Bu Bd Uro Ortho Onko Mantap Tutor

SURGERY BIMBEL UKDI MANTAP Surgery dr. Andreas W Wicaksono dr. Anindya K Zahra

GENERAL SURGERY

Lap belt marks: Correlate with small intestine rupture

Kehr’s sign • 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

Hematoma HistoryRetroperitoneal & Physical:

Cullen sign: Periumbilical echymosis Grey Turner Sign: Flank echymosis

Plain Abdomen AP & Semierect: Subdiaphragmatic Air

Plain Abdomen 3 LLD: Abdomen Posisi Subdiaphragmatic Air

Anatomi Prostat

Ruptur Uretra Anterior

Straddle Injury

Hematom penis

Butterfly Hematome

Ruptur Uretra Posterior

Major trauma. Floating prostate

Snake Bite

Derajat Gigitan Ular (Depkes) 0

1

2

3

4

Eritem (dalam 12jam)

< 3cm

3-12cm

>12-25cm

>25cm

> ekstremitas

Gejala Sistemik

-

-

Mual, pusing

Shock, Gagal ginjal Petechie, akut, coma, echymosis perdarahan

DIGESTIVE SURGERY

Migrating pain– Acute Appendicitis appendicitis

Periumbilical pain(colicky pain, visceral) referred by N. Thoracal X

Mc. Burney pain (irritative peritoneal pain, somatic)

Clinical Sign

• Rovsing’s sign : palpation in the left lower quadrant of abdomen increase the pain in the right lower quadrant Obturator sign

Alvarado Score: MANTRELS

Pathophysiology

Ileus

Herring bone

Coil spring

Radiology– Ileus

Stepladder pattern

Pneumoperitoneum

Colorectal Cancer

Clinical Manifestation

Apple Core

Filling Defect

How Does Colorectal Cancer Develop? Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.

CRC Risk Factor • • • • •

>60 yo Family history (+): mutasi gen Familial adenomatous polyposis Low fiber diet IBD

Screening Test: • FOBT • Colonoscopy • CEA (Carcinoembryonic Antigen). Normal memburuk secara progresif, radiasi ke interscapular area, scapula & bahu dextra • Asymptomatic • Biliary colic • Obstructive jaundice

Cholangitis

• Trias Charcot: 1. jaundice, 2. fever, usually with rigors, 3. RUQ abdominal pain. • Severe: hypotension, altered mental status

Congenital : Atresia bilier

• Cholestasis  jaundice with increase of direct bilirubin • 80% pd bile duct di atas level porta hepatis

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) – USG

• 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 – Ductus choledocus / choledocholithiasis

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 : Prinsipnya sama dgn di appendicitis (monggo dibaca lg)

• Temuan Klinis : – – – – –

Fever Trias Leukositosis (10.000-15.000 cells/uL) diagnosis 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

• 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 (++) – Alkaline phospatase (almost always elevated in biliary obstruction)

• 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 :

cholangitis

– 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. • Tx : Kasai hepatoportoenterostomy

• 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 – Pain in RUQ

• 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

Puddle Sign

Hernia

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

Hernia Inguinalis Direct/Medial (trigonum hasselbach)

Hernia Inguinalis indirect/lateral (canalis inguinalis)

Hernia Femoralis (canalis femoralis)

Spatium Subinguinal

UROLOGIC SURGERY

Benign Prostat Hyperplasia • Screening test : PSA ( Prostat Specific Antigen), normal value 300 ml) direseksi dalam • Residual urin > 100 ml 1 jam • BPH dengan penyulit • Disertasi : • Terapi medikamentosa tidak berhasil • Batu buli besar • Flowmetri obstruktif (> 2.5 cm) INDIKASI KONTRA TERAPI PEMBEDAHAN BPH • Multipel • Infark miokard Akut • Fasilitas TUR tidak • CVA Akut ada

TERAPI PEMBEDAHAN BPH

Batu Saluran Kemih 

Nephrolithiasis



Ureterolithiasis



Vesikulolithiasis



Uretrolithiasis

Urinary Tract Reffered Pain

Lokasi GINJAL

Gejala 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

• menyerupai tanduk rusa. URETER Nyeri pinggang kolik dan menjalar, tergantung letak batu: • rektum. - 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. - Posterior  nyeri pada perineum atau rektum

Jenis-jenis batu

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 Pyelografi antegrad/retrograd  bila fungsi voiding terganggu

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.

Staghorn

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 • Pembatasan asupan kalsium tidak dianjurkan

Tatalaksana

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)

Retrograde Urethrography

4. Continuous: fistula

5. functional: paralysis, cognitive impairment

Urinary Incontinence

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, accumulation of fluids around a testicle, swollen blood blockage in the testicle,Transillumination + spermatic cord Inflammation or injury

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 (-)

• Tx : Orchidectomy

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 towards orchidoepididymitis.

