PELAYANAN PRIMER SINDROM KARPAL TUNEL/SKT (CARPAL TUNNEL SINDROME/CTS)

PENDAHULUAN

Sindrom karpal tunel (SKT) adalah gejala neuropati saraf medianus akibat adanya penekanan di daerah pergelangan tangan sisi palmer. Penekanan tersebut akibat adanya peningkatan tekanan di dalam tunel sehingga fungsi saraf medianus berkurang (fig.1). Adapun saraf medianus berasal dari akar/root C6. C7 dan T1 dengan serabut saraf sensoris menginervasi ibu jari (1), jari telunjuk (2), jari tengah (3) sisi palmer dan separoh jari manis (4) sisi palmer dengan sisi dorsal dari ujung jari-jari tersebut.

Fig. 1 Anatomi saraf medianus yang berada dalam tunel karpal yang berbentuk oval bersama-sama dengan tendondon fleksor sublimis dan profunda. Saraf medianus berada di radial dan superfisial dalam tunel tersebut

PELAYANAN PRIMER FRAKTUR TERBUKA

A.     PENDAHULUAN

1.      Batasan (definisi)

Fraktur terbuka (open fractures) adalah diskontinuitas struktur tulang yang berhubungan dengan dunia luar (external environment) akibat kerusakkan jaringan lunak dan kulit penutup tulang yang mengalami lesi tersebut.Oleh karena itu, fraktur terbuka rentan infeksi.

2.      EPIDEMIOLOGI

Insidensi fraktur terbuka di UK 36.0 per 100.000 populasi (2002 – 2004) dengan didominasi oleh pria, tapi diatas umur 55 tahun didominasi oleh wanita.Berdasarkan RISKESDAS (riset kesehatan dasar) di Indonesia 2013 dengan hasil fraktur terbuka 5.8% dari seluruh kasus di Rumah Sakit. Penyebab kecelakaan lalu lintas adalah terbanyak (42.8%) dari seluruh fraktur terbuka yang didominasi oleh  akibat kecelakaan sepeda motor (40.6%) dan kemudian diikuti jatuh (40.9%).

ABILITY TO UNDERSTAND THE CARPAL TUNNEL SYNDROME (CTS) ON ORTHOPAEDIC BOARD EXAMINATION

1.    The Candidate should be able to understand carpal tunnel syndrome or definition (CTS):

Carpal tunnel syndrome (CTS) is a symptomatic compression neuropathy of the median nerve at the wrist area with characterized physiologically by the increasing of pressure within the carpal tunnel and decreased function of the median nerve.

SCENARIO OR CLINICAL SIGNS OR INVESTIGATION FINDING OF ORTHOPAEDIC AND TRAUMATOLOGIC EXAMINATION

WHAT IS THE CLINICAL FEATURES PROBLEM?

A feature of clinical problem is the issue related to the context of clinical medicine and it is more a tool. The summary of clinical feature problem is one or some trigger clinical signs for discussion between the Candidate and the Examiners. These triggers are always relevant, interesting and provocative at the discussion in the orthopaedic and traumatologic exam. The clinical problem could be documented in writing, photos of clinical sign, audio or video tape.

Adequate discussion of the trigger clinical features is important and there are a number of strategies to ensure the objectives and transparent, valid and reliable marks achieved. Therefore, the discussion of the key feature of clinical problem is a fundamental aspect for the Candidate passing in orthopaedics and traumatologic examination objectively. The discussion may be extended the basic medical and clinical sciences questions by the Examiners (illustration 4).

OSTEOARTHRITIS OF THE KNEE (KNEE OA)

Case Examination:

A 65-year-old female came to orthopaedic consultation with chief complaint of the right knee pain and stiffness since 5 years especially after walking. She consumed NSAIDs routinely based on general practitioner’s recommendation since 6 months ago but no improvement. She denied infection, trauma, past surgery, family and malignancy history. Physical examination on the right knee showed a bit swelling of the right knee and valgus deformity of right lower extremity (Fig. 4). Feeling examination of the right knee revealed tenderness on the margin of the knee joint, crepitus on patella and swelling. Range of the right knee motion was limited actively compared the left knee.

