surgical epidural hematom: 9 conclusion

Hematoma epidural is one of the cases emergency the need to obtain strict control because it can cause permanent disability and life threatening if not get the handling of the operation. Hematoma occurred in the space between the dura mater and the bottom tabulation of the skull bones.
Typical symptoms of hematoma epidural, namely the existence of lucid interval, where there is conscious phase between phases is not aware. And enforcement of the diagnosis based on clinical findings and of the scanning head to this day is still the gold standard for diagnosis support HED.
Action surgical evacuation can be done after the volume and location based on the results of head CT scan.
When you get the handling right and appropriate, the prognosis of patients with hematoma epidural is very good and can recover as usual.

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surgical epidural hematom: 8 Complications & Prognosis

Complications
Many complications may arise from the case of HED. When the brain herniasi, arterial - arterial anterior and posterior brain can be stopped, for the next infark can cause the brain (Ullman, 2006).
In some cases, patients with HED behavior changes can occur after several hours to days after injury. In addition, when handling and do not get adequate, then patients with HED may vegetative status or even death (Price, 2006).

Prognosis
After the blood clot is taken, for the next patient is treated in the ICU room, in which control more secure. Sometimes necessary to use ventilator patients are conscious and able to breathe by itself. Rating neurology the frequent important to determine the degree of awareness. Particular treatment may be given to reduce interference and maintain brain pressure remained stable intrakranial (Anonymous, 2004).
Mortality figures for patients who do not have a comma before surgical action is 0 and about 10% for patients with disabilities and 20% for patients in a coma in (Price, 2006).
Although the results obtained up to 0% for mortality figures and 100% for the outcome with good function, but the overall number of patient mortality with HED around 9.4% - 33%, average about 10%. In general, the motor examination before the operation, GCS score, pupil reaction, and closely associated with its outcome in patients with acute HED when they can be saved (Ullman, 2006).
As important to remind that the healing of the injury is very long and gradual. It is important also to get enough rest and adequate nutrition while waiting for the process of healing.

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surgical epidural hematom: 7 conduct operation

Most of the hematoma epidural is a surgical emergency and must be evacuate as soon as possible. Because brain hematoma epidural under generally quite normal, every effort made to reduce the pressure as soon as possible to prevent brain damage. Outcome of surgery for the hematoma epidural is very dependent on the patient's clinical condition prior to evacuation operative. When clot large, or there is doubt on the extent of brain damage underneath, it is recommended to make craniotomy flap wide standard. In the case where the hematoma epidural clearly limited to one Regio and where there is not accompanied by subdural bleeding on the CT scan appears, flap craniotomi a small modification can be used (Saanin, 2007).
HED with volume of 30 ml, 15 mm thickness and require surgical evacuation action because almost most of the patients with the HED of this kind shows that the level of awareness and poor showing signs - signs lateralisasi (Ullman, 2006).
Location is also an important factor in determining the operative. Hematoma in the Temporal, if the size or spread, can cause herniasi and cause disorients more quickly. HED in the posterior fossa, which is sometimes associated with the dissolution lateral sinus venosus, which requires surgery take action - the heart because the available space is very limited (Ullman, 2006).
In the period before the CT scan, the exploration drill often do, especially if the patient has shown symptoms lateralisasi or deorientasi quickly. Now, with a fast scanning techniques, such as how this is rarely done (Ullman, 2006).
Some circumstances be indicative actions Explore the drill hole (Price, 2006):
 intrakranial Hypertension instability with a heavy hemodinamik
 Alerts - sign herniasi start to appear
Not available  nerve surgeon for immediate consultation
 Trepanasi (or laying of the drill) should be done after consultation with the surgeon nerve, if possible, after residing in the central health.
 land or air transport is too long
Procedure in taking action to make the drill hole according to Price (2006) include:
 Make a deep hole, but not exceed, the broken bones in the skull or from the area indicated CT scan.
 If no CT scan, wimble placed on the side where the pupil is more dilatasi, 2 fingers to the anterior to the ear tragus and 3 finger over it.
In research conducted by Liu, et al in 2006, explained that with the evacuation drill holes and drainage with negative pressure is safe and effective for handling emergency the HED because trauma.

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surgical epidural hematom: 6 handling and therapy

Handling of HED depending on various factors. Side effects that may occur in the brain due to the mass by, among others, structural distortion, herniasi that threatens life, and increased pressure intrakranial (Ullman, 2006).

Two options in the handling of patients, namely 1. operative action immediately, and 2. initial observations, a conservative, and strict clinical supervision. HED notes that the speed has to be knowledgeable more quickly disbanding hematoma subdural, and patients have a very strict control, if steps taken conservative will (Ullman, 2006).
Not all cases get HED acute surgical action immediately. If lesi existing small and patients neurologist in good condition, with the supervision of the patient examination neurological the frequent be reasonable. Scanning the development can be done to assess the size of hematoma enlargement in the deorientasi. When it was found that increasing the size very quickly, then further surgical action is indicated (Ullman, 2006).

