : jarang, penyebab bervariasi: trauma adenocarcinoma gallbladder
torsi gallbladder dan DM.
• Sign & symptom :
– Biliary colic > memburuk secara progresif
– Radiasi ke interscapular area, scapula & bahu dextra (tanda terjadi iritasi pd diafragma – sensasi nyeri o/ n.phrenicus > C3-C5 dextra) – Anorexia, nausea & vomit
– Jaundice (uncommon) – Murphy sign (+)
• Patofisiologi :
• Temuan Klinis :
– Fever
– Leukositosis (10.000-15.000 cells/uL)
– RUQ tenderness
– Serum bilirubin (mildly elevated, no symptom)
– Murphy Sign (+)
• Dx :
– Berdasar triad &
temuan klinis lain
– USG (identifikasi thickening of gallbladder wall)
– CT-scan
• Komplikasi :
– Gangren & perforasi > bs diikuti abscess jika ada
superinfeksi bakteri > bs generalized peritonitis
– Fistulization : biliary-enteric fistula
Trias
• Treatment :
– Non surgery :
• Analgetik & antispasmodik
• Nutrisi parenteral (hindari oral intake)
• Antibiotik profilaksis (mencegah peritonitis & cholangitis)
• Bedrest
– Surgery :
• Laparoscopic cholecystectomy
• Open cholecystectomy
Choledocholithiasis
• 10-15% pasien cholelithiasis
• Penyebab :
– Gallstone (pigmented stone)
– Sering pada pasien dgn kronik
hemolytic disease
• Sign & symptom :
– Asymptomatic
– Biliary colic
– Obstructive jaundice
• Px lab (mirip dgn cholelithiasis) :
– Serum bilirubin (++)
• Komplikasi :
– Cholangitis
• Terjadi akibat ascending infection dari bacteria di duodenum. Bisa terjadi krn bile duct sudah terobstruksi oleh gallstone.
• Medical emergency
• Sign & symptom : jaundice, fever, malaise, rigor & abdominal pain (severe : hypotension & confusion)
• Gambaran duktus : dilated, sclerosed & strictured ducts • Initial Tx : IV fluid & antibiotik
– Pancreatitis
• Px penunjang :
– Cholangiography
– ERCP & MRCP
– USG
• Tx :
– Choledocholithotomy
– ERCP (Modalitas intervensi: endoscopic sphincterotomy,
stone removal, insertion of stent, dilation of stricture)
ERCP
Alat Dx sekaligus Tx
Pilihan Tx lihat slide sebelumnya...
Biliary Atresia
• Kelainan kongenital yg cukup jarang
(1 per 15.000 kelahiran), tapi
kejadian ini 25-30% berhubungan
dgn anomali lain seperti
stenosis/atresia duodeni, pancreas
annulare, dll.
• 80% pd bile duct di atas level porta
hepatis, 15% pada ductus
choledochus, dan 5% pada ductus
hepaticus communis.
• Etiologi : intrauterine inflammatory
process caused by fibrosis of both
the intrahepatic & extra hepatic
biliary tree.
• Murphy’s sign
: the patient stop resp. effort
when we deep palpate the RUQ >
Cholecystitis
• 4F : Fat, Forty, Female, Fertile >
Cholelithiasis
• Trias Charcot : >
Cholangitis
– Fever
– Ikterik
Puddle Sign
• PUDDLE SIGN
– For ascites 120ml
– Prone for 5 mins– Rise onto elbow & knee – Stethoscope at bottom
– Flicks near flank repeatedly
– Move stethoscope away sound becomes louder
• SHIFTING DULLNESS
– For ascites
500ml
Hernia Inguinalis Direct/Medial (trigonum hasselbach)
Trigonum hasselbach
Dibentuk tepi MRA, a. epigastrica inferior, lig. Inguinalis
Benign Prostat Hyperplasia
• Screening test :
PSA ( Prostat
Specific Antigen),
normal value
<4
ng / ml
•
Rectal toucher:
–Suspect
malignancy IF
hard, nodular,
irregular
IPSS: WISE & FUN
W eak stream
I ntermittensi
S training
E mptying incomplete
F requecy
U rgency
N octuria
PENANGANAN / PENGOBATAN BPH
