Presented on 16th Basic Surgical Course For Nurse

by :
HARI KISWANTO

CENTRAL OPERATION THEATRE

DR SARDJITO HOSPITAL
YOGYAKARTA
REVIEW OF MUSCULOSKELETAL SYSTEM

A musculoskeletal system is an organ system that gives

animals (including humans) the ability to move using the
muscular and skeletal systems. The musculoskeletal system
provides form, support, stability, and movement to the body. It is
made up of the body's bones (the skeleton), muscles, cartilage,
tendons, ligaments, joints, and other connective tissue that
supports and binds tissues and organs together.

A. THE BONE.
According to it’s shape,bone divide into 5 major classification:
 Long bone  FEMUR, HUMERUS
 Short bone  METACARPAL
 Flat bone  CRANIUM
 Irregular bone  VERTEBRA
 Sesamoid bone  PATELA.
B. MUSCLE
There are three types of muscles—cardiac, skeletal, and
smooth. Smooth muscles are used to control the flow of
substances within the lumens of hollow organs, and are not
consciously controlled. Skeletal and cardiac muscles have
striations that are visible under a microscope due to the
components within their cells. Only skeletal and smooth
muscles are part of the musculoskeletal system and only
the skeletal muscles can move the body. Cardiac muscles
are found in the heart and are used only to circulate blood;
like the smooth muscles, these muscles are not under
conscious control.
SCORING OF MUSCLE STRENGTH
C. CARTILAGE
Cartilage is a flexible connective tissue found in many
areas in the bodies of humans, including the joints between
bones, the rib cage, the ear, the nose, the elbow, the knee,
the ankle, the bronchial tubes and the intervertebral discs.
It is not as hard and rigid as bone but is stiffer and less
flexible than muscle.
D. LIGAMENT
"Ligament" most commonly refers to a band of
tough, fibrous dense regular connective tissue
comprising attenuated collagenous fibers.
Ligaments connect bones to other bones to form a
joint. They do not connect muscles to bones; that
is the job of tendons. Some ligaments limit the
mobility of articulations, or prevent certain
movements altogether.

Ligaments are interesting in that they gradually

lengthen when under tension, and return to their
original shape when the tension is removed. This
is in contrast with tendons, which are inelastic.
THE LIGAMENT AND CARTILAGE
E. TENDON
A tendon is a tough, flexible band of fibrous
connective tissue that connects muscles to bones.
The extra-cellular connective tissue between
muscle fibers binds to tendons at the distal &
proximal ends, and the tendon binds to the
periosteum of individual bones at the muscle's
origin & insertion.

F. BURSA
A bursa is a small fluid-filled sac made of white
fibrous tissue and lined with synovial membrane.
Bursa may also be formed by a synovial
membrane that extends outside of the joint
capsule.
G. JOINT
A joint is the location at which two or more bones make
contact. They are constructed to allow movement and
provide mechanical support, and are classified structurally
and functionally.

 Structural classification
Structural classification names and divides joints
according to how the bones are connected to each other.
There are three structural classifications of joints:
a. Fibrous joint - joined by dense irregular connective
tissue that is rich in collagen fibers
b. Cartilaginous joint - joined by cartilage
c. Synovial joint - not directly joined - the bones have a
synovial cavity and are united by the dense irregular
connective tissue that forms the articular capsule that
is normally associated with accessory ligaments.
 Functional classification
Joints can also be classified functionally, by the
degree of mobility they allow:
a. synarthrosis - permits little or no mobility. Most
synarthrosis joints are fibrous joints (e.g., skull
sutures).
b. amphiarthrosis - permits slight mobility. Most
amphiarthrosis joints are cartilaginous joints
(e.g., vertebrae).
c. diarthrosis - permits a variety of movements. All
diarthrosis joints are synovial joints (e.g.,
shoulder, hip, elbow, knee, etc.)
MUSCULOSKELETAL DISORDERS
1. INFLAMMATION
- REMATOID ARTRITIS
- OSTEOMYELITIS
2. DEGENERATIF
− OSTEOPOROTIC
3. METABOLIC DISTURBANCE:
- GOUT
- OSTEOPOROSIS.
4. MALIGNANCY:
− BENIGNA: OSTEOMA, CHONDROMA.
- MALIGNA: OSTEOSARCOMA, CHONDROSARCOMA.
5. FRACTURE
FRACTURE
A bone fracture is a medical condition in
which there is a break in the continuity of
the bone. A bone fracture can be the result
of high force impact or stress, or trivial
injury as a result of certain medical
conditions that weaken the bones, such as
osteoporosis, bone cancer, or
osteogenesis imperfecta, where the
fracture is then properly termed a
pathologic fracture
TYPE OF FRACTURES
All fractures can be broadly described as:
 Closed (simple) fractures are those in which the skin is
intact
 Open (compound) fractures involve wounds that
communicate with the fracture, or where fracture hematoma
is exposed, and may thus expose bone to contamination.
Open injuries carry a higher risk of infection.
Other considerations in fracture care are displacement (fracture
gap) and angulation.
Compression fractures usually occurs in the vertebrae, for
example when the front portion of a vertebra in the spine
collapses due to osteoporosis (a medical condition which
causes bones to become brittle and susceptible to fracture,
with or without trauma).
Other types of fracture are:
a. Complete fracture: A fracture in which bone fragments
separate completely.
b. Incomplete fracture: A fracture in which the bone
fragments are still partially joined. In such cases, there is
a crack in the osseous tissue that does not completely
traverse the width of the bone.
c. Linear fracture: A fracture that is parallel to the bone's long
axis.
d. Transverse fracture: A fracture that is at a right angle to
the bone's long axis.
e. Oblique fracture: A fracture that is diagonal to a bone's
long axis.
f. Spiral fracture: A fracture where at least one part of the
bone has been twisted.
g. Comminuted fracture: A fracture in which the bone has
broken into a number of pieces.
h. Impacted fracture: A fracture caused when bone
fragments are driven into each other.
 THE FRACTURE HEALING
a) HAEMATOMA
b) INFLAMATION.
c) KALUS
d) CONSOLIDATION.
e) REMODELLING.
WHEN IS THE FRACTURE HEALED?