handling prehospital
According to Price (2006), actions taken prior to reaching the health center immediately control the situation - the situation can quickly threaten the lives and provide therapy suportif early. ABC control is the cornerstone that must be remembered. Then needs to be done vena access, the provision of oxygen, and strict supervision. Kristaloid per the provision of IV fluids to maintain blood pressure remains adequate. In addition, can also be done intubasi and sedative drugs, drugs neuromuskular appropriate resistor protocol.
- Use lidokain 1 mg / kg IV BB premedikasi as to prevent increased pressure intrakranial done intubasi time (Argyle, 1996).
- There are several responses about the increased mortality in patients with head injury Moderate to heavy intubasi done before in the hospital compared with patients in diintubasi Emergency Installation (IGD).
- Heating Ventilation mask the face with a good technique can be more beneficial for the brain injury compared with intubasi pre-hospital

handling in emergency intalasi
According to Price (2006), handling up to when the Installation of Emergency Access vena others, giving oxygen, strict supervision, and the liquid kristaloid important to maintain blood pressure remains adequate. This is the first step in handling the patient until after the health center.
Intubasi using Rapid Sequence Induction (RSI), which generally includes the use of lidokain, brain protective agent sedation (eg, etomidate), and agents neuromuskular resistor as premedikasi. Lidokain have a limited effect on the situation like this, even to this day can be spelled without the risk. Premedikasi using fentanyl may also be able to increase the pressure intrakranial. Intubasi should be done after the examination neurologik basis to facilitate oksigenisasi, to protect the roads of breath, and when necessary can be done hiperventilasi.
30o elevate the head of the bed is put back after, or with the reverse Trendelenburg's position to reduce pressure and increase the flow of intrakranial back vena.
Giving manitol 0.25 - 1 g / kg IV BB after consultation with the surgeon if the nerves of the average arterial pressure - average (MAP) greater than 90 mmHg with a sign - a clinical sign of increased pressure intrakranial ongoing. Manitol can decrease the pressure intrakranial (with a decrease in brain edema in osmotik) and viskositas blood, where it can improve blood flow to the brain circulation and oxygen. Fluid must be replaced and should be avoided hipovolemia (urin monitor output produced, it is better when using a down Catheter).
Hiperventilasi to the partial pressure of CO2 ( PCO2 ) 30 - 35 mmHg can alleviate signs - signs herniasi or increased pressure intrakranial, nevertheless, it is still controversial. A decrease in PCO2 should be - the heart that is not too far ( < 25 mmHg). Hiperventilasi given if it appears a sign - a sign of increasing pressure intrakranial progress and continue on sedation, paralisis, diuresis osmotik, and if possible serebrospinal fluid drainage. How to reduce pressure intrakranial with vasokonstriksi hipokarbi and decrease the risk of hipoperfusi cell death and the injury.
Phenytoin may decrease the incidence of spastic post-trauma, although it does not mean a strain on the go or a persistent disturbance.

medication
Some classes of drugs that can be given as a therapy or to prevent further occurrence of side effects (Price, 2006):

Group Diuretik Osmotik
Manitol (Osmitrol) given to maintain serum osmolalitas < 320 mOsm so that it can prevent the occurrence of kidney failure. Dose in adults is 0.25 to 1 gr / kgBB IV, and the dose for children in accordance with the calculation of body weight on the adult dose. Contraindicate of the drug among other drugs of this history hipersensitif before, anuria, the heavy congestion tuberculosis, dehydration weight, bleeding intrakranial of the active, progressive damage to the kidneys, sistolik blood pressure < 90 mmHg. The drug is given to the safe in pregnant women.

Group Antiepilepsi
Phenytoin (Dilantin) therapy is an option to profilaksi strain. Dose pemberiannya in adults is 17 mg / kgBB IV are mixed in with the NS infus no faster than 50 mg / min, and dose to the child - the child in accordance with the calculation of body weight of adult dose. This class can not be given to patients who have a history hipersensitif before, there is sinoatrial block, sinus bradikardi, AV block 2 and 3 degrees, or in patients with Adam-Stokes syndrome. The drug is not safe when given to women in situations that are pregnant.

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surgical epidural hematom: 5 Diagnosis

All that after the injury may not be able to understand the whole, they all can be supported with a thorough medical examination and diagnostic tests. Diagnosis of head injury based on physical examination and diagnostic tests. In the examination, a doctor can get more information from patients or their families and can ask how the injury occurred. Trauma to the head can cause interference neurologist and may be obtained after a medical check-up (Anonymous, 2004).
Diagnostic tests that can be done include:

1. Laboratory examination (Ullman, 2006).
Hematokrit rate, blood chemistry, coagulate factors (including number trombosit) is very important in the assessment of patients with HED, either spontaneously or because of trauma.
Head injury can cause a heavy deliverance tromboplastin network, which it can continue on the occurrence of DIC (Disseminated Intravascular Coagulation). Coagulate previous knowledge about the action required when surgery will be done. If necessary, factors - factors that are associated can be included before the operation & in the operations.
In the adult patients, the occurrence of HED rarely cause a decrease hematokrit a significant degree because the skull bones that have been set. In the baby, where blood volume is still limited, with the epidural bleeding skull bones who ekspansil with the suture still open can lead to loss of blood, which means. Because bleeding can cause instability hemodinamik, so that the necessary degree of monitoring hematokrit regularly and carefully.

