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2. Fracture Collum Femoris Dewasa

FRACTURE COLLUM FEMORIS DEWASA

Oleh Dr H Subagyo SpB - SpOT

 

Collum femur merupakan lokasi fracture tersering yang banyak terjadi pada orang lanjut usia. Fracture ini banyak terjadi pada orang ras Kaukasia, wanita lebih sering dari pada pria, usia dekade ketujuh dan kedelapan, dan pada orang yang menderita osteoporosis. Oleh karena itu, tingkat insidensi fracturecollum femur dapat dijadikan sebagai salah satu parameter tingkat insidensi osteoporosis di suatu negara.Faktor resiko lainnya ialah adanya penyakit yang mengakibatkan kelemahan atau penurunan kekuatan pada tulang, seperti osteomalasia, diabetes mellitus, stroke, dan konsumsi alkohol. Selain itu, orang lanjut usia sering kali memiliki otot-otot yang lebih lemah dan keseimbangan yang kurang baik sehingga memiliki tendensi yang lebih tinggi untuk jatuh yang mungkin mengakibatkan fracturecollum femur ini.

Adanya hubungan antara fracturecollum femur dengan hilangnya massa tulang akibat osteoporosis post menopause meningkatkan usaha screening untuk osteoporosis sebagai salah satu bentuk pencegahan terjadinya fracture tersebut. Sebaliknya, trauma ini sangat jarang ditemukan pada orang-orang dengan massa tulang yang tinggi, seperti pada orang yang menderita osteoartritis.

Fracturecollum femur juga lebih jarang ditemukan pada orang-orang ras Negroid, dibandingkan dengan orang Kaukasia dan Asia.Alasan rendahnya tingkat insidensi pada orang Negroid belum sepenuhnya diketahui. Namun, ada berbagai hipotesis untuk menjelaskan hal tersebut, yakni karena massa tulang orang Negroid lebih tinggi, tingkat kehilangan massa tulang setelah menopause yang lebih lambat, dan adanya perbedaan struktur tulang dibandingkan orang Kaukasia.

Tingkat kejadian fracturecollum femur diperkirakan akan meningkat dua kali lipat dalam 30 tahun ke depan. Hal ini terjadi sebagai akibat semakin meningkatnya angka harapan hidup, khususnya hingga di atas usia 65 tahun yang juga semakin meningkatkan resiko terjadinya osteoporosis. Oleh karena itu, saat ini usaha pencegahan yang efektif dan efisien terus dikembangkan mengingat tingginya beban ekonomi yang akan ditimbulkan untuk terapi, rehabilitasi, dan penanganan lebih lanjut bagi para penderitanya.

 

4.1 Karakteristik Umum

Fracturecollum femur terjadi diantara ujung permukaan articular dari caput femur dan regio intertrochanterica. Fractureini ialah fracture, intracapsular di mana cairan sinovial panggul dapat menghambat penyembuhannya. Penyembuhan juga semakin terhambat akibat hancurnya suplai pembuluh darah arterial ke lokasi fracture dan caput femur; dengan adanya fracturecollum femur, cabang cervical ascendens lateralis dari arteri sircumflexi femoris medialis mempunyai resiko yang besar untuk terkena. Terputusnya aliran darah ini meningkatkan resiko nonunion pada lokasi fracture dan beresiko untuk terjadinya nekrosis avaskular pada caput femoris.


 

Gambar 4.1Collum Femur Sisi Anterior dan Posterior

 

 

4.2 Epidemiologi

 

Insidensi fracture kolum femur meningkat sejalan dengan meningkatnya usia; insidensi tertinggi terjadi pada usia antara 70 – 80 tahun. Fracture ini terjadi lebih sering pada wanita dibandingkan dengan laki-laki, yakni dengan rasio sekitar 5 : 1. Hal ini dikarenakan populasi wanita yang lebih banyak pada usia tersebut dan juga karena arsitektur dari upper end of femur sehubungan dengan osteoporosis dimana prevalensinya lebih tinggi pada wanita dibandingkan laki-laki. Lesi ini jarang terjadi pada orang yang menderita osteoarthritis pada panggulnya.

Markey melaporkan bahwa fracturecollum femur mencapai 5-10% dari semua kejadian stress fracture. Stress fracturecollum Femur adalah fracture yang jarang terjadi, tetapi apabila terjadi dapat mengakibatkan masalah yang serius.Tentunya di kelompok atlet, seperti pelari jarak jauh yang tiba-tiba mengubah atau menambah aktivitasnya, akan mempunyai prevalensi yang lebih besar terhadap terjadinya stress fracture dari collum Femur ini dibandingkan dengan populasi lainnya.

Plancher dan Donshik juga melaporkan rata-rata angka prevalensinyasekitar 10% untuk fracturecorpus femur ipsilateral, dimana sebanyak 30% tidak diketahui pada awal terjadinya.

Menurut Koval dan Zuckerman, angka kejadian FractureCollum Femur di Amerika Serikat adalah sebesar 63.3 kasus per 100.000 orang per tahun untuk wanita dan 27.7 kasus per 100.000 orang per tahun untuk pria.

Sejak ditemukan prosedurinternal fixation, angka mortalitas yang awalnyamencapai 60-85% telah berkurang hingga 8-10%; dengan demikian, angka morbiditas meningkat tajam sampai 30%, yang mengindikasikan bahwa internal fixation merupakan prosedur lifesaving. Kematian jarang terjadi karena fracture ini, tetapi terdapat beberapa gangguan medis yang mempengaruhi orang-orang pada usia yang lebih lanjut ini, seperti gangguan jantung, penyakit paru, diabetes mellitus, trombosis serebral, hipertensi, dan demensia senilis.

Angka mortalitas pada usia 60 tahun meningkat terus seiring bertambahnya usia dan mencapai puncaknya pada dekade 9 dan dekade 10. Prognosis pada laki-laki umumnya lebih baik daripada wanita; kejadian kegagalan tertinggi terjadi pada wanita yang berusia lebih dari 65 tahun.Angka morbiditas tergantung dari terapi fracture yang terjadi; lebih rendah pada fracture stadium I dan II daripada fracture stadium III dan IV. Stadium I dan II menurut Garden, di mana terjadi fracture tanpa displaced, sedangkan pada stadium III dan IV telah terjadi displaced pada fragmen-fragmen tulang, baik sebagian, maupun seluruhnya.

4.3 Mekanisme Terjadinya Fracture

Fracturecollum femur biasanya terjadi akibat jatuh, tetapi pada orang yang menderita osteoporosis, kecelakaan yang sangat ringan sekalipun sudah dapat menyebabkan fracture, misalnya akibat kaki yang tersandung karpet dan menyebabkan sendi panggul mengalami exorotasi.            

Pada orang dengan usia muda, fracture biasanya terjadi akibat jatuh dari ketinggian atau akibat kecelakaan lalu lintas yang menyebabkan hingga terlempar ke jalan. Pada pasien ini sering kali mengalami jejas multipel dan 20% di antaranya juga mengalami fracturecorpus femur.

Pada tahun 1990, Volpin melaporkan sebanyak 4,7% dari 194 tentara militer mengalami stress fractures. Fracture ini juga dapat ditemukan pada atlet pelari.

Selain itu, Zahger et al pada tahun 1988 juga melaporkan insiden yang cukup tinggi terjadinya fracture ini pada para tentara wanita Israel.

4.4 Klasifikasi

 4.4.1 Klasifikasi Berdasarkan Lokasi Anatomis

Berdasarkan lokasi anatomis dari garis fracturenya, fracturecollum femur diklasifikasikan menjadi dua bagian besar, yaitu fractureintracapsular dan fractureextracapsular. Gambar 4.2 menunjukkan gambaran klasifikasi fracture femur bagian proksimal tersebut.

 

Gambar 4.2 Klasifikasi Fracture Femur Bagian Proksimal

(A) FractureIntracapsular, (B) FractureExtracapsular

Fracture collum femur meliputi fractureintracapsular yang terdiri dari fracturesubcapital, transcervical, dan basilar (basiservikal), sedangkan fractureextracapsular terdiri dari fracture intertrochanteric dan subtrochanteric.

4.4.1.1 FractureIntracapsular

Fractureintracapsular disebut juga sebagai fracture letak tinggi collum femur. Pada kelompok ini, fragmen proksimal sering kehilangan bagian pembuluh darahnya dan oleh karena itu, penyatuan kembali (union) fracture sangatlah sulit. Hal ini merupakan kejadian serius  pada pasien usia lanjut. Pada pasien yang sangat tua dan lemah, hal ini akan mencetuskan terjadinya ketidakseimbangan metabolisme. Dengan demikian, dapat terjadi terminal illness oleh karena uremia, infeksi paru, mendengkur sewaktu tidur, ataupun akibat penyakit fatal lainnya.

Fractureintracapsular diklasifikasikan lagi berdasarkan daerah collum femur yang dilalui oleh garis fracture, antara lain:

a.  FractureSubcapitalGaris fracturenya melintasi collum femur tepat di bawah caput femur.

 

Gambar 4.3 FractureSubcapital

 b.   FractureTranscervical

Garis fracture biasanya melewati setengah panjang collum femur. Seperti pada fracturesubcapital, bila terjadi displaced pada fracture, caput femur biasanya akan kehilangan suplai darahnya dan ikut mengalami kerusakan. Oleh karena itu, pada penanganan sebagian besarfracture ini juga harus dilakukan penggantian caput femur dengan implantasi metal, daripada berusaha menyatukan fracture yang sulit sembuh dan akhirnya menjadi kolaps.