 Clinically
Upper limb Lower limb
Adult 6-8 weeks 12-16 weeks
Child 3-4 weeks 6-8 weeks
 Radiologically
○ Bridging callus formation
○ Remodelling

 Biomechanically
 GOALS OF FRACTURE TREATMENT

The goals of fracture treatment are :

a. Anatomic realignment of bone fragments,
b. Immobilization to maintain realignment,
c. Restoration of function of the part
HOW FRACTURES HEAL?
In nature
○ Regeneration vs repair
○ Three phases of healing by callus
○ Rapid process, rehabilitation slow, low risk

With operative intervention (reduction +

compression)
○ Primary bone healing
○ Slow process, rehabilitation rapid, high risk

With operative intervention (nailing or external

fixation)
○ Healing by callus
○ Rapid process, rehabilitation rapid, lesser risk
TREATING THE FRACTURE
 # Need reduction
1. Close reduction semi rigid fixation :
plaster, splint
2. Open reduction ORIF (open
reduction and internal fixation), OREF
(open reduction and external fixation),
IM nailing, pinning.
COMPARISON OF OPERATIVE AND
NON OPERATIVE # TREATMENT

Operative Non-optve

Rehabilitation Rapid Slow

Risk of joint stiffness Low Present
Risk of malunion Low Present
Risk of non-union Present Present
Speed of healing Slow Rapid
Risk of infection Present Low
Cost ? ?
 COMPLICATIONS OF FRACTURES
Early Late
General Other injuries Chest infection
PE UTI
ARDS Bed sores
Bone Infection Non-union
Malunion
AVN
Soft-tissues Plaster sores/WI Tendon rupture
N/V injury Nerve compression
Compartment syn. Volkmann contracture
ORTHOPAEDIC INSTRUMENTS

RONGEUR

HOWMANN’S
RETRACTOR
 BONE
CURRETAGE

BONE HOLDING
FORCEPS
VERBRUGGE

LOWMANN
 BONE
SEEZLE

ELEVATOR

RASPATORIUM

SERRATED
JAWS
 CANCELOUS
TAPER

DRILL GUIDE

DRILL GUIDE

DEPTH GAUGE

CORTICAL TAPER

4.5 mm SCREW DRIVER

 QUICK COUPLING DRILL SET
AND SAWS

BONE DRILL

PLIER POINTED
WIRE CUTTER
REDUCTION
Persiapan Operasi
 Alat Steril
 Alat Unsteril
ALAT STERIL
PERSIAPAN ALAT STERIL
1. Basic set orthopaedi
2. Korentang
3. Slang
4. Bengkok
5. Slope meja
6. Electric burr
7. Couter handpiece
8. Suction canule
9. BMHP
ALAT TIDAK STERIL
PERSIAPAN ALAT TIDAK STERIL
1. M eja mayo
2. Mesin couter
3. Suction machine
4. Lampu operasi
5. Traction table (k/p)
6. Fluoroscopy (k/p)
Contoh ORIF Pada # Femur 1/3 Medial
 Intsrumen yang disiapkan :
1. Scalpell mess : 1 buah
2. Pincet Chirurgis : 2 buah
3. Hemostatic forceps : 3 buah
4. Scissors : 2 buah
5. Needle holder : 2 buah
6. Towel grip : 5 buah
7. Raspat : 1 buah
8. Curretage : 1 buah
9. Retractors : 2 buah
10. Langenbeck : 2 buah
11. Howmann : 1 buah
12. Verbrugge No 3 : 3 buah
Alat tambahan
 Drill bit 3,2 mm : 1 pcs
 Drill guide 3,2 mm : 1 pcs
 Large Fragmen Depth gauge : 1 pcs
 Taper 4,5 mm : 1 pcs
 Screw driver 4,5 mm : 1pcs
Suture
 Soft tissue : Vicryl no
1, Vicryl no 0
 Kulit  Optional,
Nylon 2/0,Monosyn
3/0
 Sofratulle
 Drain