2. Vetting radiologist
- Radiography (Ullman, 2006).
skull bones show a picture fracture drift shadow vascular branch of a. meningea media. picture fracture occipital, frontal or vertex is also sometimes found.
There is no guarantee fracture indicate the existence of HED. However, 90% of the cases related to the HED skull bones fracture. In the child - children, the number is smaller because the skull bones deformabilitas greater.
- CT - Scan head (Ullman, 2006).
CT scan method is the most accurate and sensitive in HED diagnose acute. Found a very unique. Space formed by HED layer is limited by dura to the bottom of the tabulation of the skull bones, especially in the suture line, shape description lentikuler or bikonveks. Hidrocephalus sometimes appear in patients with large posterior fossa.
Liquid serebrospinal not mixed with epidural bleeding, where bleeding is more homogeneous and visible dens. Quantity of hemoglobin in the hematoma also determine the number of rays of radiation absorbed.
picture density of hematoma in the brain compared with parenkhim change depending on the time after injury. In the acute phase picture hiperdens (picture bright in CT scan). Then the hematoma became isodens in 2 - 4 weeks, and subsequently became hipodens (dark picture). Many acute bleeding can be seen as a isodens or areas with low density, which shows the possibility of bleeding is in progress or the rate of low serum hemoglobin.
The picture on the air show HED acute fracture in the sinus or the mastoid space cavity.
About 10 - 50% of cases associated with the HED other lesi intrakranial. Lesi include hematoma subdural, contusion cerebral, and hematoma intraserebral.
At the time of surgery or the next otopsi, 20% of patients HED found blood on the epidural and subdural space. (Price, 2006)
- Magnetic resonance Imaging (MRI) (Ullman, 2006).
Acute bleeding in the MRI appears as a isodens, making it less suitable to detect the existence of bleeding due to acute trauma.
- Electroencephalogram (EEG) (Anonymous, 2004).

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surgical epidural hematom: 4 clinical manifestations

Most of the cases of HED was trauma, sometimes the form of blunt trauma to the head. Patients can prove the existence of previous head injury, such as the scalp laserasi, cephalohematoma, or contusion. Systemic diseases sometimes appear in the examination. Based on the severity of impact, the patient sometimes does not appear lost consciousness, lost consciousness in a short period of time, or lost the awareness that prolonged (Ullman, 2006).
Sign and symptoms of HED include heavy headache, nausea, vomiting, and enlargement of the size of one or both pupil (ipsilateral or bilateral) in accordance with the direction of head trauma or a sudden weakness of arm or leg. The sign of a more dangerous HED is increasing degrees nervous, like croon, confused, or the inability to wake up from the situation does not realize that in the (comma). Because the brain controls all functions of the body, changes the pattern of breath can occur. Short of breath - a short, gasping breathing, or a very slow breath is a sign warning that someone needs help (Anonymous, 2007).
Alerts appear in the lucid intervals of 20 - 50% of patients with HED. Originally the head injury that occurred the decrease in awareness. Once again improved awareness, HED continues to cause mass bleeding is increased pressure intrakranial, decrease the level of awareness of, and may cause the emergence herniasi syndrome (Ullman, 2006).
In the patients with hypertension intrakranial a heavy, a sign - a sign Cushing response may appear. Trias Cushing include the classic systemic hypertension, bradikardi, and respiratory depression. The response was usually start to appear when the brain perfused decrease because of the increased pressure intrakranial (Ullman, 2006).

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surgical epidural hematom: 3 patofisiology

Hematoma epidural (HED) located outside the dura but the cavity in the skull shape and characteristics resemble biconvex or convex lens. About 70 - 80% found in the HED Temporal or temporoparietal region caused by tear artery meningea media due cracked skull bones (Price, 2006).
Blood that occurs usually comes from the arterial duct, but in the third case can occur due to bleeding vein, Because it is not rare HED caused tear sinus venosus region, especially in the parieto-occipitalis posterior fossa or on. Figures incident injury and is less related to the cause of a more lightweight. Usually, HED venosus occurs with depression fraktur skull bones, where the dura from the bone tear and it resulted in made room for blood to akumulasion. In some patients, especially in cases with clinical manifestations of delayed, HED venosus can therapy action with non-operating (Price, 2006).
HED generally be regarded stable, the maximum size to be happening within minutes of injury, however, Borovich explained that progresivitas of HED on 9% of patients took place in the first 24 hours. Re-bleeding that persists can lead to the occurrence estimated progresivitas. One case of HED can become chronic and known a few days after injury (Ullman, 2006).
In some cases of HED are reported without beginning with trauma. Etiology disease include infections in the skull bone, blood vessel malformasi the dura mater, the skull bones to metastase. HED can also develop spontaneously in the patient-related problems coagulate with primary treatment (eg, liver disease end of the stadium, alcoholic chronicles, other diseases related to disfungsi platelet) (Ullman, 2006).