 

 

Gambar 4.4 FractureTranscervical

c.       FractureBasilar atau Basiservikal

Garis fracturenya melintasi bagian basis collum femur. Jenis fracture ini berada pada perbatasan collum femur sehingga sempat diperdebatkan apakah termasuk fractureintracapsular atau fractureextracapsular. Pada daerah ini mempunyai suplai darah yang baik dan bila terjadi fracture disini tidak mungkin mempengaruhi viabilitas dari caput femur. Biasanya fracture ini ditangani dengan internal fixation, sering hasilnya baik.

 

Gambar 4.5 FractureBasilar atau Basiservikal

 

4.4.1.2 FractureExtracapsular

Fractureextracapsularyang termasuk dalam fracture collum femur merupakan fracture-fracture yang terjadi pada daerah intertrochanteric dan daerah subtrochanteric.

 a.  Fracture Intertrochanteric

Pada fracture ini, garis fracture melintang dari trochanter mayor ke trochanter minor. Tidak seperti fractureintracapsular, salah satu tipe fractureextracapsular ini dapat menyatu dengan lebih baik. Resiko untuk terjadinya komplikasi non-union dan nekrosis avaskular sangat kecil jika dibandingkan dengan resiko pada fractureintracapsular.,      

Fracture dapat terjadi akibat trauma langsung pada trochanter mayor atau akibat trauma tidak langsung yang menyebabkan twisting pada daerah tersebut.            

Berdasarkan klasifikasi Kyle (1994), fracture intertrochanteric dapat dibagi menjadi 4 tipe menurut kestabilan fragmen-fragmen tulangnya.Fracture dikatakan tidak stabil jika:

  1. Hubungan antarfragmen tulang kurang baik.
  2. Terjadi force yang berlangsung terus menerus yang menyebabkan displaced tulang menjadi semakin parah.
  3. Fracture disertai atau disebabkan oleh adanya osteoporosis.

 

                Gambar 4.6 menunjukkan klasifikasi Kyle untuk fracture intertrochanteric.

 b.  Fracture Subtrochanteric

Fracture subtrochanteric biasanya terjadi pada orang usia muda yang disebabkan oleh trauma berkekuatan tinggi atau pada orang lanjut usia dengan osteoporosis atau penyakit-penyakit lain yang mengakibatkan kelemahan pada tulang. Ada beberapa hal yang perlu diperhatikan pada fracture ini, antara lain:

  1. Perdarahan yang terjadi cenderung lebih massif dibandingkan perdarahan pada fracture collum femur lainnya. Hal ini terjadi karena pada daerah subtrochanteric terdapat anastomosis dari cabang-cabang arteri femoral bagian medial dan lateral.
  2. Fragmen fracture dapat terextensi ke region intertrochanteric yang mungkin menyulitkan pelaksanaan internal fixation.
  3. Bagian proksimal mengalami abduksi, exorotasi, dan flexi akibat psoas sehingga corpus femur harus diposisikan sedemikian rupa untuk menyamai posisi tersebut. Jika tidak, maka resiko untuk terjadinya non-union atau malunion akan sangat tinggi..              

Pada X-ray dapat ditemukan gambaran-gambaran fracture yang perlu diperhatikan sebagai suatu bentuk warning sign, seperti ditunjukkan pada gambar 4.7 berikut ini.

 

 Gambar 4.7 Fracture Subtrochanteric – Warning sign pada X-ray

Keterangan Gambar 4.7

(a)     Comminution, dengan extensi ke fossa piriformis

(b)     Displacement pada fragmen medial, termasuk trochanter minor

(c)      Lytic lesion pada femur

 

4.4.2 Klasifikasi Menurut Garden

Klasifikasi fracturecollum femur yang banyak digunakan ialah klasifikasi menurut Garden yang dikemukakan pada tahun 1961. Garden mengklasifikasikan fractureintracapsularini secara simple dan logis berdasarkan berbagai stadium dari displacement yang terlihat pada foto x-ray sebelum tereduksi. Fracturecollum femur dibagi menjadi 4 stadium berdasarkan derajat displacement dari fragmen fracture.

Klasifikasi ini juga memberikan informasi yang jelas tentang derajat kehancuran korteks posterior dan inferior dan apakah retinakulum posterior masih menempel atau tidak (stuktur dimana pembuluh darah utama menuju ke caput femoris) dan membantu dalam menentukan prognosis dari setiap stadium fracture yang terjadi.

  • Stadium I  : Fractureincomplete atau fracture impaksi valgus (valgus malalignment) tanpa displaced tulang
  • Stadium II : Fracturecomplete tanpa displaced tulang
  • StadiumIII :Fracturecomplete dengan displaced sebagian dari fragmen-fragmen  tulang yang mengalami fracture
  • Stadium IV : Fracturecomplete dengan displaced total atau seluruh fragmen-fragmen tulang yang mengalami fracture

 

Gambar 4.8 Klasifikasi FractureCollum Femur Menurut Garden

 

4.4.2.1 Klasifikasi Garden – Stadium I

Pada fracturecollum femur stadium I akan ditemukan:

1.     Fracture inkomplet pada collum

2.     Eksternal rotasi dari fragmen distal

3.     Fragmen proksimal di dalam valgus

4.     Trabekula tulang medial dari caput membuat sudut lebih dari 180o dengan korteks medial dari femur.

Bila fracture ini tidak di fiksasi ke posisi semula, maka akan menjadi fracture komplet dan memberikan gambaran fracture pada stadium II, III, atau IV, tergantung dari exorotasi pada fragmen-fragmen distal. Merupakan fracture stabil dengan prognosis yang baik.

Gambar 4.9 Klasifikasi Garden – Stadium I

 

4.4.2.2 Klasifikasi Garden – Stadium II

Pada fracturecollum femur stadiumIIakan ditemukan:

1.     Fracture oblik komplet melalui collum

2.     Fragmen kapital tidak displaced

3.     Fragmen distal pada posisi yang normal dengan fragmen proximal

4.     Trabekula medial pada caput membuat sudut sekitar 160o dengan korteks femur medial

Rotasi lateral pada fragmen distal dapat menyebabkan pergeseran fragmen, yang menyebabkan fracture menjadi stadium III atau Korteks posterior dari femur masih belum kolaps dan retinaculum posterior masih intact.Fracture ini stabil dan mempunyai prognosis yang baik.

 

Gambar 4.10 Klasifikasi Garden – Stadium II

 

4.4.2.3 Klasifikasi Garden – StadiumIII

Pada fracturecollum femur stadium IIIakan ditemukan:

1.     Fragmen distal berotasi ke arah lateral

2.     Fragmen proximal miring ke varus dan berotasi ke arah medial

3.     Trabekula medial dari caput tidak pada tempatnya pada pelvis

Korteks posterior collum tidak kolaps; retinakulum posterior masih intact memegang fragmen-fragmen bersama, tapi masih bisa terluka.Rotasi ke arah lateral yang lebih jauh dari fragmen distal akan membuat fracture ini menjadi stadium IV. Fracture ini, bila dapat ditangani, dapat menjadi fracture stabil dengan prognosis yang baik.

 

Gambar 4.11 Klasifikasi Garden – Stadium III

 

4.4.2.4 Klasifikasi Garden – StadiumIV

Pada fracturecollum femur stadium IV akan ditemukan:

1.     Fragmen kapital terpisah sempurna dari fragmen distal dan kembali ke posisi normalnya pada acetabulum; saat ini trabekula medial berada pada tempatnya pada pelvis.

2.     Fragmen distal berotasi lateral

3.     Fragmen distal bergeser ke atas dan ke anterior ke fragmen proximal

Korteks posterior dari collum kolaps dan retinakulum posterior stripped or torn dari bagian posterior collum femur.Fracture ini sulit ditangani dengan sempurna; dan bahkan bila reduksi tercapai, defek pada korteks posterior membuatnya tidak stabil.Prognosis sangat buruk.

 

Gambar 4.12 Klasifikasi Garden – Stadium IV

 

4.4.3 Klasifikasi Menurut Pauwell

Klasifikasi Pauwell telah digunakan sejak tahun 1935.Berdasarkan besarnya sudut yang dibentuk oleh garis fracture dengan sumbu horizontal pada corpus femur, Pauwell mengklasifikasikan fracturecollum femur, sebagai berikut:

  • Tipe I :Garis fracture membentuk sudut <30o dari sumbu horizontal.
  • Tipe II :Garis fracture membentuk sudut 30o – 50o dari sumbu horizontal.
  • Tipe III :Garis fracture membentuk sudut >70o dari sumbu horizontal.

 

Gambar 4.13 Klasifikasi Pauwell

 

4.4.4 Klasifikasi Menurut Hence

Hence mengklasifikasikan fracture collum femur intracapsularmenjadi 2 bagian besar dan lebih sederhana, yaitu:

1. Fracture non-displaced

Fracture tanpa disertai adanya pergeseran fragmen-fragmen tulang.

2. Fracture displaced

Fracture dengan disertai adanya pergeseran fragmen-fragmen tulang, baik sebagian ataupun seluruhnya.

4.4.5 Klasifikasi Menurut Linton

Klasifikasi Linton membagi fracture collum femur intracapsularberdasarkan garis fracture dan posisi fragmen-fragmen tulangnya dengan pembagian sebagai berikut:

  1. Stage I     : fractureincomplete
  2. Stage II    : fracturecomplete, undisplaced
  3. Stage III   : fracturecomplete dengan displaced parsial
  4. Stage IV    : fracturecomplete dengan displaced total

4.5 Etiologi

Latihan yang salah merupakan faktor resiko tersering, termasuk peningkatan mendadak dari kuantitas dan intensitas latihan serta perpindahan ke aktivitas yang baru. Faktor lain yang berperan antara lain densitas tulang yang rendah, komposisi tubuh yang abnormal, defisiensi makanan, abnormalitas biomekanik, dan menstruasi yang tak teratur.