Dulu: Mencegah / menurunkan angka kematian karena BPH
Sekarang: Meningkatkan kualitas hidup
ALTERNATIF PENANGANAN BPH
• IPSS <8 Watchful Waiting
• IPSS 8-18 Pemberian obat
• Alpha1 adrenergik blocker
(Prazosin)
• 5 Alpha reductase inhibitor
(Finasterid)
• IPSS >18 Operatif
Invasive: open prostatecomy
Less Invasive: TURP
WATCHFUL WAITING
• Sebagian besar tanpa keluhan
• Tanpa penyulit / gejala
• Kualitas hidup tetap baik
INDIKASI
• BPH dengan IPSS ringan (<8)
• Baseline data normal
• Flowmetri : non obstruktif
FOLLOW-UP
• Tiap 3-6 bulan
• Ulangi :
• IPSS
• Flow (6 bulan)
• PSA (6-12 bulan)
TERAPI BPH DENGAN
BLOCKER
INDIKASI :
• IPSS ringan dan sedang
SYARAT :
• Normotensi / hipertensi ringan
• Urin normal
• Faal Ginjal Normal
• PSA
4 ng%
• Miokard Infark (-), CVA (-)
KONTRAINDIKASI
• Hipotensi postural / ortostatik
• Alergi terhadap
bloker
TERAPI PEMBEDAHAN BPH
Di Amerika : 300.000 – 400.000/tahun
Di Urologi RS Dr. Soetomo
Ke 2 terbanyak setelah urolithiasis
150/tahun
INDIKASI TERAPI PEMBEDAHAN BPH
• Retensi urin akut
• Retensi urin kronis (selalu > 300 ml)
• Residual urin > 100 ml
• BPH dengan penyulit
• Terapi medikamentosa tidak berhasil
• Flowmetri obstruktif
INDIKASI KONTRA TERAPI PEMBEDAHAN BPH
• Infark miokard Akut
• CVA Akut
PEMBEDAHAN BPH
• TUR Prostat: 90 – 95%
• Open prostatektomi
: 5 – 10 %
• BPH yang besar
(>50 – 100 gram)
Tidak habis
direseksi dalam
1 jam
• Disertasi :
• Batu buli besar
(> 2.5 cm)
• Multipel
• Fasilitas TUR tidak
ada
Batu Saluran Kemih
Nephrolithiasis
Ureterolithiasis
Vesikulolithiasis
• menyerupai tanduk rusa.
• rektum.
Lokasi Gejala
GINJAL Nyeri regio flank, dapat berupa
- Nyeri kolik akibat aktivitas peristaltik otot polos sistem kalises, atau - Nonkolik akibat peregangan kapsul ginjal, hidronefrosis, atau infeksi pada ginjal
URETER Nyeri pinggang kolik dan menjalar, tergantung letak batu: - Proksimal pinggang setinggi pusar (T10)
- Medial medial paha/skrotum (L1-3) - Distal ujung penis (S2-3), +disuria
VESICA Gejala iritasi, miksi tiba-tiba berhenti dan menjadi lancar kembali dengan perubahan posisi tubuh.
Nyeri berkemih pada ujung penis, skrotum, perineum, pinggang, atau kaki. Anak sering mengeluh enuresis nokturna, sering menarik-narik penisnya (laki-laki) atau menggosok-gosok vulva (perempuan)
URETHRA Miksi tiba-tiba berhenti retensi urin. Batu pada uretra - Anterior benjolan keras di penis, atau tampak di meatus uretra eksterna. Nyeri pada glans penis.
Diagnosis –Px Penunjang
Urinalisis
• Hematuria, kristal, tanda infeksi
Darah Rutin dan Kimia Darah
• Terutama ureum, creatinin, asam urat
Radiologi
• BNO hanya untuk batu
radioopak (kalsium, sistin)
• IVP bisa untuk batu
non-opak (urat, struvit)
• USG aman untuk ibu hamil dan yang KI IVP
Struvite Stones
• >>
women
• Struvite (magnesium ammonium phosphate) stone
• Infection with urease producing bacteria
(e.g. Proteus,
Klebsiella, Pseudomonas and Enterobacter), resulting in
hydrolysis of urea into ammonium and
increase in the
urinary pH
6,10.
• They can grow very large and form a cast of the renal pelvis
and calices resulting in so-called
staghorn calculi
. The
struvite accounts for approximately 70% of these calculi,
and
is usually mixed with calcium phosphate
thus
rendering them
opaque
. Uric acid and cystine are also
found as minor components.
