• No results found

Bu Bd Uro Ortho Onko Mantap Tutor

N/A
N/A
Protected

Academic year: 2021

Share "Bu Bd Uro Ortho Onko Mantap Tutor"

Copied!
192
0
0

Loading.... (view fulltext now)

Full text

(1)

Surgery

BIMBEL UKDI MANTAP

SURGERY

dr. Andreas W Wicaksono dr. Anindya K Zahra

(2)
(3)
(4)

• 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

(5)

History & Physical:

Grey Turner Sign: Flank

echymosis

Cullen sign: Periumbilical

echymosis

(6)
(7)

Abdomen 3 Posisi

Plain Abdomen LLD:

Subdiaphragmatic Air

(8)
(9)

Ruptur

Uretra

Anterior

Hematom penis

Butterfly

Hematome

Straddle

Injury

(10)

Ruptur Uretra Posterior

(11)
(12)
(13)

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

(14)
(15)
(16)
(17)
(18)

Migrating pain–

appendicitis

Periumbilical pain(colicky pain,

visceral) referred by N. Thoracal X

Mc. Burney pain (irritative

peritoneal pain, somatic)

(19)

Clinical Sign

Obturator sign

• Rovsing’s sign :

palpation in the left

lower quadrant of

abdomen increase the

pain in the right lower

quadrant

(20)
(21)
(22)

Radiology– Ileus

Stepladder pattern Herring bone Coil spring

(23)
(24)
(25)
(26)
(27)
(28)

How Does Colorectal Cancer Develop?

(29)

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

(30)
(31)
(32)

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

(33)

• Internal Hemorrhoids →

Internal hemorrhoidal plexus

– V. Rectus Inferior – V. Rectus Media

• External Hemorrhoids →

external hemrroidal plexus

(34)
(35)

• 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)

(36)
(37)

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 jaundice

Gallstone 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

(38)
(39)

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)

(40)

• 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

(41)

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 (+)

(42)

• Patofisiologi :

(43)

• 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

(44)

• Treatment :

– Non surgery :

• Analgetik & antispasmodik

• Nutrisi parenteral (hindari oral intake)

• Antibiotik profilaksis (mencegah peritonitis & cholangitis)

• Bedrest

– Surgery :

• Laparoscopic cholecystectomy

• Open cholecystectomy

(45)

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 (++)

(46)

• 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)

(47)

ERCP

Alat Dx sekaligus Tx

Pilihan Tx lihat slide sebelumnya...

(48)

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.

(49)

• 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

(50)

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

(51)
(52)
(53)

Hernia Inguinalis Direct/Medial (trigonum hasselbach)

Trigonum hasselbach

Dibentuk tepi MRA, a. epigastrica inferior, lig. Inguinalis

(54)
(55)
(56)
(57)
(58)

Benign Prostat Hyperplasia

• Screening test :

PSA ( Prostat

Specific Antigen),

normal value

<4

ng / ml

Rectal toucher:

–Suspect

malignancy IF

hard, nodular,

irregular

(59)
(60)

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

(61)

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)

(62)
(63)

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

(64)

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

(65)

Batu Saluran Kemih

Nephrolithiasis

Ureterolithiasis

Vesikulolithiasis

(66)
(67)

• 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.

(68)
(69)

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

(70)

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.

(71)
(72)

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.

(73)

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

(74)
(75)

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)

(76)
(77)
(78)
(79)
(80)
(81)
(82)
(83)

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

(84)

Testicular Torsion

• Sign : Sudden pain in

scrotal, nausea and

vomiting, no fever

• Physical Exam

– Cremaster reflex (–)

– Phren sign (-)

(85)

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

(86)
(87)
(88)
(89)
(90)

• Translumination test

/ diapanoscopy

• Positive : Hydrocele,

Hernia Scortalis

(91)
(92)
(93)
(94)
(95)
(96)
(97)
(98)
(99)
(100)
(101)

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

(102)

Fracture Complication

• Late Complications

– Local:

• Delayed Union • Non-union • Malunion • Joint stiffness • Contractures • Osteomyelitis

• Growth disturbance or deformity

• Systemic:

– Gangrene – Tetanus

(103)
(104)
(105)

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

(106)

Humeral Fracture

• Collum chirurgicum:

n. axillaris

• Sulcus radialis (shaft) :

n. radialis

• Distal end :

n. medianus/ n.radial

• Epicondylus medial:

(107)
(108)

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

(109)

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:

(110)

Carpal Tunnel

Syndrome

N. medianus

(111)

GuyonTunnel

Syndrome

Cubital Tunnel

Syndrome

(112)

Claw hand

N. Ulnaris

(113)

Drop hand

N. Radialis

(114)

Preacher’s Hand

N. medianus

(115)
(116)

• 4R :

– 1. Recognition

– 2. Reduction

– 3. Retention

– 4. Rehabilitation

Management of Fracture

(117)

Recognition

• Anamnesis

– History of trauma?