Beberapa faktor predisposisi fracturecollum femur ialah variasi anatomi, osteopenia relatif, kondisi fisik yang buruk, kondisi medis sistemik yang menyebabkan demineralisasi dari tulang, atau inaktivitas beberapa saat, dapat membuat tulang lebih mudah mendapatkan stress fracture.

Seperti yang dilaporkan oleh Monteleone pada tahun 1995, penelitian menunjukkan bahwa wanita mempunyai insidensi lebih banyak terhadap stress fracture, yang diakibatkan karena variasi anatomi.Wanita cenderung untuk mendapatkan direct axial force saat latihan beban berat dari beberapa aksis tulang panjang dibandingkan dengan pria.Wanita juga mempunyai 25% otot lebih sedikit dibandingkan dengan pria.Hal ini membuat tekanan terpusat dan stabilitas tahanan melalui anatomi tulang.

Pada tahun 1987, Markey melaporkan bahwa Hersman et al mendokumentasikan bahwa wanita mempunyai insidensi stress fracture yang lebih tinggi.Tingginya insidensi ini akibat perbedaan mekanik dan variasi anatomi antara wanita dan pria. Perbedaan pada wanita ini meliputi stride lengths, number of strides per distance, pelvis yang lebih lebar, coxa vara, dan genu valgum.

Latihan yang menginduksi abnormalitas endokrin diketahui dengan baik dapat mengakibatkan amenorrhea atau defisiensi nutrisi, yang dapat menyebabkan demineralisasi dari tulang dan membuat pasien beresiko terhadap jejas.Stress fracture, khususnya pada tulang trabekular, telah menunjukkan penurunan isi mineral pada tulang.Penurunan ini dapat mengakibatkan penurunan esterogen pada sirkulasi, yang terjadi pada atlet wanita yang mengalami amenorrhea. Kurangnya proteksi dari esterogen mengakibatkan penurunan massa tulang. Trias atlet wanita yaitu amenorrhea, osteoporosis, dan gangguan makan mempengaruhi beberapa wanita aktif. Kehilangan massa tulang yang irreversibel pada pasien akan meningkatkan terjadinya resiko fracture lebih besar.

Kebanyakan individu bukan atlet yang kompetitif dan tidak akan pada tingkat latihan yang optimal. Individu sering memaksa dirinya untuk berpartisipasi pada tingkat dimana mereka tidak merasa tubuhnya sehat.Flexibilitas, Kekuatan otot, dan koordinasi neuromuskular memberikan kontribusi pada luka bila mereka tidak dilatih.

4.6 Patofisiologi

Caput femoris mendapat suplai darah dari tiga sumber, yaitu pembuluh intramedula pada collum femur (arteri-arteri metafiseal inferior), pembuluh servikal asendens pada retinakulum kapsular (arteri-arteri epifiseal lateralis); dan pembuluh darah pada ligamentum kapitis femoris (arteri ligamentum teres).Pasokan intramedula selalu terganggu oleh fracture; pembuluh retinakular juga dapat terobek kalau terdapat banyak pergeseran.Pada manula, pasokan yang tersisa dalam ligamentum teres sangat kecil dan pada 20% kasus tidak ada. Itulah yang menyebabkan tingginya innsidensi nekrosis avaskular pada fracturecollum femur yang disertai pergeseran.

4.6.1 FractureSubcapital

4.6.1.1 Mekanisme FractureSubcapital pada Collum Femur

Pada pasien usia lanjut khususnya pada wanita, terjadi perubahan struktur pada bagian ujung atas femur yang menjadi predisposisi untuk terjadinya fracture pada collum femur. Karena hilangnya tonus otot dan perubahan pada keseimbangan sensasi yang berhubungan dengan usia, pasien ini dituntut untuk mengubah pola berjalan mereka.

Perubahan cara berjalan bertanggung jawab pada pengaturan kembali weight-bearing bony trabeculae pada bagian ujung atas femur di sepanjang garis fracture baru. Proses ini bersama dengan osteoporosis senilis menyebabkan lemahnya dari collum femur, yang dapat menghasilkan disolusi dari beberapa trabekula tulang, pada garis yang lebih atau kurang ke aksis panjang collum yang dimulai superior pada hubungan antara caput dan collum; hal ini sebanding dengan fatique or stress fracture.

Apabila, sebagai hasil beban vertikal atau minor twist, fracture inkomplit dapat menjadi fracture komplit yang meluas melalui korteks inferior, pasien jatuh karena hilangnya penyokong dari panggul. Pasien tidak akan menahan fracture karena dia jatuh; fracture dapat terjadi diawal atau setelah terjatuh.

Fracture dapat disebabkan karena lemahnya collum femur terhadap aksi stress dari arah vertikal dan rotasional yang terus-menerus, seperti ketika ekstremitas berexorotasi dan tubuh berotasi ke arah yang berlawanan. Pada mekanisme ini, aspek posterior dari collum mengenai lingkaran dari acetabulum karena berotasi ke arah posterior; pada keadaan ini acetabulum berperan sebagai titik tumpu. Pada pasien usia muda, mekanisme yang sama disebabkan oleh kekerasan, sehingga menyebabkan fracture pada collum femur.

Kemiringan suatu garis fracture seperti yang terlihat pada x-rays antero posterior (AP) dari fracture yang tereduksi sangat penting pada semua fracturesubcapital; Akan tetapi jarang sekali kemiringan ini berubah. Keadaan ini dimulai pada aspek superior collum pada sambungan dari caput dan collum dan memanjang kebawah dan keluar sampai mengenai korteks inferior dari collum femur. Perbedaan sifat berbagai tingkatan yang terlihat pada foto x-ray berhubungan dengan derajat pergeseran dari fragmen-fragmennya; seperti pergeseran terutama disebabkan oleh karena rotasi lateral dari fragmen distal.

Kemiringan garis fracture pada fracturesubcapital dibagi menjadi:

  1. Garis fracture dimulai dari superior cervcio-capital jucntion
  2. Garis fracture meluas secara oblik melewati collum pada korteks inferior
  3. Ujung lancip dari collum femur menempel pada fragmen proximal.

Kadang-kadang jatuhnya trochanter menyebabkan impaksi fracturesubcapital; dengan demikian, mekanisme ini biasanya menghasilkan fracture trochanter.

Pengaruh Rotasi Lateral Ekstremitas pada FractureSubcapital

  1. Ekstremitas berotasi ke arah lateral
  2. Pelvis berotasi ke arah yang berlawanan
  3. Tension force terjadi pada bagian anterior collum femur dimana
  4. Compression force terjadi bagian posterior collum femur
  5. Fracture inkompleta terjadi disepanjang axis panjang collum femur
  6. Fragmen kapital di dalam valgus yang kecil

Jikaforce atau tekanan berlanjut:

  1. Fractureakan menjadi kompleta
  2. Fragmen kapital berada pada posisi normal dengan fragmen distal
  3. Collum posterior tidak comminutif
  4. Retinaculum posterior (Retinaculum of Westbrecht) masih utuh

Exorotasi yang lebih jauh lagi pada ekstremitasakan menyebabkan:

  1. Caput femur berotasi ke arah medial dan pada posisi abduksi
  2. Ekstremitas berotasi ke arah lateral
  3. Garis fracture terbuka pada sisi anterior
  4. Korteks posterior terkompresi pada garis fracture tapi tidak kolaps
  5. Retinaculum posterior masih utuh dan fragmen-fragmen tidak terpisah

Dengan exorotasi yang lebih jauh lagi pada ekstremitas dan complete displacement dan detachment pada fragmen, akan terjadi:

  1. Ekstremitas pada exorotasi yang maksimal
  2. Fragmen distal bergeser ke atas karena kontraksi otot
  3. Caput kembali ke posisi normal pada asetabulum dan dengan asumsi posisi varus berhubungan dengan collum
  4. Fragmen anterior terletak di anterior dari caput
  5. Kolaps kompleta dari korteks posterior yang terpisah oleh fragmen trigangular mayor dari korteks posterior berdekatan dengan caput
  6. Retinaculum posterior hancur, membuat detachmen komplit pada fragmen-fragmen.

6.1.2 Patologi dari FractureSubcapital

Pada fracturesubcapital, nasib dari caput femur tergantung dari besar dan luasnya sirkulasi yang terganggu. Derajat dari displacement fragmen-fragmen menandakan beratnya gangguan yang terjadi. Pada undisplaced fracture dapat diasumsikan bahwa sirkulasi masih baik; pada displaced fracture yang parsial, pembuluh darah retinakular postero-lateral terlindungi pada kebanyakan kasus, tetapi pada displaced fracture total, pembuluh darah ini ruptur dan tergantung dari adekuatnya pembuluh darah foveal, iskemik dari caput femoris dapat terjadi pada berbagai tingkat.

Kejadian pada x-ray sangat tidak nyata untuk menentukan keberadaan nekrosis avaskular pada caput sampai terdapat redisplacement dari fracture diikuti oleh fiksasi. Pemeriksaan histologis memperlihatkan nekrosis parsial atau total dari caput femur yang terjadi pada kira-kira 2/3 dari displaced fracture.

Walaupun letak valgus terhadap caput memastikan stabilitas dari fracturesubcapital, valgus yang ekstrim (lebih dari 180o) menyebabkan torsi dan obliterasi dari pembuluh darah foveal sehingga hancur, atau pada displaced fracture, yang hanya merupakan suplai pembuluh darah yang tersisa untuk caput femur. Rotasi dari caput femur dalam berbagai bentuk (vertikal, coronal atau sagital) mempunyai pengaruh yang sama terhadap pembuluh darah fovea. Revaskularisasi caput pada displaced fracture tergantung dari patensi pembuluh darah fovea (bila terjadi) dan biasanya pada beberapa pembuluh darah metafisis inferior yang akan terbagi. Kontribusi dimana collum femur membuat revaskularisasi pada caput tidaklah berarti.