Faktor Risiko –
Batu Kalsium
(70-80%):• Hiperkalsiuri
– absobtif
– renal (reabsorbsi turun)
– resorptif (kalsium tulang) pada hiperparatiroidisme • Hiperoksaluri
– post operasi usus atau banyak konsumsi makanan yang kaya oksalat (teh, kopi instan, soft drink, dll)
• Hiperurikosuria
– asam urat bertindak sebagai inti batu/nidus untuk terbentuknya batu kalsium oksalat.
• Hipositraturia
– Di dalam urine, sitrat bereaksi dengan kalsium membentuk kalsium sitrat cegah ikatan kalsium dengan oksalat atau fosfat.
• Hipomagnesuria.
– Di dalam urine magnesium bereaksi dengan oksalat menjadi magnesium oksalat cegah ikatan kalsium dengan oksalat.
Prevensi Batu Kalsium
• Menurunkan konsentrasi kalsium dan oksalat
• Meningkatkan konsumsi sitrat
minum jeruk nipis/air
lemon sesudah makan malam
• Meningkatkan asupan cairan
• Hindari soft drink (>1 L/minggu)
• Batasi asupan protein (1 gr/kgBB/hari).
– Protein tinggi
ekskresi kalsium & asam urat,
sitrat
• Batasi asupan natrium
reabsorpsi kalsium
Bladder Carcinoma
• Cancer age
• Painless gross
hematuria all along
micturition, reccurent
• Risk factor
– Male
– Cigarette
– Amine aromatic
substance exposure
(paint, textile)
– UTI
• 90%: Transitional Cell
Carcinoma (TCC)
Scrotal Swelling
Disorders Etiology Clinical
Testicular torsion Intra/extra-vaginal torsion
Sudden onset of severe testicular pain followed by inguinal and/or scrotal swelling. Gastrointestinal upset with nausea and vomiting.
Hidrocele Congenital anomaly, blood blockage in the spermatic cord
Inflammation or injury
accumulation of fluids around a testicle, swollen testicle,Transillumination +
Varicocoele Vein insufficiency Scrotal pain or heaviness, swelling. Varicocele is often described as feeling like a bag of worms Hernia skrotalis persistent patency of
the processus vaginalis
Mass in scrotum when coughing or crying. Bowel sound on scrotum. Strangulated → nausea,
vomiting, fever, edematous, erythematous, discolored
Orchitis Mumps virus Testicular pain and swelling, fatigue, fever, chills, Testicular enlargement, induration of the testis, Erythematous scrotal skin
Testicular Torsion
• Sign : Sudden pain in
scrotal, nausea and
vomiting, no fever
• Physical Exam
– Cremaster reflex (–)
– Phren sign (-)
Phren’s sign
• Prehn's sign, the physical lifting of the testicles
relieves the pain
– Negative Prehn's sign
indicates
no pain relief
with
lifting the affected testicle, which points towards
testicular torsion which is a surgical emergency
and must be relieved within 6 hours
– Positive Prehn's sign indicates there is pain relief
with lifting the affected testicle, which points
• Translumination test
/ diapanoscopy
• Positive : Hydrocele,
Hernia Scortalis
Complication of Fracture
Early complications
• Local:
– Vascular injury causing haemorrhage, internal or external
– Visceral injury causing damage to structures such as brain, lung or bladder
– Damage to surrounding tissue, nerves or skin – Haemarthrosis
– Compartment syndrome (or Volkmann's ischaemia) – Wound infection, more common for open fractures
• Systemic:
– Fat embolism – Shock
Fracture Complication
• Late Complications
– Local:
• Delayed Union • Non-union • Malunion • Joint stiffness • Contractures • Osteomyelitis• Growth disturbance or deformity
• Systemic:
– Gangrene – Tetanus
Fraktur clavicula:
>>
di 1/3 lateral
, pada anak2.
• Fragmen medial clavicula terangkat
krn m. SCM, fragmen lateral jatuh
(shoulder drop), dan proksimal humerus
tertarik ke medial krn m. pectoralis major.
• Pada anak, fraktur terjadi inkomplit,
disebut greenstick fracture.
Fraktur Humerus:
• >> di collum chirurgicum, pada lansia
osteoporosis.
• Pada tuberculum majus : avulsion
fracture.
• Direct contact bagian humerus dgn
nervus:
1) collum chirurgicum: n. axillaris,
2) sulcus radialis: n. radialis,
3) akhir distal: n. medianus,
4) epicondylus medial: n. ulnaris
Fraktur scapula:
Banyak terjadi pada acromion.