ORTHOPAEDICS EMERGENCIES

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ORTHOPAEDICS EMERGENCY (Primary Management)

FRAKTUR FRAGILITAS: MANAJEMEN FRAKTUR FRAGILITAS DI PUSKESMAS

 Armis

Bagian Orthopaedic dan Traumatologi

Fakultas Kedokteran UGM, Rumah Sakit DR Sardjito

Yogjakarta

A.   PENDAHULUAN (INTRODUCTION)

1.      Batasan (definition):

Fraktur fragilitas adalah fraktur patologis karena kualitas tulang menurun (osteoporosis) sehingga trauma energi ringan (tivial injury) seperti terpleset atau kegiatan sehari-hari dan lain-lain dapat menimbulkan fraktur. Adapun osteoporosis adalah penyakit skeletal sistemik dengan karakteristik penurunan massa tulang (low bone mass) sehingga rentan terjadi fraktur fragilitas.

2.      Epidemiologi dan faktor risiko

Osteoporosis primer umumnya terjadi pada wanita pasca menoupause (postmenopause) yang merupakan tantangan pada pelayanan kesehatan primer dengan pembiayaan penatalaksanaan yang mahal seperti di US diperkirakan 20% - 30 % dari biaja kesehatan seluruhnya pada wanita ras Kaukasia.

CLOSED FRACTURES: THE ROLE OF GENERAL PRACTITIONER (GP) AND FAMILY MEDICINE IN CLOSED FRACTURES MANAGEMENT AT PUSKESMAS

Armis

Professor in Orthopaedic and Traumatologic

UGM, Sardjito Hospital, Yogjakarta

INDONESIA

INTRODUCTION

Fracture is a discontinuity of bone structures. If the soft tissues around the fracture site are intact is called CLOSED FRACTURE, vice versa the soft tissues and skin around the fracture site are not intact, therefore the fracture site is related with external environment is called OPEN FRACTURE.  The fracture is caused by high energy trauma may produce many fracture fragments is called FRACTURE COMMUNITIVE or produce many regions of bone fractures and also bones in different part of the body is called MULTIPLE FRACTURES. The high energy trauma is associated more than one body system is called MULTIPLE TRAUMA. If fracture is caused by low energy trauma is called FRAGILITY FRACTURE.

                                                   A             B                                      C

Fig. 1 A and B. Open fracture type IIIA of the segmental comminuted distal left femur and open intercondylar left femur fracture T type. C. Open comminuted fracture type IIIA of the left tibial plateau Schatacker VI and fracture lines extend to distal of the tibia (OPEN COMMINUTED OF THE DISTAL LEFT FEMUR and OPEN COMMINUTED OF THE PROXIMAL TIBIA/MULTIPLE FRACTURE)  

PRACTICING IN THE OBJECTIVES ASSESSMENT GUIDANCE OF THE ORTHOPAEDICS AND TRAUMATOLOGIC EXAMINATION

PREFACE

 “Is the Candidate mark objective and transparent, valid and reliable in Orthopaedics and Traumatologic examination without prejudices and disparities?”

I always reflect this interesting examination question during ten years’ experience in the Indonesian National Board Orthopaedics and Traumatologic Examiner. Because of the Examiners are able to initiate an interesting topic knowledge or skill question of the scenario independently.  This question stimulates me to solve the problem. Therefore, I think all the Examiners should be able to make a similar perception to evaluate the learning objectives of the examination.

I attempt to design the objectives examination assessment guidance of the Orthopaedics and Traumatologic examination including:

DISLOCATION OF THE KNEE JOINT

SCENARIO

A-20-year male arrived at the emergency with pain and swelling of the left knee joint caused by struck the tree during riding of motorcycle one hour ago (fig. 9). He is conscious and without others region injury.

Fig. 9. Right knee in closed traction

How the candidate solves the scenario problem

OSTEOMYELITIS AND NON-UNION

Case Examination:

A 16-year-old male came to orthopaedic consultation complaining pain during weight bearing, valgus angulation right distal lower leg with shortening. He had open right lower leg fracture and had been operated debridement and internal K-wire fixation of the fibula with external fixation of the tibia 11 months ago. Physical examination revealed valgus angulation and 11 x 7 cm cicatric on antero-medial aspect of the right distal lower leg without sinus. AP and lateral projections radiographs of the right lower leg showed a gap on tibia and fibula and closed of medullary canal of the fragments fracture end with K-wire fixation and bowing to medial. On the tibia showed external fixation without callus formation and a bit medial angulation (Fig.6).