Faktor-faktor lain yang mempengaruhi sirkulasi dari caput femur:

  1. Manuver manipulasi yang tidak baik dan terlalu kuat dapat memutuskan sisa pembuluh darah yang masih utuh.
  2. Penundaan yang terlalu lama sebelum dilakukan reduksi dapat mengakibatkan trombosis atau pembuluh darah yang kusut atau membuat nondisplacefracture atau partially displaced fracture menjadi fully displaced fracture. Displaced fracture yang ditangani pada 24 jam pertama mempunyai insidensi yang lebih tinggi untuk terjadinya union daripada fracture yang ditangani setelah 48 jam. Bila memungkinkan, fracture harus direduksi dan difiksasi dalam 12 jam awal setelah luka.
  3. Pembuluh darah fovea mungkin terluka oleh alat-alat operatif (nails, pins, and screw) menembus fovea capitis.

Nekrosis avaskular tidaklah mencegah terjadinya bony union, menjadikan fracture menjadi adekuat untuk direduksi dan distabilisasi menggunakan rigid fixation. Pada displaced fracture, nekrosis iskemik total mungkin terjadi bila pembuluh darah foveal tidak mampu memberikan revaskularisasi pada kepala. Akan tetapi dengan reduksi dan fiksasi yang adekuat, reduksi dan fiksasi tulang dapat terjadi; tetapi revaskularisasi berlawanan dengan garis fracture dari collum sangat lambat dan sering datang sebelum revaskularisasi sempurna dari caput terjadi. Kolaps segmental lanjut terjadi kira-kira 1 dari 3 kasus dan disebabkan oleh kolaps dari trabekula yang nekrosis pada penahan beban caput femur; hal ini tidak akan terjadi selama 2 sampai 3 tahun setelah luka tetapi dapat juga terjadi lebih awal.

Nonunion jelas meningkatkan insidensi nekrosis avaskular; terjadi pada kira-kira 60% dari kasus non-union.Insidensi nonunion dan nekrosis iskemik langsung dihubungkan dengan beratnya displacement, dan faktor yang paling dominan adalah gangguan suplai pembuluh darah ke caput femur.

Meskipun pada beberapa kasus, nekrosis iskemik tidak akan menjadi jelas dan nyata dengan x-ray selama 2 sampai 3 tahun, kehadiran x-ray akan dapat sering dideteksi lama sebelum periode ini dengan melihat flattening dari caput femur.

4.6.2 FractureTranscervical

Fracture trans-servikal, menurut definisi, bersifat intracapsular. Fracture ini penyembuhannya kurang baik karena:

  1. Dengan robeknya pembuluh darah intrakapsul, cedera itu melenyapkan persediaan darah utama pada caput
  2. Tulang intra-articular hanya mempunyai periosteum yang tipis dan tidak ada kontak dengan jaringan lunak yang dapat membantu pembentukan kalus
  3. Cairan sinovial mencegah pembekuan hematoma akibat fracture itu. Karena itu ketepatan aposisi dan impaksi fragmen tulang menjadi lebih penting dari biasanya. Terdapat bukti bahwa aspirasi hemartrosis dapat meningkatkan aliran darah dalam caput femoris dengan mengurangi tamponade.

4.7 Manifestasi Klinis

Biasanya terdapat riwayat jatuh, yang diikuti nyeri panggul.Tungkai pasien terletak pada rotasi lateral, dan kaki tampak pendek.Tetapi hati-hati, tidak semua fracturepanggul demikian jelas.Pada fracture yang terimpaksi pasien mungkin masih dapat berjalan; dan pasien yang sangat lemah atau cacat mental mungkin tidak mengeluh sekalipun mengalami fracture bilateral.

Selain itu juga pasien biasanya berusia lanjut dengan riwayat jatuh dan ketidakmampuan untuk berjalan.Pada inspeksi, gambaran luka terletak pada posisi exorotasi dan ada pemendekan dari kaki.Perlekatan kapsul ke fragmen distal mencegah exorotasi yang berlebihan pada kaki.Pada palpasi, terdapat nyeri tekan di sekitar otot panggul bagian anterior dan lateral.Trochanter mayor terevelasi pada tempat luka. Semua pergerakan menyebabkan nyeri kecuali pada kasus yang sangat jarang dari fracture impaksi.

Pada pemeriksaan foto X-Ray, dua pertanyaan harus terjawab: apakah terdapat fracture dan apakah mengalami pergeseran. Biasanya patahan itu jelas, tetapi fracture yang terimpaksi dapat terlewatkan bila tidak hati-hati. Pergeseran dinilai melalui bentuk bayangan tulang yang abnormal dan tingkat ketidakcocokan garis trabekular pada caput femoris dan ujung Collum femur.

 Penilaian ini penting karena fracture yang terimpaksi atau tak bergeser (stadium I dan II Garden) dapat membaik setelah fiksasi internal, sementara fracture yang displaced sering mengalami non-union dan nekrosis avaskular.

4.8 Diagnosis

Terdapat 3 situasi dimana fracturecollum femur dapat terlewatkan, kadang-kadang dengan akibat yang menakutkan:

  1. Fracture-tekanan. Pasien orang lanjut usia dengan nyeri panggul yang tidak diketahui mungkin mengalami fracture-tekanan; pemeriksaan sinar-X hasilnya normal tetapi scan tulang akan memperlihatkan hot area.
  2. Fracture yang terimpaksi. Garis fracture tidak terlihat, tetapi bentuk caput dan Collum femoris berubah; selalu bandingkan kedua sisi.
  3. Fracture yang tidak nyeri. Pasien yang berada di tempat tidur dapat mengalami silent fracture.

 4.8.1 Anamnesis

Menegakkan diagnosis pada seorang atlet yang mengalami nyeri di daerah panggul dan inguinal dimulai dengan anamnesis lengkap dan pemeriksaan fisik.Anamnesis dasar harus ditanyakan seperti keluhan akhir-akhir ini dan deskripsi lengkap dari keluhan tersebut.Seorang ahli harus menanyakan pasien apakah gejala-gejala tersebut berhubungan dengan olahraga tertentu ataukah pada aktivitas tertentu.Anamnesis aktivitas secara komprehensif haruslah dilakukan, seperti perubahan aktivitas, peralatan yang digunakan, intensitas, dan teknik yang dilakukan haruslah dicatat.Beberapa hal penting yang perlu ditanyakan, antara lain:

1. Anamnesis mengenai riwayat menstruasi harus dilakukan juga pada semua pasien wanita. Amenorrhea sering berhubungan dengan penurunan level serum esterogen. Kurangnya perlindungan esterogen dapat mencetus penurunan massa tulang. Trias seorang atlet wanita, yaitu amenorrhea, osteoporosis, dan gangguan makanan mempengaruhi beberapa wanita aktif. Tanda dan gejala dari trias tersebut meliputi rasa lemah, anemia, depresi, ‘flu’ like syndrome, lanugo, erosi enamel gigi, penggunaan laksatif.
2. Kebiasaan makan yang buruk dapat menimbulkan gangguan sistem endokrin, kardiovaskular, dan gastrointestinal dan dapat menyebabkan kehilangan massa tulang yang irreversibel. Seorang ahli harus waspada akan timbulnya stress fracture dan cepat mengetahui tanda-tanda trias wanita, khususnya mencatat fracture jarang terjadi karena trauma yang minimal.
3. Kebanyakan seorang atlet mengatakan bahwa onset nyeri yang sangat terjadi selama 2-3 minggu, dimana berhubungan dengan perubahan segera pada aktivitas dan peralatan yang digunakan. Secara khusus, seorang pelari (runners) selalu menambah jarak dan intensitas lari mereka, mengubah medan yang ditempuh, atau mengganti sepatu lari mereka. Disini, seorang ahli tentunya harus menanyakan tentang catatan latihan dan seberapa jauh jarak lari seorang atlet dengan lengkap.
4. Ciri khas dari semua stress fracture seperti:

  • Partisipasi pada aktivitas repetitive cyclic
  • Onset nyeri yang tiba-tiba
  • Perubahan aktivitas dan perlatan saat ini
  • Pernah trauma
  • Nyeri dengan beban berat
  • Nyeri hilang sewaktu istirahat
  • Menstruasi yang tidak teratur
  • Presdisposisi osteopenia

5. Pasien biasanya melaporkan riwayat nyeri yang bertambah ataupun akut pada panggul depan,inguinal, atau lutut yang bertambah berat bila beraktivitas. Ciri khas yang tampak pada stress fracture adalah riwayat latihan yang berhubungan dengan lokasi nyeri yang bertambah dengan aktivitas dan berkurang bila beristirahat atau dengan aktivitas yang tidak memerlukan beban berat. Nyeri biasanya bertambah buruk dengan latihan yang terus-menerus. Nyeri dapat dicetuskan dengan aktivitas yang diulang-ulang, dan reda bila beristirahat.
6. Pemeriksa harus menanyakan apakah gejala-gejala tersebut pernah terjadi di masa lalu, dan bila pernah, apakah pasien pernah berusaha menggunakan es atau penghangat atau obat-obat tertentu (seperti asetaminofen, aspirin, NSAID). Pertanyaan yang harus ditanyakan adalah keikutsertaan pasien pada program terapi fisik sebelumnya, dan seorang ahli juga harus mengerti mengapa pada masa lalu itu dipilih penatalaksanaan yang seperti itu.

4.8.2 Pemeriksaan Fisik

Pemeriksaan Fisik yang komprehensif dari seorang atlet dengan nyeri panggul dan inguinal harus dilakukan dengan cermat dan harus juga dievaluasi sistem neurologi dan muskuloskeletalnya. Gabungan penemuan bermakna dari anamnesis dan pemeriksaan fisik haruslah dapat dijadikan patokan dan pegangan untuk proses evaluasi lebih lanjut. Derajat dan tipe fracture biasanya menentukan derajat klinis dari deformitas yang terjadi.