Fraktur scaphoid:
Fraktur carpal tersering.
Fraktur – avaskuler – nekrosis –
degenerasi; diTx bedah penyatuan
os carpal = arthrodesis
Fraktur hamatum:
Bisa melukai n. et a. ulnaris
Fraktur metakarpal:
Fraktur metakarpal 5 (boxer’s
fracture)
Fraktur falang:
Distal – comminuted, painful
hematome. Proksimal – hati2
tendon flexor
Humeral Fracture
• Collum chirurgicum:
n. axillaris
• Sulcus radialis (shaft) :
n. radialis
• Distal end :
n. medianus/ n.radial
• Epicondylus medial:
Cubital Tunnel syndrome:
Penekanan n. ulnaris saat melewati cubital tunnel.
Cubital tunnel = saluran yang terbentuk oleh arcus tendineus m. flexor
carpi ulnaris yang mengubungkan humerus dan ulna.
Tanda gejala: lesi n. ulnaris pada sulcus ulnaris di posterior epycondylus
medialis.
Guyon Tunnel Syndrome:
Penekanan n. ulnaris saat melewati canalis ulnaris (Guyon tunnel).
Guyon tunnel = saluran yanng dibentuk oleh os pisiform dan hammulus os
hammati
Carpal Tunnel Syndrome:
Penekanan struktur-struktur yang melewati carpal tunnel (canalis carpalis),
terutama n. medianus.
Canalis carpalis = saluran yang berada di pergelangan tangan dan dibentuk
oleh os carpal dan retinaculum flexorum.
Tanda gejala: paresthesia, hypoesthesia, atau anesthesia pada 3 ½ lateral
jari tangan
Nerve Injury
• N. Axilaris :
m.deltoideus, sensoris:
bahu
• N. Muskulokutaneus:
compartemen anterior
brachium
– m.bisep brachii
– m. brachialis
– m.coracobrachialis
• N. Ulnaris: Claw hand
• N. Radialis: Drop hand
(can’t extend hand)
• N. Medianus:
Carpal Tunnel
Syndrome
N. medianus
GuyonTunnel
Syndrome
Cubital Tunnel
Syndrome
Claw hand
N. Ulnaris
Drop hand
N. Radialis
Preacher’s Hand
N. medianus
• 4R :
– 1. Recognition
– 2. Reduction
– 3. Retention
– 4. Rehabilitation
Management of Fracture
Recognition
• Anamnesis
– History of trauma?
– Mechanism of injury?
– Localized pain, aggravated by movement
– Decreased function
– “heard the bone break”
LOOK (Inspection)
Symetricity right-left
Swelling, wound, deformity (angulation, rotation,
shortening), abnormal movement, discoloration
(ecchymoses)
Bone exposure
FEEL (Palpation)
Localized tenderness
Distal neurological status (S&M), pulsation
Aggravation of pain and muscle spasm during even the
slightest passive movement
Feeling and listening the crepitus
unnecesary
!
Reduction
• Restore a fracture to correct allignment
• Closed Reduction
– Traction : Skin traction, skeletal traction
• Open Reduction
– ORIF
– OREF
Skeletal Traction
Femur fracture managed with skeletal traction and use of a Steinmann pin in the distal femur.
Indications for External Fixation
• Open fractures that have
significant soft-tissue
disruption (eg, type II or III
open fractures)
• Soft-tissue injury (eg, burns)
• Pelvic fractures
• Severely comminuted and
unstable fractures
• Fractures that are associated
with bony deficits
• Fractures associated with
infection or nonunion
• Closed reduction is needed if the fracture is significantly displaced or angulated. Indications for surgical intervention include the following:
– Failed nonoperative (closed) management
– Unstable fractures that cannot be adequately maintained in a reduced position
– Displaced intra-articular fractures (>2 mm)
– Patients with fractures that are known to heal poorly following nonoperative management (eg, femoral neck fractures)
– Large avulsion fractures that disrupt the muscle-tendon or ligamentous function of an affected joint (eg, patella fracture)
– Impending pathologic fractures
– Multiple traumatic injuries with fractures involving the pelvis, femur, or vertebrae
– Unstable open fractures or complicated open fractures
– Fractures in individuals who are poor candidates for nonoperative
management that requires prolonged immobilization (eg, elderly patients with proximal femur fractures)
– Fractures in growth areas in skeletally immature individuals that have increased risk for growth arrest (eg, Salter-Harris types III-V)
– Nonunions or malunions that have failed to respond to nonoperative treatment
Bidai /Splint adalah alat yang digunakan untuk mengimobilisasi
bagian tubuh, alat tersebut dapat bersifat lunak ataupun kaku
(rigid)
• Plaster slab adalah lempengan gips untuk imobilisasi sendi atau
daerah cidera sehingga terjadi penyembuhan. Sebagian besar
fraktur dislab untuk 24-48 pertama untuk mengakomodasi
pembengkakan, sebelum dipasang gips sirkuler.