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surgical epidural hematom: 2 definition

Epidural bleeding, hematoma epidural, epidural hemorrhage is a pile of blood that appears, usually due to head trauma, in the layer between the duramater (brain out layer) and the bones of the deep skull (Anonymous, 2007).
In general, the brain membrane coated by the brain (meningens) that cover the entire surface of the brain and consists of 3 layers. Namely: duramater, arakhnoid, and piameter. Duramater is a membrane that consists of hardware and network fibrous rope attached closely with the Interna tabula or in part kranium. Duramater but not attached to the membrane arakhnoid below, so that there is the potential space subdural space (Krantz et al., 1997).
The conventional, said duramater consists of two layers, namely layers endosteal and meningeal layers. Endosteal layer is not close surface the periosteum in bone kranium. This layer does not continue through the foramen magnum to the prolonged duramater spinalis. Around the foramen kranii all, this continued with a layer of periosteum on the outside bone cranium. In the suture, layer is directly related to the ligament sutural. Also inherent in the most strong bones - the bones in the base kranii (Snell, 1997).
Meningeal layer is the duramater of fact. Fibrous membrane is dense and strong that envelop the brain to continue after the passing away as the duramater spinalis. This layer is also a wrapper for Tubular nerve kranialis while walking through the foramina kranii. Cranium outside, this layer integrates with nerve epineurium. Meningeal layer is formed to the septum in four, divide the cavity into cranium space - space is related with the free and
a part - the brain. Septa function is to prevent shifting the brain (Snell, 1997).
Duramater got many branches of the a. carotis Interna, maxillaris, pharyngeus ascendens, occipitalis, and vertebralis. From the clinical angle, the most important is a. meningea media, which rarely broken on head injury (Snell, 1997).
A. meningea media branch from a. maxillaris in the fossa infratemporalis. Log in to cranium cavity and walk to the front and in a lateral flow, on the top surface of the pars squamous ossis temporalis. Log in to cranium cavity through the foramen spinosum and is located between the meningeal layers and layers endosteal duramater. Branch anterior (frontal) groove or tunnel on the angulus anteroinferior ossis parietalis and in accordance with the way the brain gyrus precentralis below. Branch posterior (parietal) and the supply curve back pars posterior dura mater (Snell, 1997).
V. meningea located in the lining endosteal dura mater. V. meningea media following the branch - the branch a. meningea media and empty into the plexus venosus pterigoideus or sinus sphenoparietalis. Veins located lateral against artery (Snell, 1997).
Under the duramater that there is a second layer of thin and see-through layer called arakhnoid. Third layer is a PIA mater closely attached on the surface of the cortex serebri. Serebrospinal circulasi fluid between the membrane and arakhnoid PIA mater in space subarakhnoid (Krantz et al., 1997).

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surgical: fracture 10 conclusion

Fracture open fracture or open fracture is associated with the outside world as a result of violence. Muscle and skin of the injury and damage to heavy network software will be proportionate to the energy that straight cause. Damage is accompanied by bacterial contamination, causing an open fracture problem of infection, healing disturbances and interference functions.

Many classifications of indicators used for diagnostic studies and appeal. All systems are based on the number of assessment of damage that occur on the network software and bones, with no / no contamination. Everything related to the severe trauma that occurred. System Gustillo and Anderson (1978) system is the most widely used. This type of classification can be increased.

The main objective is to restore the function of the extremity of pain. This depends on the rapid healing of wounds, with the recovery and software network union (fusion) fracture and restoration in accordance with the anatomical location. It is also important to prevent complications.

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surgical: fracture 9 handling

The main objective is to restore the function of the extremity of pain. This depends on the rapid healing of wounds, with the recovery and software network union (fusion) fracture and restoration in accordance with the anatomical location. It is also important to prevent complications (Armis, 2001).
Fracture action on the open must be made as soon as possible. Delay time can lead to complications of infection. The optimal time to act before the 6-7 hour (golden period). Give toksoid, anti-tetanus serum (ATS), or human tetanus globulin. Give antibiotics for Gram-positive bacteria, and negative with a high dose. Make checks culture and resistance from the germs basic fracture open wound (Mansjoer et al., 2000).
Assessment and management is conducted in the emergency unit aims to:
1. First before handling definitive.
2. Resuscitate. Lost a lot of blood on the fracture open resuscitate necessary action.
3. Initial assessment (preliminary assessment). A thorough examination and careful observation is the basis in the patient.
4. Debrideman
Technical debrideman according Mansjoer et al. (2000) is as follows:
a. Perform general narcosis or local anesthesia and light injuries when small.
b. When the injury is quite broad, post tourniquet first (pump or Esmarch)
c. Wash the entire extremity for 5-10 minutes and then do the shearing. irrigated wound with sterile NaCl solution or water 5-10 minutes.
d. Perform decontamination measures and the kerchief.
e. Eksisi wound layer for layer, from the skin, subkutis, fascia and muscle. Eksisi musculature that is not vital. Discard bones, small bones that are not attached to the periosteum. melestarikan large bone fragment that is necessary to stability.
f. Fracture always open wound is left open and when it closed a week after the edema disappeared and the (secondary suture) or it can also be sewn only situation when the injury is not too wide (rarely injured sewing).
5. Antibiotic therapy.
Giving antibiotics immediately after true diagnosis. Ideally a high dose of broad spectrum antibiotics such as benzylpenicillin 1 mega units every 6 hours plus flucloxacillin 500 mg every 6 hours. If the wound is very dirty need additional attention to gentamicin in addition to kidney function. Clinical treatment is done to wound is not infected. The provision of anti-tetanus should be careful. Now widely used tetanus immunoglobulin (human) in patients who had not got immunization. And also have to give tetanus booster toksoid. Debrideman and antibiotics can prevent adequate gas gangrene (Armis, 1994).
Cefazolin is an antibiotic that adequate to open fracture type I and II. If wound contamination there is a heavy (fracture open type III), aminoglikosida can be added (eg gentamicin or tobramicin). When therapy is required then profilaksi penicillin may be added. Profilaksi and tetanus immunization should be given to patients who have not been immunized (Arneja & Buckley, 2004).
Fracture is open emergency to do the operation. Objective is to clean wounds, remove the network contaminated and death and a foreign object. Penetrating injury (simple puncture) is cleaned and sewed, but the wound is large and needs to be done contaminated toilet and wound exploration. If the wound needs to be dilated, all of the network is broken and discarded dead. Leave the wound is open. Cleaning should be wound with a physiological fluid or liquid detergent and remove foreign substances that enter into the wound. Network irrespective of the bones are removed and die, but the fragments of bone that should not. Vena vital need to immediately go through life member distal movement of the fracture. Nerve can be abandoned and in-repair operation on the next (secundere repair) who have previously given the identification (Armis, 1994).
The problem fixation on the Internal fracture with contamination in general is contraindicate. However, after fixation Internal installation wound healed and no more infection. Fracture degrees on the open and sometimes I degree II Internal fixation can be done. In the case of severe damage to the network that require action, then arterial repair Internal fixation is installed for the indication (Armis 1994).
Usage eksterna fixation (external fixation devices), only the fracture III opens with a degree fiksasi fragment-fragment fracture and simplify wound care (Armis, 1994).
Wound treatment during 7-10 days. On the plaster cast made hole (window) in order to clean the wound every day. If the wound has healed the treatment on bone fracture as fracture closed. Complications can cause osteomyelitis continuation fracture such as delayed union and non union (Armis, 1994).