Inspeksi

Pemeriksaan dimulai dengan observasi pasien.Wajah yang menyeringai menahan sakit atau gaja berjalan seorang pasien tentunya membuat pola tertentu. Pasien dengan displacedfracturecollum femur biasanya tidak dapat berdiri atau biasanya dibawa dengan tempat tidur. Perhatikan pucak iliaca apakah ada perbedaan tinggi antara kiri dan kanan, sehingga dapat ditentukan apakah tinggi dan fungsi dari kaki kiri dan kanan berbeda.Alignment dan panjang dari ekstremitas biasanya normal; Namun, gejala klasik pasien dengan displacedfracture adalah ekstremitas yang memendek dan dari luar tampak terputar.Pemeriksaan setiap otot yang atrofi ataupun tidak simetris juga merupakan suatu hal yang penting.

Palpasi

Menentukan setiap titik nyeri tekan di regio panggul dan inguinal bagian depan. Tanda fisik yang paling sering ditemukan pada stress fracture pada umumnya adalah nyeri tekan tulang setempat; Namun, biasanya collum femur letaknya dalam dan nyeri tulang atau nyeri tekan biasanya tidak ditemukan.Palpasi pada trochanter dengan nyeri tekan biasanya mengindikasikan bursitis pada trochanter.

Range of Motion

Menentukan range of motion dari panggul dengan memflexi, extensi, abduksi, adduksi, endorotasi serta eksternal dan flexi dan extensi dari lutut.Penemuannya seperti nyeri dan keterbatasan gerak pasif pada panggul. Melakukan passive straight-leg raise, Thomas, dan rectus femoris stretch test. Memeriksa iliotibial band dengan tes Ober.Sebagai tambahan pemeriksaan untuk range of motion pada panggul, dapat dilakukan pemeriksaan tulang belakang (spine) dan sendi pada extremitas inferior lainnya karena pola nyeri alih dapat membingungkan. Pemeriksaan kedua low back,baik aktif maupun pasif, dengan melihat flexi ke depan, side bending, dan extensi. Lakukan juga straight-leg raise test dan Tes Laseque dan Bragard sign. Pasien dengan nyeri di regio femoralis anterior dan lutut bisa mempunyai patologi di sendi panggulnya.Nyeri yang dihasilkan pada pasien dengan endorotasi, exorotasi, atau manuver provokasi lainnya dapat menyingkirkan patologi panggul akibat gangguan tulang belakang (spine).

Tabel 4.1 Range of Motion pada Sendi Panggul

Gerakan

ROM

Flexi

120o

Extensi

30o

Abduksi

45 – 50o

Adduksi

20 – 30o

Endorotasi

35 – 45o

Exorotasi

35 – 45o

Tes Passive Straight Leg Raise

  • Tujuan : memeriksa low back pain akibat herniasi diskus
  • Langkah-langkah pemeriksaan:
    • Pasien berbaring supine, kedua tungkai dalam posisi lurus.
    • Pemeriksa meletakkan salah satu tangan di bawah lutut dan tangan lainnya untuk mengangkat tungkai hingga pasien merasakan nyeri.

Tes Thomas

  • Tujuan : memeriksa hip flexion contracture
  • Langkah-langkah pemeriksaan:
    • Pasien berbaring dalam posisi supine, menekuk salah satu tungkai ke arah dada dan tungkai lainnya tetap dalam keadaan extensi.
    • Hasil tes positif jika pasien tidak dapat mempertahankan tungkai dalam posisi tersebut.

Tes Ober

  • Tujuan : memeriksa kontraktur pada iliotibial band
  • Langkah-langkah pemeriksaan:
    • Pasien berbaring miring ke arah tungkai yang sehat sehingga tungkai sehat berada di bawah dalam keadaan ditekuk dan tungkai yang bermasalah di bagian atas dalam keadaan lurus.
    • Pemeriksa meletakkan tangan di krista iliaka superior untuk stabilisasi, kemudian angkat kaki yang atas, lakukan extensi, dan arahkan ke bagian belakang kaki sehat. Lihat apakah kaki tersebut bisa beradduksi ke bawah dan belakang meja periksa.
    • Hasil test positif jika pasien tidak dapat adduksi melewati meja periksa.

Muscle Strength (Kekuatan Otot)

Penentuan kekuatan otot secara manual sangatlah penting untuk dilakukan apakah terdapat kelemahan ataukah lokasi kelemahan itu berhubungan dengan cedera saraf.Sebagai tambahan, pengevaluasian stabilitas dinamis dari pelvis, termasuk otot-otot fleksor, ekstensor, dan abduktor panggul.Gaya berjalan Trendelenburg menandakan kelemahan abduksi dari panggul.Tes flexi panggung (L2, L3), extensi (L5, S1, S2), abduksi (L4, L5, S1), dan adduksi (L3, L4).

Pemeriksaan Sensoris

Selama dilakukan pemeriksaan sensoris, penurunan atau hilangnya sensibilitas dapat mengindikasikan atau menyingkirkan kerusakan saraf yang spesifik.Refleks otot-otot sangat membantu untuk mengevaluasi pasien dengan nyeri panggul.Refleks yang abnormal menandakan abnormalitas fleksus saraf.Refleks yang asimetris adalah hal yang sangat signifikan, sehingga, refleks dari pasien harus dibandingkan antara kiri dan kanan.

Hop Test (Tes Lompat)

Sekitar 70% pasien dengan stress fracture pada femur mempunyai hasil yang positif pada Hop Test. Pada Hop test, pasien melompat pada sisi kaki yang terkena untuk menimbulkan gejala. Manuver lain yang dapat menyebabkan stress pada femur juga dapat merangsang timbulnya rasa nyeri.

4.8.3 Pemeriksaan Penunjang

Pemeriksaan Laboratorium

Pemeriksaan laboratorium biasanya tidak begitu diperlukan untuk mendiagnosis fracturecollum femur.Pemeriksaan ini dilakukan lebih untuk menilai kondisi pasien secara sistemik.

Pemeriksaan Radiologi

Foto X-Ray

Foto polos biasa merupakan foto yang sering digunakan sebagai tindakan awal pada fracture panggul karena ini merupakan alat yang universal dan terdapat dimana-mana. Tujuan utama pembuatan foto X-Ray adalah untuk menyingkirkan fracture dan mengindentifikasi letak dan luasnya fracture.

Foto polos mempunyai sensitivitas yang rendah. Adanya formasi tulang periosteal, sklerosis, kalus, atau garis fracture memberi petunjuk terjadinya stress fracture; walaupun demikian, pemeriksaan radiologi foto polos dapat memberikan gambaran normal pada pasien dengan fracturecollum femur, dan perubahan radiografi tidak akan pernah berubah.

Tension fracture harus dibedakan dari compression fracture, dimana menurut Devas (1965) dan Fullerton dan Snowdy (1988), biasanya terletak pada aspek inferior collum femur.Pemeriksaan radiografi dapat menunjukkan garis fracture pada aspek superior dari collum femur, yang merupakan lokasi terjadinya tension fracture.

Pemeriksaan radiologi standar pada panggul meliputi foto AP (Antero-Posterior) dari panggul dan pelvis dan Foto Lateral. Posisi frog-leg lateral tidak dianjurkan karena dapat mengakibatkan displacedfracture. Bila fracturecollum femur dicurigai, foto endorotasi dari panggul dapat membantu mengindentifikasi fracture yang non-displaced atau fracture impaksi. Bila dicurigai adanya fracture panggul tetapi tidak terlihat pada pemeriksaan X-ray standar, scanning tulang atau MRI harus dilakukan.

Kadang-kadang, foto polos ini mempunyai kekurangan. Spiral fracture sangat sulit dilihat dari 1 sudut saja. Comminutif juga tidak mudah diidentifikasi seperti pada CT-Scan. Beberapa stress fracture adalah fracture simple dan tidak terlihat pada foto polos. Dengan demikian, foto polos tidak selalu dapat mendeteksi fracturecollum femur tetapi diperlukan pemeriksaan radiologi lain yang dapat menunjang diagnosis dari fracture ini.

Pada foto X-ray mungkin didapatkan hasil positif palsu atau negative palsu.Beberapa fracturecollum femur tidak terlihat pada foto polos yang diambil selama evaluasi awal. Bila kecurigaan klinis kuat, kasus ini dapat di evaluasi lebih lanjut dengan MRI, yang dapat menunjukkan edema sumsum tulang, atau nuclear medicine bone scanning, yang dapat memperlihatkan peningkatan tracer uptake. Pemeriksaan nuclear medicine bone scanning ini harganya lebih mahal dari pemeriksaan MRI dan sangat sensitif. Pencitraan ini dilakukan pada 48-72 jam setelah trauma, dimana sensitivitasnya dibawah MRI.

 

Gambar 4.14 Foto X-Ray FractureCollum Femur

FractureSubcapital, Garden IV

 

 Bone Scan (Scanning Tulang)

Scanning tulang dapat membantu pada stress fracture, tumor atau infeksi.Scanning tulang merupakan indikator yang sangat sensitif pada bone stress, tetapi mempunyai spesifisitas yang rendah.

Pada masa lalu, scanning dinyatakan tidak merupakan indikasi sebelum 48-72 jam setelah fracture; tetapi pada penelitian tahun 1990 oleh Holder et al, scanning ini mempunyai sensitivitas sebesar 93%, tanpa peduli kapanpun kejadiannya.

Gambar 4.15 Bone Scan FractureCollum Femur Sinistra

 

CT-Scan

CT-Scan berperan penting dalam mengevaluasi panggul setelah terjadi fracture.CT sangat baik dan berguna untuk abnormalitas tulang itu sendiri.Karena resolusinya yang baik, dapat berbagai potongan, dan kemampuannya untuk dilihat dalam posisi coronal dan sagital, CT-Scan berguna untuk mendeteksi fracturecomminution preoperatif dan mendeteksi seberapa jauh terjadinya penyatuan union pada post operatif.