Orchitis

Varicocele

Hydrocele

Hydrocele Types

• Translumination test / diapanoscopy • Positive : Hydrocele, Hernia Scortalis • Negative : Mass

Fimosis and Parafimosis

Epispadia and Hypospadia

Cryptoorchidismus

Management

ORTHOPAEDIC SURGERY

Fracture

Colle’s and Smith’s

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 – Thromboembolism (pulmonary or venous)

Fracture Complication • Late Complications – Local: • • • • • • •

Delayed Union Non-union Malunion Joint stiffness Contractures Osteomyelitis Growth disturbance or deformity

• Systemic: – Gangrene – Tetanus – Septicaemia

Non-Union and Mal-Union

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 scapula: Banyak terjadi pada acromion.

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 hamatum: Bisa melukai n. et a. ulnaris

Fraktur scaphoid: Fraktur carpal tersering. Fraktur – avaskuler – nekrosis – degenerasi; diTx bedah penyatuan os carpal = arthrodesis

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: n. ulnaris

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: Preacher’s hand

Carpal Tunnel Syndrome N. medianus

Cubital Tunnel Syndrome

Epicondylus medial

GuyonTunnel Syndrome

Claw hand N. Ulnaris

Drop hand N. Radialis

Preacher’s Hand N. medianus

Orbita

Management of Fracture • 4R : – 1. Recognition – 2. Reduction – 3. Retention – 4. Rehabilitation

Recognition • Anamnesis – History of trauma? – Mechanism of injury? – Localized pain, aggravated by movement – Decreased function – “heard the bone break” – “feel the ends of the bone grating”

Physical Examination 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

Traction

Skeletal Traction

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

ORIF vs OREF

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

Retention / Immobilization 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 * Aryadi K, Syaiful AH. Penggunaan Gips Paris. In: Petunjuk pemasangan gips paris pada kasus orthopaedi, Divisi Orthopaedi dan traumatologi, 2006. hal 2-6

GIPS/CAST

Supracondylar Fracture of Humerus

Arm Sling

Open Reduction To Prevent Brachial Artery Injury!

U Slab • Humeral shaft fracture

Volar Slab

Compartment Syndrome • 6 P of Compartment Syndrome – – – – – –

Pain Pallor Pulseless Paresthesis Paralysis Pressure

• Tx : Fasciotomy

Compartment Syndrome

•

Fasciotomy

• Casts and tight bandages –remove or loosen any constricting bandages

Muscle of Calf

Artery of Calf

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 – Cranial nerve disorders

Multiple Myeloma • Sign : bone pain • X-ray “punched out lession”

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 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 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 World Health Organization Definitions Based on Bone Density Levels

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

Forearm Fracture

Vertebral Fracture

Hip Fracture

Osteoporosis

ATLS

Shoulder Dislocation

Anterior Shoulder Subluxation/Dislocation • Radiographs:

Axillary View

True AP

Y view

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 relation of axillary nerve)

Hip Dislocation Posterior (flexi, adduksi, endorotasi)

Anterior

(flexi, abduksi, exorotasi)

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 osteoblasticosteolytic 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-onend" 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.

The Canadian Journal of Diagnosis / May 2001

Ewing’s Sarkoma • Annual incidence at birth to 20 y.o (teenagers and young adult) • Most common site : pelvis • Radiologic : onion peel

Ewing’s Sarkoma

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 quickly

Acute Achilles Tendon Rupture Diagnosis • • • •

Weakness in plantar flexion Gap in tendon Palpable swelling Positive Thompson test

Open Fracture

Vertebral Fracture

ONCOLOGIC SURGERY

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

Benign Breast Lumps

Breast Cancer

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 • Sometimes uses a special vacuum tools to get larger core biopsies from breast tissue

Epidermoid Cyst • Benign cyst underneath skin that arise with ruptured pilosebaceous follicle • Associated with trauma (piercing-needle) • Common location : auricular lobe, plantar

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 Mastitis

• infeksi payudara dengan tanda radang lengkap, dapat menjadi abses, terjadi pada ibu menyusui

Fibroadenoma mammae (FAM)

• tumor jinak, biasa terjadi pada usia muda (15-30 tahun), konsistensi kenyal, batas tegas, tidak nyeri, dan mobile

Kelainan fibrokistik

• tumor berbatas tidak tegas, konsistensi kenyal atau kistik, nyeri terutama saat menjelang haid, membesar, bilateral atau multipel.

Kistosarkoma filoides

• menyerupai FAM yang besar, bulat lonjong, batas tegas, mobile, ukuran dapat mencapai 20-30 cm

Galaktokel

• massa kistik akibat tersumbatnya duktus laktiferus pada ibu yang baru menyusui

Mastitis and Abscess Mammae

Galactocele • Galaktokel merupakan massa berisi susu yang tersumbat apada duktus laktiferus. • Px : – Solid mass – Tanda radang (-)

TERIMA KASIH

Brief Introduction

Appendicitis • The most common general surgical emergency • Peak 10-30 y.o • Male > 1.3x • Obstruction: lymphoid hyperplasia, fecalith, etc

Ileus Peritonitis Obstructive Ileus: -Primary, secondary - Inside lumen, In the - Localized, wall, outside the wall generalized - High level, low level

Anamnesis

Cardinal symptoms

Appendicitis

Ileus

Peritonitis

- 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

Physical Examination 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