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surgical: fracture 8 complications

Complications that can occur often or in the case fracture open include:

a. Dislocated Infection / Osteomyelitis
Fracture infection can prevent the bone fusion. This mainly occurred in the fracture with shifting fragments fracture. Infection is rarely found on fracture on fracture closed. Infection often occurs in the open or on the fracture handling fracture with internal fixation (Mc Rae & Esser, 2002).
Infections caused by bacteria from an open wound or from the blood circulation. Difficult to diagnose osteomyelitis based on clinical signs and patient age. Standard that is used to establish the diagnosis is with culture microbiologist taken from the center of infection or drainage of fluid (Armis, 2001).

b. Tetanus
Most cases of tetanus occurred after the hair cuts, and trauma laserasi dish. Organism responsible (Clostridium tetani) is a gram positive rod, spore anaerobic the form, which are spread everywhere in the environment.
Injuries tend to be tetanus necrosis by a network is with a heavy environmental contamination. Moreover, therapy can delay placing a wound in this category. The biggest risk of such injuries cause tetanus, but it must be emphasized that the injury was small pin or needle puncture has become precursor of this disease.
Early phases of therapy include the destruction of organisms debrideman with surgery and antibiotics and provision of antitoxin for the toxin sirkulated not fiksation (Sabiston, 1995).

c. Union delayed
That is not a fragment fracture ignites but still showed activity biologic (Armis, 2001).
This is a clinical terminology which means that there is no signs of a union in the average bone continuation in general. When a student or a doctor establish the diagnosis has been delayed union then need to consider the appropriate treatment for these complications. Conservative therapy in the sense to wait until union occurs, or when 6 months operative not have the development of a union such as fracture tibia with the fibula intact, fraktur kruris and fibula with the union earlier, the necessary action osteotomi on the fibula (Armis, 1994).

d. Nonunion
That is not fracture ignites without any signs recover after 6-9 months in both clinical and radiologist. kinds of types :
- Atrophy nonunion: the narrow end of the fragment, such as the tip of the pencil, avaskular, and lack the capacity to recover biology.
- Hypertrophic nonunion: hipervaskularisasi happen and the high capacity for the healed, but the lack of mechanical stability. Hypertrophy end of the fragment.
- Oligotrophic nonunion
- Infected nonunion: the process of nonunion associated with chronic infection of the bone.
Causes of nonunion are:
- Infection in the bone
- Blood vessel damage to the bones
- Movement for the fixation is not adequate
- The loss of fragments, such as apposition distracts so that there gaps between the fragment-fragment fracture
- Corrosion implant
- Interposes, network software means is between muscle or fragment fragment-fracture
- The process of bone pathologies called fracture pathologies

e. Nerve trauma
Perifer nerve trauma can cause contuse, voltage, or lost. Neuropraxia described as small trauma that cause physiological block and recovery occurred in a few weeks. Axonotmesis is damage and axon degeneration perifer will occur. Axon regeneration will be approximately 1 mm per day so that recovery will occur until many months depending on the length of nerve distal from the trauma. The dissolution is neurotmesis whole nerve, the result happens to the other end of the fibrosis. To lesi is cutting edge and need to do repair (Armis, 1994).
Lesi nerve on open fracture always mean that the nerve is lost and the need for exploration were identified, while sewing the fourth week after the post-trauma. When the nerve is intact and injury leave are closed. Nerve can be due to recessive calus called nerve trauma secondary (Armis, 1994).