Scanning tulang dapat membantu pada stress fracture, tumor atau infeksi.Scanning tulang merupakan indikator yang sangat sensitif pada bone stress, tetapi mempunyai spesifisitas yang rendah.Pada masa lalu, scanning dinyatakan tidak merupakan indikasi sebelum 48-72 jam setelah fracture; tetapi pada penelitian tahun 1990 oleh Holder et al, scanning ini mempunyai sensitivitas CT-Scan sangat sering digunakan untuk mengevaluasi bone injury. Walaupun demikian, fracture aksial pada foto polos juga kadang-kadang tidak terlihat dengan CT-Scan.Potensial ini berkurang dengan adanya foto polos orthogonal dan CT-Scan multidetektor yang baru.

 

Gambar 4.16 CT ScanFracture Collum Femur Sinistra

 

MRI (Magnetic Resonance Imaging)

MRI telah menunjukkan keakurasian pada kejadian fracture yang segera dan wajar dilakukan dalam waktu 24 jam setelah kejadian; walaupun harganya mahal.MRI memiliki sifat sensitif dan spesifik pada pendeteksian fracturecollum femur, karena dapat menunjukkan garis fracture dengan jelas dan adanya edema pada sumsum tulang. Kontras Superior dari MRI dengan pulse yang teratur biasanya digunakan, resolusi spasial intrinsik, dan kemampuan dalam membuat berbagai potongan (coronal, axial, dan yang terjarang, sagittal) membuat MRI sebagai alat penunjang yang sangat baik, khususnya pada stress fracture, yang pada foto polos dapat memberikan gambaran yang normal.Dengan MRI, stress fracture nampak sebagai fracture yang berupa garis pada korteks yang dikelilingi oleh daerah yang edema di kavitas medularis.

Pada tahun 1993, penelitian oleh Quinn dan McCarthy, T1-weight MRI menemukan bahwa MRI mempunyai sensitivitas sebesar 100% pada pasien dengan pemeriksaan radiologi biasa yang tidak jelas.

Shin et al juga menunjukkan bahwa MRI mempunyai sensitivitas, spesifisitas dan ketepatan sebesar 100% dalam mengidentifikasi fracturecollum femur.

MRI merupakan alat yang paling sensitif untuk mendeteksi perubahan sumsum tulang yang berhubungan dengan nekrosis avaskular, walaupun pada pemeriksaan radiologi foto polos dalam keadaan normal.Oleh karena itu, MRI merupakan alat yang terpilih dan sangat berguna. Bila terdapat nekrosis avaskular setelah operasi fiksasi dari fracture femur, pasien dapat menggunakan penggantian dari protesis yang ada. Lebih pentingnya, MRI dapat digunakan untuk mendeteksi stadium awal nekrosis iskemik pada caput femur, dimana intervensi dapat dimulai sebelum kerusakan lebih jauh terjadi.Kerusakan ini dapat meliputi kolapsnya caput femur, osteoarthritis sekunder, atau fragmentasi.

MRI pada saat ini juga sering digunakan untuk mendeteksi adanya fracturecollum femur. Sumsum tulang normal pada pelvis dan panggul dapat mempunyai gambaran patchy intermediate-signal-intensity sehubungan dengan sumsum tulang merah yang persisten.Dan juga, area subchondral dari caput femur dapat kadang-kadang mempunyai lapisan sumsum tulang merah yang tipis.Variasi normal ini tidak boleh dibingungkan karena fracture.

Gambar 4.17 MRI Fracture Collum Femur Sinistra

 

Ultrasonografi (USG)

USG tidak memegang peranan penting pada evaluasi rutin fracture panggul. Walaupun demikian, USG masih digunakan dalam penelitian untuk mengevaluasi derajat distensi pada kapsul sendi panggul setelah terjadinya fracture dan pada penelitian peningkatan tekanan intracapsular.Sonogram dapat juga menggambarkan adanya hematoma intracapsular, yang echogenik, yang dapat dibedakan secara jelas dengan cairan sinovial (anechoic).

Kedokteran Nuklir (Nuclear Medicine)

Hasil: Hampir 80% dari fracture dapat tervisualisasi dalam 24 jam setelah trauma, terlihat dengan adanya peningkatan diffuse tracer uptake. Setelah 3 hari trauma, 95% dari fractureakan terlihat, dan sensitivitas fracture maksimal ditemukan pada hari ke-7; pengetahuan ini mungkin dapat membantu menganalisa kasus. Bila hasil sensitivitasnya tinggi, hal ini dapat digunakan untuk mendiagnosis kecurigaan akanfracturecollum femur.

Nuclear Medicine dengan menggunakan Technetium-99m methylene diphosphonate (99mTc-MDP) juga ditemukan efektif dalam memprediksi komplikasi selama penyembuhan yang berhubungan dengan fracturecollum femur. Stromqvist et al mendemonstrasikan bahwa bone scan dengan menggunakan 99mTc-MDP pada panggul dilakukan dalam 2 minggu setelah dilakukan operasi fiksasi untuk fracturecollum femur mempunyai prognosis yang baik terhadap fracturedisplaced, nonunion, atau kolapsnya caput femur segmental.

Walaupun sensitif, skintigrafi tulang ini tidak spesifik untuk fracture. Proses lain seperti infeksi, inflamasi, atau tumor dapat mengambarkan peningkatan  uptake. Bagaimanapun juga, secara klinik, skintigrafi merupakan alat yang bersensitivitas tinggi pada pendeteksian fracture.

4.9 Tata Laksana Non-Medikamentosa

Penatalaksanaan fracturecollum femur harus dimulai secepat mungkin setelah terjadinya trauma. Cegah semua pergerakan tungkai dan lakukan imobilisasi. Hal ini sangat penting karena apabila kita mengangkat pasien dalam posisi yang tidak tepat, makadapat mengubah fracture simpel undisplaced menjadi fracturecomplete dandisplaced.

Segera lakukan foto x-ray dengan posisi antero-posterior (AP) dan lateral. Ketika hal ini dilakukan, asisten membuat traksi pada tungkai untuk mencegah trauma yang lebih jauh pada sisi fracture. Hasil x-rayakan dijadikan sebagai patokan atau acuan untuk menentukan kualitas dan menentukan apa yang akan dilakukan terhadap fracture yang terjadi.Bila memungkinkan, lakukan reduksi dan fiksasi pada fracture pada 12 jam pertama dan tidak melebihi 24 jam; perlu diingat bahwa insidensi nonunion akan lebih rendah jika pasien dioperasi dalam 12 jam pertama daripada yang dioperasi setelah 48 jam.

Terapi operatif lebih disukai dan dipilih pada penangananfracturecollum femur. Tipe sfesifik dari terapi operatif yang akan digunakan tergantung dari usia pasien dan karakteristik dari fracture, seperti lokasi, displacedatau nondisplaced, dan derajat comminution.

Pilihan terapi antara internal fixation dan arthroplasty setelah fracturecollum femur harus berdasarkan atas perfusi dan viabilitas dari caput femoris. Saat ini, hal ini biasanya ditentukan berdasarkan klasifikasi Garden atau menurut usia pasien.

Venografi, pengukuran tekanan sumsum tulang, skintigrafi dengan radionuklir, dan angiografi disarakan untuk memprediksi viabilitas dan suplai darah ke caput femur pada fracturecollum femur.Prosedur ini efektif dan sering digunakan.

Pada pasien usia muda, diperlukan reduksi dari fracturecollum femur secepat mungkin untuk menurunkan resiko terjadinya nekrosis avaskular. Reduksi anatomik dan fiksasi adalah tujuan utama dari dilakukannya tindakan operatif. Pasien usia muda biasanya dilakukan dengan reduksi tertutup atau terbuka, dengan peletakan percutaneus 3 canul paralel dari lag screw.Prosedur ini dilakukan dalam posisi supine di meja fracture. Canulasi paralel lag screw membuat kompresi ada lokasi fracture dan mempertahankan reduksi ketika fracture menyembuh.

 

Gambar 4.18 Tata Laksana Fracture Collum Femur dengan Internal Fixation

Pada pasien lanjut usia dengan klasifikasi fracture Garden I atau II juga dapat dilakukan parallel cannulated screw fixation, walaupun hal ini biasanya dilakukan secara in situ. Hemiarthroplasty merupakan prosedur yang dipilih pada pasien usia lanjut dengan displacedfracturecollum femur. Level aktivitas pasien sebelumnya juga sangat penting dalam menentukan tipe hemiarthroplasty yang akan dilakukan.

 Independent ambulator berguna pada cemented hemiarthroplasty, karena nyeri setelah operasi dan hilangnya komponen sangat minimal pada pendekatan ini. Hemiarthroplasty merupakan pendekatan yang paling sering dilakukan pada pasien dengan posisi lateral dekubitus.Setelah insisi dibuat dan terlihat otot, caput femorus diekstrasi dan collum femur dipotong untuk penempatan protesisnya.

Ada berbagai macam prostetik yang dapat digunakan, dari alat yang unipolar (Austin-Moore Protesis) sampai bipolar. Kebanyakan dari protesis ini disemen; walupun demikian, pada pasien lanjut usia, yang biasanya mempunyai penyakit kardiopulmonal, penekanan yang berlebihan dari semen haruslah dihindari untuk mencegah komplikasi metabolik dan mekanik lebih lanjut.Gambar 4.19 menunjukkan foto x-ray dari fracture collum femur displaced yang ditangani dengan pemasangan protesis.