• Lempengan Gips/CAST → Dapat Digunakan Pada
– Imobilisasi Fraktur
– Imobilisasi pada penyakit tulang dan sendi – Pencegahan deformitas muskuloskeletal
Retention / Immobilization
* Aryadi K, Syaiful AH. Penggunaan Gips Paris. In: Petunjuk pemasangan gips paris pada kasus orthopaedi, Divisi Orthopaedi dan traumatologi, 2006. hal 2-6
Open Reduction To Prevent
Brachial Artery Injury!
U Slab
• Humeral shaft
fracture
Compartment Syndrome
• 6 P of Compartment
Syndrome
– Pain
– Pallor
– Pulseless
– Paresthesis
– Paralysis
– Pressure
• Tx : Fasciotomy
•
Fasciotomy
• Casts and tight
bandages
–remove or
loosen any
constricting
bandages
Compartment Syndrome
Paget’s Disease
• Paget disease is a localized disorder of bone
remodeling that typically
begins with
excessive bone resorption followed by an
increase in bone formation
. This osteoclastic
overactivity followed by compensatory
osteoblastic activity leads to a structurally
disorganized mosaic of bone (woven bone),
which is mechanically weaker, larger, less
compact, more vascular, and more susceptible
to fracture than normal adult lamellar bone.
• Sign and Sympton including the following:
– Bone pain (the most common symptom)
– Secondary osteoarthritis (when Paget disease
occurs around a joint)
– Bony deformity (most commonly bowing of an
extremity)
– Excessive warmth (due to hypervascularity)
– Neurologic complications (caused by the
compression of neural tissues)
• Skull involvement may lead to the following:
– Deafness
– Vertigo
– Tinnitus
– Dental malocclusion
– Basilar invagination
Multiple Myeloma
• Sign : bone pain
• X-ray
Multiple Myeloma
• Symptomatic myeloma:
– Clonal plasma cells >10% on bone marrow biopsy or (in
any quantity) in a biopsy from other tissues
(plasmacytoma)
– A monoclonal protein (paraprotein) in either serum or
urine (except in cases of true non-secretory myeloma)
– Evidence of end-organ damage felt related to the plasma
cell disorder (related organ or tissue impairment, ROTI,
commonly referred to by the acronym "CRAB"):
• HyperCalcemia (corrected calcium >2.75 mmol/L) • Renal insufficiency attributable to myeloma
• Anemia (hemoglobin <10 g/dL)
• Bone lesions (lytic lesions or osteoporosis with compression fractures)
• Asymptomatic (smoldering) myeloma:
– Serum paraprotein >30 g/L AND/OR
– Clonal plasma cells >10% on bone marrow biopsy AND
– NO myeloma-related organ or tissue impairment
• Monoclonal gammopathy of undetermined
significance (MGUS):
– Serum paraprotein <30 g/L AND
– Clonal plasma cells <10% on bone marrow biopsy AND
– NO myeloma-related organ or tissue impairment
Osteomyelitis
• Inflammation of the
bone and bone marrow
caused by an infecting organism.
• Although bone is normally resistant to bacterial
colonization, events such as
trauma, surgery,
presence of foreign bodies, or prostheses
may
disrupt bony integrity and lead to the onset of
bone infection
• Pathogenesis (Waldvogel, 1971) :
1.
Hematogenous
2.
Contiguous focus of infection
3.
Direct inoculation
• Osteomyelitis is often diagnosed clinically with nonspecific
symptoms
– fever,
– chills,
– fatigue,
– lethargy,
– irritability.
• The classic signs of inflammation,
including local pain,
swelling, or redness
, may also occur and normally disappear
within 5-7 days
Osteomyelitis
• S aureus
is the most common pathogenic
organism recovered from bone, followed
by Pseudomonas and Enterobacteriaceae.