f. Trauma vena
Trauma can be a blood vessel contuse, laserasi or damaged. Thrombus or aggravate spasm will iskhemi incident. Arterial Spasme not have any correlation to the damage to the network (Armis, 1994)
Indications iskhemi after trauma:
- Extreme pain (Pain)
- pulse lost (Pulseless)
- Priesthood
- Pale because the blood does not go back there (Pale)
- fingers can not do extension (Paralyse)

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surgical: fracture 7 Classification

Many classifications of indicators used for diagnostic studies and appeal. All systems are based on the number of assessment of damage that occur on the network software and bones, with no / no contamination. Everything related to the severe trauma that occurred. System Gustillo and Anderson (1978) system is the most widely used. This type of classification can be increased with time (Armis, 2001).

Classification fracture open Gustillo:
- Type I:
Wounds on the skin of less than 1 cm
Clear
There is no contamination on the fracture
- Type II:
Wounds on the skin more than 1 cm
Damage to the network software are
No rip apart the skin or
Fragment is not broken
- Type III:
Injury because the strength of
Damage extensive network software
Injured or destroyed by the severe
Or blood vessel damage and need repair
Fracture or broken, including fracture or segmental bone loss and is not in accordance with the size of wounds on the skin

In 1984 Gustillo modify the classification of type III with subtypes based on the degree of contamination, extent of periosteal stipping, and opening the bones and there is no damage or blood vessel (Armis, 2001).

Classification open fracture type III:
- Type IIIA:
Network soft enough to cover the bones although there is damage to the network is large enough.

- Type IIIb:
Damage a wide range of network software with periosteal stripping and exposure of bone.

- Type IIIc:
Fracture with arterial damage that requires repair.
This system is simple and very useful. However, this category is the loss on the examiner's subjective assessment of risk so that an error occurred. The variables used for each type is also not specific (Armis, 2001).

According Klebuc & Varner (2004) degrees of complexity and wound therapy on the open fracture influenced by several factors, among others:
a. Energy level (fall from a height, traffic accident at high speed, and caliber bullet wounds in the shoot)
b. Degree of contamination
c. Degree of damage to the network software
d. The complexity of the fracture / fracture fragment patterns
e. Damage vascular / vein

Read More - surgical: fracture 7 Classification

surgical: fracture 6 definition

Definition
Fracture open fracture or open fracture is associated with the outside world as a result of violence. Fracture has a risk of infection, delayed union and nonunion. Fracture is open on the long bones often be amputated to save the life of the patient. However, doctors now more focus on specialist treatment to maintain function and prevent complications (Armis, 2001).
On the fracture is open there is a connection between the bones with the outside environment. Muscle and skin of the injury and damage to heavy network software will be proportionate to the energy that straight cause. Damage is accompanied by bacterial contamination, causing an open fracture problem of infection, healing disturbances and interference function (Krantz et al., 1997).

Diagnosis open fracture
To diagnose a fracture need to be open anamnesis, physical examination and the examination was the right diagnosis so that certainly can known:
1. Anamnesis:
Patients complained about the pain, deformitas, the inability of the body of the sick, injured and bleeding on the skin (Armis, 2001).
2. Physical examination
Examination showed the wounds and deformities. Wounds on the skin should be assessed and the condition of long bones, if there is contamination. Check up to the bone concerned. Checking on the network software in general covers a larger area of fracture own. Interference in the system are examined with a view neuromuskuler color and skin sensitivity to the stimulus. Ask the patient to the distal part of the lesi. Do not forget to check the patients vital signs to predict the shock the next time (Armis, 2001).
If there are open wounds near joints, should be considered is related to the wound or into the joints, and surgical consultation should be done. May not enter or liquid pigment to prove hollow joints associated with injury or not. The best way to prove the relationship with the open wound is a joint exploration and surgical wound cleaning (Krantz et al., 1997).

3. Radiology examination
Like closed fracture, radiologist examination is the key to diagnose a fracture.
To detect such fracture or dislocation, Palmer et al. (1995) states that the rays is not enough with only one image:
a. 2 photos with the necessary projection of perpendicular to one another when there is suspected fracture or dislocation, except in the pelvis where the image oblique will be very useful. Sometimes required several projecting eg at the wrist, but first note the projection routine first.
b. Make sure that the image seen on the joints above and below the fracture in the arms or legs, except when the clinical fracture clear that there is only on the most distal part. But in this case also the closest socket must join photo.
c. Damaged tendon and blood vessel can not be seen with the photo routine.
Photo rays must meet several requirements, namely broken bones must lie in the mid-ray image and should permeate this place, the vertical rays because the image is a photo image shadow. When the rays penetrate the sloping, images become hazy, unclear, and the other from the reality. Should always be made with two pieces of photo direction perpendicular to each other (Sjamsuhidajat & de Jong, 1997).
On bone, joint proximal long and the distal photo must participate. If there is doubt over the existence of broken bones or not, the image should be made members of the same movement for a healthy comparison. If not acquired certainty of aberration, such as fissure, should the image repeated after one week; cracked will become apparent as local hiperemia around the bone fracture that will appear as dekalsifikasi (Sjamsuhidajat & de Jong, 1997).
Special inspections such as CT scan is often required, such as broken bones in the vertebra with symptoms neurologist (Sjamsuhidajat & de Jong, 1997).