 

Gambar 4.19 Tata Laksana Fracture Collum Femur dengan Protesis

Weight bearing setelah operasi untuk pasien semua umur tergantung pada tipe fracture, permintaan pasiennya sendiri, dan pilihan ahli bedahnya. Pada umumnya, pasien yang menjalanin reduksi dan fiksasi dengan cannulated lag screw biasanya dibatasi dalam menjalani weight-bearing setelah prosedur tersebut. Bedanya, pasien yang menjalani hemiarthroplasty diperbolehkan melakukan weight-bearing; tentunya dengan pembatasan posisi tertentu untuk mencegah timbulnya dislokasi sendi panggul.

Fracture yang bergeser tidak akan menyatu tanpa fiksasi internal, dan bagaimanapun juga manula harus bangun dan aktif tanpa ditunda lagi kalau ingin mencegah komplikasi paru-paru dan ulkus dekubitus. Fracture yang terimpaksi dapat dibiarkan menyatu, tetapi selalu terdapat risiko pergeseran pada fracture-fracture itu, sekalipun berada di tempat tidur; jadi fiksasi akan lebih aman.

Bagaimana bila operasi dianggap berbahaya? Berada ditempat tidur dengan traksi mungkin lebih berbahaya, dan membiarkan fracture tanpa diterapi akan terlalu nyeri; pasien yang paling tidak cocok untuk operasi kadang-kadang justru sangat membutuhkan operasi.

Prinsip terapi adalah reduksi yang tepat, fiksasi secara erat dan aktivitas dini.Bila pasien dibawah anestesi, panggul dan lutut diflexikan dan paha yang mengalami fracture ditarik keatas, kemudian dirotasikan secara internal, lalu diektensikan; akhirnya diikatkan pada footpiece.Pengawasan dengan sinar-X (sebaiknya dengan penguat) digunakan untuk memastikan reduksi pada foto antero-posterior dan lateral.

Diperlukan reposisi yang tepat pada fracture stadium III dan IV; fiksasi pada fracture yang tereduksi hanya mengandung kegagalan. Bila fracture stadium III dan IV tidak dapat direduksi secara tertutup, dan pasien berumur dibawah 60 tahun, dianjurkan untuk melakukan reduksi terbuka melalui pendekatan anterolateral. Tetapi pada pasien usia diatas 70 tahun cara ini jarang diperbolehkan, kalau dua usaha yang cermat untuk melakukan reduksi tertutup gagal, lebih baik dilakukan penggantian prostetik.

Sekali direduksi, fracture dipertahankan dengan pen atau canulated screw atau kadang-kadang dengan screw kompresi geser (screwpanggul yang dinamis) yang ditempelkan pada corpus femur. Insisi lateral digunakan untuk membuka femur bagian atas. Wire pemandu, yang disiapkan dibawah kendali fluoroskopik, digunakan untuk memastikan bahwa penempatan alat pengikat tepat. Dua screw berkanula sudah mencukupi; keduanya harus terletak sejajar dan memanjang sampai plate tulang subkondral; pada foto lateral keduanya berada ditengah-tengah pada caput dan Collum, tetapi pada foto anteroposterior screw distal terletak pada korteks inferior Collum femur.

Sejak hari pertama pasien harus duduk di tempat tidur atau kursi.Dia dilatih untuk melakukan latihan pernapasan, dianjurkan berusaha berdiri sendiri dan mulai berjalan (dengan alat penopang) secepat mungkin.Secara teoritis, idealnya adalah menunda penahanan beban, tetapi ini jarang dapat dipraktekan.

Penggantian Prostetik

Beberapa ahli menyampaikan bahwa prognosis untuk fracture stadium III dan IV tidak dapat diramalkan sehingga penggantian prostetik selalu lebih baik. Pandangan ini meremehkan morbiditas yang menyertai penggantian. Karena itu, kebijaksanaan kita adalah mencoba reduksi dan fiksasi pada semua pasien yang berumur di bawah 75 tahun dan mempersiapkan penggantian atau replacement bagi pasien-pasien berikut ini:

  1. Pasien yang sangat tua dan sangat lemah
  2. Pasien yang gagal menjalani reduksi tertutup. Penggantian yang paling rendah resiko traumanya adalah prostesis femur atau prostesis bipolar tanpa semen yang dimasukkan dengan pendektatan posterior.

Total hip replacement mungkin lebih baik pada pasien dengan:

a.     Terapi telah tertunda selama beberapa minggu dan dicurigai ada kerusakan acetabulum

b.     Pada pasien dengan penyakit metastatik atau penyakit Paget

Total Hip Replacement (THR)

Total Hip Replacement adalah prosedur operasi dimana tulang dan kartilago persendian panggul yang rusak diganti dengan sendi artifisal.Sendi artifisial ini disebut sebagai prostesis dan difiksasi dengan semen tulang yang dikenal sebagai methylmethacrilate. Jenis prostesis yang lain tidak memerlukan semen tapi memiliki pori-pori mikroskopis yang memungkinkan pertumbuhan tulang normal ke dalam prostesis.Gambar 4.20 menunjukkan bagian-bagian prosthesis yang digunakan.

 

Gambar 4.20 Total Hip Replacement (THR)

 

Hip Implant (Prostesis)

Gambar 4.21 Hip Implant

 Desain Implan

Sendi panggul disebut sebagai juga sebagai sendi ball and socket karena caput femoris yang berbentuk sferis bergerak di dalam rongga berbentuk mangkok yaitu acetabulum. Untuk meniru gerakan ini implan yang digunakan dalam THR memiliki tiga bagian, yaitu corpus atau stem yang akan dimasukkan ke dalam femur untuk memberikan stabilitas, head implant yang akan menggantikan caput femoris, dan cup implant yang akan menggantikan permukaan acetabulum.

Konstruksi Implan

Bagian corpus implan terbuat dari titanium atau campuran cobalt/chromium. Bagian head terbuat dari keramik atau campuran cobalt/chromium yang dibuat selicin mungkin untuk memudahkan pergerakan dalam rongga cup implant.Cup implant sendiri terbuat dari logam, ultrahigh molecular weigth polyethylene, atau gabungan logam dan polyethylene.

Pemasangan Implan

Terdapat tiga cara pemasangan implan yang biasa digunakan dalam prosedurTotal Hip Replacement, yaitu:

1.        Cemented Hip Implant

Dengan cara ini implan yang sudah terpasang difiksasi dengan menggunakan semen tulang yang disebut methylmethacrilate. Cara ini direkomendasikan bagi mereka yang berusia diatas 60 tahun, dan bagi pasien usiamuda dengan kualitas dan densitas tulang yang kurang baik. Gambar 4.22 menunjukkan cemented hip impant.


 

Gambar 4.22 Cemented HipImplant

 

2.        Porous Hip Implant

Cara ini dirancang agar implan dapat langsung terpasang pada tulang tanpa perlu menggunakan semen. Implan yang digunakan dengan cara ini memiliki topografi permukaan yang kondusif bagi pertumbuhan tulang baru. Permukaan implan dibuat dengan tekstur khusus sehingga tulang yang baru tumbuh ke dalam permukaan implan.Karena implan jenis ini mengandalakan pembentukan tulang baru untuk stabilitasnya, maka memerlukan waktu penyembuhan yang lebih lama.Cara ini direkomendasikan untuk mereka yang berusia di bawah 50 tahun, bagi pasien yang aktif, dan bagi pasien dengan kualitas tulang yang baik.

 

 

Gambar 4.23 Porous Hip Implant

 

3.        Hybrid Hip Implant

Cara ini merupakan gabungan dari cemented hip implant dan porous hip implant. Bagian cup biasanya dipasang tanpa semen sedangkan bagian corpus dipasang dengan semen.

 

Prosedur Operasi                 

Terdapat tiga prosedur operasi THR, yaitu Traditional hip replacement surgery, minimally invasive hip replacement surgery, dan computed assisted hip replacement surgery.

 

1.       Traditional Hip-replacement Surgery

Berikut adalah langkah-langkah operasi pada THR:

  • Pasien di anestesi, setelah itu dilakukan asepsis – antisepsis.
  • Dibuat insisi sengan ukuran yang sesuai di atas sendi panggul.
  • Kaki pasien digerak-gerakkan sehingga caput femoris mengalami dislokasi. Sebuah reamer khusus kemudian digunakan untuk mengangkat kartilago dan tulang di permukaan acetabulum serta membentuk mangkok sehingga pas dengan bentuk implan yang akan dipasang.
  • Bagian cup implant dilekatkan di tempatnya menggunakan semen atau deangn penekanan ke dalam permukaan acetabulum. Setelah bagian cup implant terpasang dilakukan pemasangan lapisan plastik untuk melapisi permukaan dalamnya.
  • Sebuah gergaji khusus kemudian digunakan untuk memotong caput femoris. Dengan instrumen khusus, bagian tengah tulang femur dikuretase dan dibentuk sehingga membentuk kanal yang pas dengan bentuk corpus implan.
  • Setelah kanal femur terbentuk, bagian corpus dan head implant dipasang. Jika digunakan semen, maka semen di injeksikan terlebih dahulu. Jika tidak digunakan semen, maka implan dimasukkan begitu saja ke dalam kanal.
  • Setelah semua implan terpasang, head implant diletakkan di dalam cup implant. Ligamen-ligamen disesuaikan untuk mendapatkan fungsi panggul yang maksimal. Kemudian lapis demi lapis jaringan dikembalikan di tempatnya semula. Pemasangan drain dilakukan untuk memungkinkan pengaliran cairan selama beberapa jam setelah operasi. Sesudah semua lapisan dijahit dan drain dipasang, panggul ditutup dengan perban elastis.

  

Gambar 4.24 Post Operasi THR

2.       Minimally Invasive Hip Replacement Surgery

Yang dimaksud dengan Minimally-Invasive Hip Replacement Surgery adalah operasi THR dengan insisi yang lebih kecil dibanding operasi tradisional. Pada operasi ini digunakan jenis implan yang sama dengan operasi tradisional, hanya saja operator memerlukan instrumen khusus supaya implan dapat terpasang dengan baik.