• Less-common organisms involved include
anaerobe gram-negative bacilli.
• Intravenous drug users may acquire
pseudomonal infections
• Acute hematogenous osteomyelitis has a
predilection for the long bones of the body.
• The ends of the bone near the growth
plate (the metaphysis) is made of a maze
like bone called cancellous bone.
• It is here in the rapidly growing
metaphysis
Supracondylar Fracture
• Outstretched arm
• >> children
Elbow Dislocation
• Elbow dislocations are not common
• Falls onto an outstretched hand, usually there is a
turning motion in this force drive and rotate
the elbow out of its socket
• Elbow dislocations can also happen in car
accidents
• The elbow is stable because of the combined
stabilizing effects of bone surfaces, ligaments,
and muscles. When an elbow dislocates, any or
all of these structures can be injured to different
degrees.
Osteoporosis
A systemic skeletal disease characterized
by low bone mass and micro architectural
deterioration of bone tissue lead to bone
fragility and susceptibility to fracture
Densitometri Osteoporosis
Level Definition
Normal Bone density is within 1 SD (+1 or −1) of the young adult mean.
Low bone mass Bone density is between 1 and 2.5 SD below the young adult
mean (−1 to −2.5 SD).
Osteoporosis Bone density is 2.5 SD or more below the young adult mean
(−2.5 SD or lower).
Severe
(established) osteoporosis
Bone density is more than 2.5 SD below the young adult mean, and there have been one or more osteoporotic fractures.
Incidence of osteoporotic Fx
Vertebral Fracture Forearm Fracture Hip FractureAnterior Shoulder
Subluxation/Dislocation
• Radiographs:
True AP Axillary View Y viewAnterior Shoulder Subluxation/Dislocation
• Dislocation:
– Complete separation of articular surfaces
• Subluxation:
– Abnormal translation of humeral head on glenoid without
complete separation of articular surfaces
• Humeral head can dislocate
anteriorly, posteriorly or
inferiorly
• Anterior dislocation most
common
• Mechanism:
– Forced extension, abduction, external rotation
– Direct blow to posterior or posterolateral shoulder
– Repeated episodes of overuse (subluxation)
• Physical Exam:
– Intense pain
– Arm held in adduction & external rotation
– Humeral head palpable anteriorly – Unable to completely internally
rotate or abduct the shoulder – Thorough neuro exam (close
Hip Dislocation
Posterior
(flexi, adduksi, endorotasi)
Anterior
Osteosarcoma
• X-rays of area of suspected infection would
not demonstrate darkened areas typical of
osteomyelitis.
• Conventional features
– Destruction of normal trabecular bone pattern
– a mixture of radiodense and radiolucent areas
– periosteal new bone formation
– formation of Codman's triangle (triangular
elevation of periosteum)
No osteoblastic appearance,
fracture can be seen
Notice the
osteoblastic-osteolytic appearance
Codman triangles (white arrow); and the large soft tissue mass (black arrow)
Osteosarcoma of the distal femur,
demonstating dense tumor bone formation and a sunburst pattern of periosteal reaction.
Periosteal reactions
onion-skin
(Ewing’s sarkoma) "sunburst" and "hair-on-end" periosteal reaction
Codman's triangle
• Radiographs of the primary tumor usually show a large, destructive, mixed lytic and blastic mass. The tumor
frequently breaks through the cortex and lifts the periosteum, resulting in reactive periosteal bone formation. The triangular shadow between the cortex and raised ends of periosteum is known radiographically as
Codman triangle and is
characteristic, but not diagnostic of this tumor.
Ewing’s Sarkoma
• Annual
incidence at
birth to 20 y.o
(teenagers and
young adult)
• Most common
site :
pelvis
• Radiologic :
onion peel
Acute Achilles Tendon Rupture
• Adults 40-50 y.o.