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surgical: fracture 5 handling

Fracture is usually attached to the trauma. Therefore, it is very important to conduct the examination of the way the breath (Airway), the process of respiration (breathing) and circulation (circulation), whether the shock occurs or not. When you have stated there is no longer a problem, do a new anamnesis and physical examination in detail. Time of accident it is important to know asked how long the hospital, given the golden period 1-6 hours. When more than 6 hours, complications of the infection. Make anamnesis and physical examination in a rapid, concise and complete. Then, do a photo radiologist. Installation of splint made to reduce pain and prevent the occurrence of more serious damage on the network software in addition to facilitate the process of making images (Mansjoer et al., 2000)
Management of fracture in general follow the principle of medical treatment in general, namely the first and primary is not injury patient (primum non nocere). Iatrogenic additional injury to the patient occurred due to a wrong action and / or excessive action. The second, treatment was based on the diagnosis and the right prognosis. Third, in cooperation with the laws of nature, and the fourth, select the correct treatment of each patient individually (Sjamsuhidajat & de Jong, 1997).
To fracture itself, is a principle to restore the position of the bones to fracture the position (repositioning) and maintain that position during the healing of broken bones (immobilises). Repositioning the situation does not need to achieve as fully as the bones have the ability to adjust the shape of the back like (remodeling / swapugar). The feasibility of repositioning a dislocation is determined by the fragment and the dislocation aksim ad, ad peripheriam, and KUM kontraktione the form of rotation, or digest. In general, angulasi in the field of joint movement until about 20-30 degrees will be may swapugar, while angulasi that is not in the field of movement joints will not be through. However, the rotation between the two fragments are never corrected by the process swapugar. There is no rotation can not be known fragment of the image rays, but must be known from the clinical examination. The easiest way to check this rotation is to compare the rotation member of the fracture with a healthy rotation members. Abridgment members caused by a broken towing muscle tonus fracture fragments so that the bones are on both sides. Abridgment members on the adults and abridgment members up and down on the child usually does not cause problems (Sjamsuhidajat & de Jong, 1997).

Mansjoer et al. (2000) mentioned that in fracture treatment can be either closed or conservative operative:
1. Conservative therapy, consisting of:
a. Protection only, for example mitela for fracture collum chirurgicum humeri with a good position.
b. Immobilises without any repositioning, such as the plaster cast on the fracture incomplete and fracture with good position.
c. Closed repositioning and fixation with plaster cast, for example, on the fracture suprakondilus, fracture Colles, Smith fracture. Repositioning may be in local or general anesthesia.
d. Traksi, for repositioning slowly. In the children used traksi skin (traksi Hamilton Russel, traksi Bryant). Traksi skin for 4 weeks, and the burden of < 5kg. To traksi adult / definitive traksi must traksi skeletal form balanced traction. 2. Operatif therapy, consisting of:
a. Open repositioning, fixation Interna.
b. Closed repositioning with fixation control radiologis followed eksterna.
Therapy operatif with anatomical repositioning followed by the Interna fixation (open reduction and internal fixation), artroplasti eksisional, eksisi fragments, and the endoprostesis.

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surgical: fracture 4 diagnosis

1. Anamnesis
Often patients come with complaints that have been broken because bone explained the situation for these fracture patients. Otherwise might, broken bones are not by people, and they come out with strained, especially with the broken fragments with a minimum of disturbance. Diagnosis fracture also begins with the anamnesis: the existence of a particular trauma, such as falls, twist , light, strong, and how trauma is. In the perception of trauma can be even though it is actually light weight, can be rather mild, although it is actually heavy. In addition to historical trauma, pain complaints are usually found, although the fracture fragments broke stable, sometimes does not cause pain complaints. Many broken bones have a unique injury (Sjamsuhidajat & de Jong, 1997).
Fracture's main complaint is pain, swelling, and deformities lost or reduced function.
When there is no trauma history means fracture pathologies. Trauma must be itemized type, light-weight trauma, trauma and the direction or position of the extremity (trauma mechanism) (Reksoprodjo et al., 1995).

From anamnesa can only suspected:
- Possibility of poly trauma
- Possibility of multiple fracture
- Possibility of fractures particular, for example: fracture Colles, fracture supracondylair humerus, fracture collum femur
- On anamnesa have pain but can not clear the fracture incomplete
- No interference function, for example: fracture femur, the patient can not walk. Sometimes the function still survive in the fracture incomplete impacted and fracture (impaksi bone cortical in bone spongiosa) (Reksoprodjo et al., 1995).

2. Physical examination
Also find possible common complications, such as: multiple shock on fracture, fracture pelvis or fracture open, signs of sepsis in the fracture open infected (Reksoprodjo et al., 1995).