– Mechanism of injury?

– Localized pain, aggravated by movement

– Decreased function

– “heard the bone break”

(118)

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

!

(119)

Reduction

• Restore a fracture to correct allignment

• Closed Reduction

– Traction : Skin traction, skeletal traction

• Open Reduction

– ORIF

– OREF

(120)
(121)

Skeletal Traction

Femur fracture managed with skeletal traction and use of a Steinmann pin in the distal femur.

(122)
(123)

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

(124)

• 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

(125)

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

(126)
(127)
(128)
(129)

Open Reduction To Prevent

Brachial Artery Injury!

(130)

U Slab

• Humeral shaft

fracture

(131)
(132)

Compartment Syndrome

• 6 P of Compartment

Syndrome

– Pain

– Pallor

– Pulseless

– Paresthesis

– Paralysis

– Pressure

• Tx : Fasciotomy

(133)

Fasciotomy

• Casts and tight

bandages

–remove or

loosen any

constricting

bandages

Compartment Syndrome

(134)
(135)
(136)
(137)

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.

(138)
(139)

• 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)

(140)

• Skull involvement may lead to the following:

– Deafness

– Vertigo

– Tinnitus

– Dental malocclusion

– Basilar invagination

(141)

Multiple Myeloma

• Sign : bone pain

• X-ray

(142)

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)

(143)

• 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

(144)

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

(145)

• 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

(146)

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

(147)
(148)
(149)
(150)
(151)

Supracondylar Fracture

• Outstretched arm

• >> children

(152)

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.

(153)
(154)

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

(155)

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.

(156)

Incidence of osteoporotic Fx

Vertebral Fracture Forearm Fracture Hip Fracture

(157)
(158)
(159)
(160)
(161)

Anterior Shoulder

Subluxation/Dislocation

• Radiographs:

True AP Axillary View Y view

(162)

Anterior 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

(163)

Hip Dislocation

Posterior

(flexi, adduksi, endorotasi)

Anterior

(164)

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)

(165)

No osteoblastic appearance,

fracture can be seen

Notice the

osteoblastic-osteolytic appearance

(166)

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.

(167)

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.

(168)
(169)

Ewing’s Sarkoma

• Annual

incidence at

birth to 20 y.o

(teenagers and

young adult)

• Most common

site :

pelvis

• Radiologic :

onion peel

(170)
(171)

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

(172)

Diagnosis

• Weakness in plantar flexion

• Gap in tendon

• Palpable swelling

• Positive Thompson test

(173)
(174)
(175)
(176)
(177)
(178)

The Breast

Tumors Onset Feature

Breast 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

(179)
(180)
(181)

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

(182)

Epidermoid Cyst

• Benign cyst underneath

skin that arise with

ruptured pilosebaceous

follicle

• Associated with trauma

(piercing-needle)

• Common location :

(183)

Demoid Cyst

• An abnormal growth

(teratoma) containing

epidermis, hair follicles,

and sebaceous glands,

derived from residual

embryonic cells.

• Common site :

– Periorbital

– Ovarian

– Spinal

(184)

Atheroma

• Cause by blockage of

the duct of

sebacceous gland

• Also known as

Retention Cyst

• Puncta (+)

(185)

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.

(186)

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

(187)
(188)

Galactocele

• Galaktokel

merupakan massa

berisi susu yang

tersumbat apada

duktus laktiferus.

• Px :

– Solid mass

(189)
(190)

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

(191)

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

(192)

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

Physical

Examination

References

Related documents

Article 1977 (1) of Indonesian Civil Code implies that the possession of objects or assets could constitute an ownership of those objects for the bearer. Those two

Table 9 shows the descriptive statistics of each variable: personal attitude (PROAP), subjective norm (PRONS), perceived behavioural control (PROCCP) and

While the fruit juice concen- trates division is expected to report weaker revenues and operating profit because of lower sales revenues, we expect the fruit preparations division

in favour of the hypo thes is tha t sugges ts tha t TCR rearrangemen t can be inf luenced by gene t ic background.. The reason beh ind th is d ifference is

Collecting without enquiry Cheque signed by the employee for his personal account drawn on his employer’s account – Lloyds Bank v Chartered Bank of India, Australia &amp; China.

The diameter of the bolt shank is assumed to fully fit in the bolt hole. As illustrated, the position of origin is pointed by the arrow; direction represents the length of the

It is not about creating a foreign ministry itself EU, because the establishment of the EEAS shall not affect the right of Member States to act on their own through

FTIR spectrum of the nanosized tin dioxide powder prepared by microwave assisted liquid mixed technique method is shown in Figure 3.T he broad band around 3600- 3201