primarily affected (M>F)
• Athletic activities,
usually with sudden
starting or stopping
• “Snap” in heel with pain,
which may subside
Diagnosis
• Weakness in plantar flexion
• Gap in tendon
• Palpable swelling
• Positive Thompson test
The Breast
Tumors Onset FeatureBreast cancer 30-menopause Invasive Ductal Carcinoma , Paget’s disease (Ca Insitu), Peau d’orange , hard, Painful, not clear border,
infiltrative, discharge/blood, Retraction of the nipple,Axillary mass
Fibroadenoma mammae
< 30 years They are solid, round, rubbery lumps that move freely in the breast when pushed upon and are usually painless. Fibrocystic
mammae
20 to 40 years lumps in both breasts that. increase in size and
tenderness just prior to menstrual bleeding. occasionally have nipple discharge
Mastitis 18-50 years Localized breast erythema, warmth, and pain. May be lactating and may have recently missed feedings.fever. Philloides
Tumors
30-55 years intralobular stroma . “leaf-like”configuration.Firm, smooth-sided, bumpy (not spiky). Breast skin over the tumor may become reddish and warm to the touch. Grow fast.
Duct Papilloma 45-50 years occurs mainly in large ducts, present with a serous or bloody nipple discharge , mass ussually small, not always palpable
Biopsy
Excisional or incisional biopsy
• In this type of biopsy, a surgeon cuts through the skin to remove the entire tumor (called an excisional biopsy) or a small part of a large tumor (called an incisional
biopsy).
Enucleation
• surgical removal of a mass without cutting into or dissecting it. Eg: eye, oral pathology, uterine fibroids (without hysterectomy)
FNA
• does not require an incision
Core biopsy
• uses needles that are slightly larger than those used in FNA • Local anasthesia
Epidermoid Cyst
• Benign cyst underneath
skin that arise with
ruptured pilosebaceous
follicle
• Associated with trauma
(piercing-needle)
• Common location :
Demoid Cyst
• An abnormal growth
(teratoma) containing
epidermis, hair follicles,
and sebaceous glands,
derived from residual
embryonic cells.
• Common site :
– Periorbital
– Ovarian
– Spinal
Atheroma
• Cause by blockage of
the duct of
sebacceous gland
• Also known as
Retention Cyst
• Puncta (+)
Callus & Clavus
• Callus: toughened area of
skin which has become
relatively thick and hard
in response to repeated
friction, pressure, or
other irritation.
• Clavus: specially-shaped
callus of dead skin that
usually occurs on thin or
glabrous (hairless and
smooth) skin surfaces,
especially on the dorsal
surface of toes or fingers.
Diagnosis banding benjolan payudara
• infeksi payudara dengan tanda radang lengkap, dapat menjadi abses, terjadi pada ibu menyusui
Mastitis
• tumor jinak, biasa terjadi pada usia muda (15-30
tahun), konsistensi kenyal, batas tegas, tidak nyeri, dan mobile
Fibroadenoma
mammae (FAM)
• tumor berbatas tidak tegas, konsistensi kenyal atau kistik, nyeri terutama saat menjelang haid, membesar, bilateral atau multipel.
Kelainan fibrokistik
• menyerupai FAM yang besar, bulat lonjong, batas tegas, mobile, ukuran dapat mencapai 20-30 cm
Kistosarkoma
filoides
• massa kistik akibat tersumbatnya duktus laktiferus pada ibu yang baru menyusui
Galactocele
• Galaktokel
merupakan massa
berisi susu yang
tersumbat apada
duktus laktiferus.
• Px :
– Solid mass
Appendicitis
Ileus
Peritonitis
• The most common
general surgical
emergency
• Peak 10-30 y.o
• Male > 1.3x
• Obstruction: lymphoid
hyperplasia, fecalith, etc
Obstructive Ileus:
- Inside lumen, In the
wall, outside the wall
- High level, low level
-Primary, secondary
- Localized,
generalized
Appendicitis
Ileus
Peritonitis
Cardinal
symptoms
- migrating pain
(periumbilical to
RLQ)
- nausea and
vomiting
- abdominal pain
- vomiting
- no defecation
and flatus
- meteorismus,
distension
- abdominal pain
- meteorismus
- nausea, vomiting
- no defecation
and flatus
- restlessness
Anamnesis
Appendicitis Ileus Peritonitis Physical Examination • tenderness and rebound tenderness at McBurney point • Rovsing’s sign • Psoas sign • Obturator sign
• scar, distension, darm contour, darm steifung • hyperperistaltic (early), metallic sound, absence of bowel sound (late) • diffuse tenderness, hernia • absence of bowel sound • loss of liver dullness (perforation) • shifting dullness • defans muscular
Rectal touche • tenderness • impact faeces • rectal tumour • blood or mucus • collapse of ampulla recti (obstructive) • tenderness