3. Vetting status localise
Mansjoer et al. (2000) mentioned that in the examination status localise fracture must include:
a. Look, if there is a search:
- Deformitas, consists of a projection of abnormal (eg, the fracture condilus laterals humerus), angulasi, rotation and abridgment.
- Function laesa (loss of function), for example, on the fracture cruris can not walk.
- See also the size of long bones, compare left and right, for example, on the bottom of the leg covering apparent length (distance between the umbilicus with maleolus medialis), and true length (distance between the malleolus medialis with SIAS).
b. Feel, if there is a painful hit. Examination painful axis is not done anymore because it will add to trauma.
c. Move, to search for:
- Krepitasi, fracture feel when driven. But in the spongiosa bone or cartilage epifisis not feel krepitasi. This should increase because not done trauma.
- Pain when moved, both the active and passive movements.
- How far interference-interference functions, movements that are not able to do, range of motion (degrees from the scope of joint movement, and strength).

4. Radiology examination
Radiology examination is the key to diagnose the fracture. Radiography long bones should include adjacent joints (joints in the distal proximal and fracture) to avoid dislocation of joints associated with the fracture. Results from radiography joints can be confusing because the extremity is not standard at the position, such as fracture and stress due to the wrong place fracture (Displaced fracture). In this case the fracture not appear until the bones absorbted lesi location (1-4 weeks), especially if lesi fracture occur in bone scaphoideus. Additional examination as tomography, CT scan, MRI, etc. are not needed difficult diagnosis true with x-ray images (Armis, 2001).

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surgical: fracture 3 classification

According Mansjoer et al. (2000) classification fracture are divided into:
1. According cause:
a. Jump
b. Not direct: as a result sustain the burden that exceeds the ability of the bones.

2. According to the form:
a. Closed fracture / fracture closed: fragments of the bone is not related to the world outside the room or in the body.
b. Open fracture / fracture open: there is a wound that connect with the world outside the room or in the body.

3. According to is:
a. Fracture complete, when all through the broken bone or cut through the bone cortex.
b. Fracture is not complete, when the fracture line does not cut through all the bones, such as:
- Hairline fracture (broken cracked hair)
- Buckle fracture or torus fracture, if there is a bending of the compression cortex bone spongiosa underneath, usually at the distal radius of children.
- Green stick fracture, on the one cortex with other angulasi cortex that occurred in long bones of children.

4. According to the form of broken lines and the mechanism related to the trauma:
a. The broken cross: angulasi or direct trauma
b. Broken line oblique: trauma angulasi
c. The spiral fracture: trauma rotation
d. Fracture compression: trauma-FLEKSI on axial bone spongiosa
e. Fracture avulsi: trauma tug / tracks muscle inserts on the bone, such as fracture patella.

5. According to the number of broken lines:
a. Fracture cominutif: fracture line more than one and each other.
b. Fracture segmental: the broken more than one but not related. When the two broken lines bifokal called fracture.
c. Fracture multiple: broken line, but more than one bone at a different place, such as fracture femur, fracture cruris, and fracture spine.

6. According shift:
a. Fracture undisplaced (not shifted), the complete fracture fragments but not the second shift, periosteum intact.
b. Displaced Fracture (shift), shifting occurs fracture fragment-fragment which is also called the location of fragments, divided:
- Dislocation longitudinum cum ad contraction (shifting direction axis and overlapping)
- Dislocation ad axim (the shape shifting angle)
- Ad latus dislocation (where the shift in the second fragment avoid each other).

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surgical: fracture 2 definition

Definition of fraktur in general:
Fraktur is disrupsi (separated with the action or circumstances which forced the separate abnormal) on the continuity or bone deformation linier result discontinuity the bone caused by the style exceeds the elasticity of bone. So essentially there are bones discontinuities (Armis, 2001).
Fraktur is a fracture or dissolution network continuity bone and / or cartilage which is mostly caused by trauma. Trauma that caused a bone fracture can be either direct trauma, such as the impact on the bottom arm, which caused fracture radius and ulna, and can not be direct trauma, such as a fall on the hands that causes bones clavikula or distal radius fracture (Sjamsuhidajat & de Jong, 1997 ).

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surgical: fracture 1

Trauma system muskuloskeletal often appear dramatic, and will be found in 85% of blunt trauma, but rarely the cause of the threat or the threat of loss of life of member movement. However muskuloskeletal trauma must be reviewed and handled in an appropriate and adequate in order not to endanger the lives and movement members. Doctors need to recognize the existence of this trauma, the anatomy traumatic, protect people with disabilities from the next and can take action to prevent complications (Krantz et al., 1997).
Trauma is a prominent topic at the moment. Perhaps the bed surgical orthopedics, more than 50% of trauma cases by place. Understanding about the first, ambulance service, needs to be improved, especially in the fracture open. Not infrequently open fracture occurred in an accident, not an open fracture is simple, but the network software which will determine the appropriate action is taken, the members maintained movement and be amputated. For example, such as the fracture is open, along with large blood vessel rupture, or rupture with perifer nerve, or loss of a broad skin. Therefore, understanding the damage repair network software needs to be improvement and implementation of network software must be made by a specialist surgical orthopedics in accordance with local conditions. Also understanding the difficult that may arise and how to overcome, including rehabilitated, must also be by a specialist surgical orthopedics (Reksoprodjo et al., 1995).
Some experts think that at the end of this century is the century trauma and trauma from year to year will always increase, due to the increased demand that will increase human mobility (Armis, 1994).

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