EXAMPLE CASE OF ROTATOR CUFF TEAR ARTHROPATHY (RTA)

Case Examination

 

A 65-year-old male came to orthopaedic consultation with chief complaint of the right shoulder pain especially at night and weakness. He was a right dominant, retired mathematics teacher at favorite high school and NSAID treated without improvement. He had gout arthritis problem since 15 years ago. Inspection of the right shoulder of patient was asymmetric, atrophy of the right side of upper extremity and tenderness in the anterior aspect especially on subacromial of the right shoulder. Active and passive movement (ROM) of the right shoulder was limited

 

Part A: The objectives examination evaluation of the history taking and physical examination data collection for some possibilities or accurate diagnosis determination

 

Learning Objectives Evaluation in Examination

Orthopaedics and Traumatologic Examination : Part A

There are two versionsof the orthopaedic and traumatologic examination:

1.  A real case of exam.

After orthopaedics and traumatologic case selection by the examiners team; the Examiner asks the Candidate to collect the history taking and collect physical examination data of the orthopaedic and traumatologicpatient for analyzing and making the possibilities diagnosis.The Candidate should be able to select the important information and the reasoning of the investigations before presenting the summary

2.        Scenario or clinical signs or investigation findings exam.

The Examiner is able to select the scenario or clinical signs or radiographs of x-ray or laboratory of the patient and then the Candidate is able to ask some key of information in history taking,important data of the physical examinationand investigation findings. These information and key data are able to support the differential diagnosis or possibilities of the illness on the scenario orclinical signs or abnormalities of the investigation finding.

Orthopaedics and Traumatologic Examination : Part B and Part C

Part B: The objectives examination evaluation of the accurate diagnosis determination or possibilities of the abnormalities, patient’s problem, management and complications  

Learning Objectives Evaluation in Examination

The Examiner should be able to evaluate the Candidate ability to:

1.       To decide the problem determination (acute and long-term) of the patient

After the Candidate determines the diagnosis, he/she should be able to consider the impact of the problem on the individual or the severity of the illness process or “how bad” that disease. Example severity of fracture or dislocation must be classified into stable or unstable or other classification system. Unstable fracture of the lower extremity can contribute shortening or malunion and degeneration process of the bearing joint become happened at the long time.The risk factors of 4 parts of the humeral head fracture or femoral neck fracture in elderly condition can lead to avascular necrosis of the head humerus or femur.

THE OBJECTIVES ASSESSMENT GUIDANCE OF THE ORTHOPAEDICS AND TRAUMATOLOGIC EXAMINATION

PREFACE

 “Is the Candidate mark objective and transparent, valid and reliable in orthopaedics and traumatologic examination without prejudices and disparities?”

I always reflect this interesting examination question during ten years’ experience in the Indonesian National Board Orthopaedics and Traumatologic Examiner. Because of the Examiners are able to initiate an interesting topic knowledge or skill question of the scenario independently. This question stimulates me to solve the problem. Therefore, I think all the Examiners should be able to make a similar perception to evaluate the learning objectives of the examination.

I attempt to design the objectives examination assessment guidance of the orthopaedics and traumatologic examination including:

Acknowledgement

ACKNOWLEDGEMENT

To my family: Nyoman Rapiani Armis (my wife), Andrianti (Agung her husband), Ratih Yulianti (Didit her husband). Arief Prasetyo (Susan his wife), Khresna Adi S (Rieke his wife) and my grandchildren: Sekar, Rafid, Safa, Rafa, Nanya and Sofia thank you for permitting our time to support this concept.

To Prof. Bill Cumming, Prof. Joe Ghabrial, from Australia, Prof. Bala Subramanian from Singapore, They are my teachers, mentor and role model and got me started, thank you for inspiration and your support.

Introduction

INTRODUCTION

A Candidate of orthopaedics and traumatologic always makes an effort to have an excellent mark in musculoskeletal system examination. The challenge is still the examiner’s subjectivity of the examination of the candidate’s competence evaluation, according to orthopaedics and traumatologic curriculum. Competency measurement during orthopedics and traumatologic education is expected to become the candidate’s ability for future practice or to be adequate the requirement for higher degree education, and meet knowledge, skill, attitude and professionalism of learning objectives. A successful candidate’s marks in the examination should be correlated with educational institution curriculum in teaching.   Therefore, how does the examiner achieve the objective assessment in orthopaedics and traumatologic examination?