Ada dua metode yang dapat dipakai.Metode yang pertama menggunakan insisi tunggal selebar 3 hingga 6 inci dan dengan prosedur operasi yang mirip dengan operasi tradisional. Metode yang kedua menggunakan insisi selebar 2 hingga 3 inci di atas inguinal untuk memasukkan cup implan, dan insisi selebar 1 hingga 2 inci di atas pantat untuk memasukkan stem dan headimplant.Keuntungan dari minimally-invasive hip replacement surgery adalah:

  • Jumlah anestesi yang dibutuhkan lebih sedikit
  • Kurangnya nyeri yang diakibatkan oleh insisi dan bekas luka
  • Kurangnya kerusakan otot akibat insisi yang lebar
  • Kurangnya kehilangan darah
  • Lama perawatan di rumah sakit lebih pendek
  • Pasien lebih cepat kembali ke aktivitas normal

 

        Tabel 4.2 Perbandingan Traditional vs. Minimally Invasive

 

Traditional Hip Replacement Surgery

Minimally Invasive Hip Replacement Surgery

Panjang Insisi

8 – 10 inches

3 – 4 inches

Lama Operasi

± 83 menit

± 50 menit

Lama Dirawat

5 – 7 hari

3 – 4 hari

Masa Recovery

12 minggu

4         – 6 minggu

3.     Computer Assisted Hip Replacement Surgery

Computer Assisted Hip Replacment Surgerymembantu operator untuk menempatkan implan setepat mungkin dengan bantuan komputer. Selama operasi berlangsung komputer akan memberi informasi letak tungkai dan pelvis pasien, letak implan serta instrumen yang digunakan operator.

Prosedur ini memberikan hasil operasi yang relatif lebih baik dibandingkan prosedur operasi yang lain. Dan dengan adanya visualisasi yang lebih baik berkat bantuan komputer, maka operator dapat menjalankan prosedur yang kurang invasif dibanding prosedur lain.

Keuntungan dan Kerugian Total Hip Replacement

  •  Keuntungan THR

Keuntungan THR adalah berkurangnya nyeri dan kembalinya fungsi normal sendi. Terapi operatif akan menghilangkan nyeri yang sudah tidak memberikan respon terhadap terapi non-operatif. Selain itu, operasi akan mengembalikan stabilitas sendi sehingga memungkinkan penderita berdiri dan berjalan secara lebih mudah. Dengan THR, deformitas sendi juga diperbaiki sehingga fungsi sendi dapat diperbaiki.

  •  Kerugian THR

Kerugian THR adalah lamanya waktu pemulihan dan mahalnya biaya yang harus dikeluarkan.Setelah operasi terdapat berbagai latihan yang harus diikuti.Untuk itu diperlukan komitmen dan kemauan yang keras dari penderita.Selain itu biaya juga harus menjadi pertimbangan.Besarnya biaya bervariasi tergantung pada jenis pembedahan, terapi dan medikasi lain, pemeriksaan penunjang yang dilakukan, dan dukungan asuransi.

Komplikasi Total Hip Replacement

Komplikasi THR tersebut dapat dilihat dalam tabel dibawah ini.

Tabe 4.3 Komplikasi Total Hip Replacement

Komplikasi

Persentase

Dislokasi

2-5 %

Infeksi

1-2 %

Leg Length Discrepancy

4 % (> 2 cm)

Deep Vein Thrombosis (DVT)

3 %

Emboli Pulmonal

1-8 %

Angka kematian : 0.3 - 3.4  %

Skiatik dan Femoral Nerve Palsy

1 %

Fracture atau penetrasi tulang

1-2 %

Kematian

0.3 %

Revisi dari Hip Replacement

Meskipun THR memberikan hasil yang memuaskan pada sebagian besar pasien, namun seiring berjalannya waktu sendi artifisial akan menjadi aus. Proses ini berjalan pelan tapi pasti. Sepuluh tahun setelah THR 90% implan akan berfungsi dengan baik. Setelah 20 tahun persentase menurun menjadi 80% dan setelah 25 – 30 tahun hanya 50% implan yang dapat berfungsi. Pasien yang sendi artifisialnya aus memerlukan hip replacement revision.

Penyebab tersering sendi artifisial menjadi aus adalah aseptic loosening dimana implan menjadi longgar di dalam tulang.Sebab lainnya adalah osteolisis atau resorbsi tulang, infeksi, patahnya implan, dislokasi komponen implan, dan patah tulang di sekitar implan.

Pasien yang mengalami hal-hal di atas akan mengeluhkan nyeri di daerah panggul yang seringkali menjalar ke tungkai. Mereka juga cenderung mengeluhkan rasa sakit yang terasa di bagian dalam, berlangsung terus-menerus, dan memburuk pada malam hari atau saat hendak memulai gerakan. Pasien juga akan mengalami penurunan kemampuan fungsional, dan sering kali juga mengalami pemendekan tungkai satu sisi. Pada pasien-pasien ini, pemeriksaan radiologis akan membantu menegakkan diagnosis.

Operasi revisi tidaklah mudah dan membutuhkan keterampilan khusus, peralatan khusus serta fasilitas untuk melakukan bone-grafting. Operasi ini juga akan membutuhkan waktu yang lebih lama, perawatan yang lebih lama, waktu pemulihan yang lebih lama, dan memberikan resiko komplikasi yang besar.

Tata LaksanaFracture Abduksi Impaksi dan FractureSubcapitalUndisplaced dan Fracture Transcervikal

Semua fracture abduksi impaksi harus di fiksasi. Bila deformitas pada valgus parah (lebih dari 180o), impaksi harus dihancurkan kembali dan fragmen-fragmen disusun ulang. Menangani fractureundisplaced dengan harapan untuk mencegah pergeseran dari fragmen-fragmen. Bila fracture ini difiksasi dengan adekuat, penyatuan tulang (bony union)akan tercapai 100% pada setiap kasus. Untuk fracture ini, bisa digunakan three Knowles pins.

Preoperative x-ray dari fracture valgus impaksi

Garis fracture

  1. Caput is in slight valgus. (Sudut yang dibuat dari trabekula media caput femur dengan korteks lateral femur tidak melebihi 180o)
  2. Caput terletak di atas collum pada foto lateral

Preoperative x-ray dari FractureUndisplaced (AP view)

  1. Trabekula medial dari caput membuat sudut 160o dengan korteks lateral femur
  2. Caput terletak di atas collum pada foto lateral

Internal Fixation

  1. Letakkan pasien pada meja fracture pada posisi supine
  2. Lindungi tungkai yang tidak dipengaruhi dengan foot stirrup dengan abduksi sudut 45o dan rotasi netral
  3. Lindungi kaki yang dipengaruhi dengan foot stirrup dengan abduksi sudut 20o, flexi netral dan extensi dan patella sedikit diangkat.

Lakukan foto AP dan Lateral untuk menentukkan ada atau tidaknya displacement fragmen-fragmen yang terjadi. Bila tidak ada, dapat melanjutkan prosedur selanjutnya.

Memasukkan Guide Pins

  1. Buat insisi sepanjang 4 inch pada bagian lateral paha dibawah trochanter mayor dan ditengah corpus femur.
  2. Perdalam insisi sampai ke tulang dan diseksi subperiosteal sampai terlihat dasar dari trochanter dan ujung atas femur sekitar 3 inch.
  3. ¼ sampai 1 inch dibawah tepi tulang bagian bawah trochanter mayor dan ditengah antara korteks anterior dan posterior femur pada korteks lateral, buat bor lubang berdiameter 3/16 inch dan langsung buat sudut kira-kira 45o dengan korteks lateral
  4. Masukkan guide pins, diameter 2.5 mm ke collum dan caput. Pin langsung pada sudut 45o dari corpus dan paralel dengan lantai. Masukkan pin perlahan sampai terdapat tahanan tulang subchondral p ada caput femur (biasanya 3¾ sampai 4 inches)

Tata Laksana Partially Displaced Fracture (Stadium III) dan Fully Displaced Fracture (Stadium IV)

Karena penyatuan tulang (bony union) merupakan tujuan dilakukannya fiksasi internal pada fracture abduksi impaksi dan undisplaced, kegagalan penyatuan ini merupakan kejadian yang cukup sering pada displaced fracture. Kegagalan penyatuan (union) jauh lebih sering terjadi lagi pada fully displaced fracture (Stadium IV) daripada pada partially displaced fracture (Stadium III).

Nonunion disebabkan oleh kegagalan pencapaian reduksi yang adekuat dan fiksasi yang mantap dari displaced fracture. Reduksi anatomi yang tidak adekuat pada displaced fracture menyebabkan stabilitas tidak tercapai. Bila dinding postero-inferior pada collum femur kolaps, kekuatan exorotasi dilawan dan redisplacement dari fragmen-fragmen terjadi. Bila stabilisasi dapat tercapai, fracture ini harus segera ditangani secepat mungkin seperti displaced fracture.

Agar supaya stabilitas dapat dikembalikan, defek pada korteks posteroinferior harus di netralkan.Hal ini dapat dicapai dengan menempatkan fragmen proximal pada posisi slight valgus dan men-telescopingcollum femur sampai ke fragmen proximal, supaya defek dapat dihilangkan. Sekarang kekuatan pada sisi fractureakan seimbang.

Efek yang sama ini dapat dicapai dengan melepas penahan tulang dari collum femur bagian anterosuperior dan membiarkan caput duduk berhadapan langsung dengan collum pada slight valgus. Kedua prosedur ini memperpendek collum femur tetapi ini merupakan pengorbanan kecil untuk penyatuan tulang kembali dari displaced fracture.

Berbagai alat telah dirancang untuk membuat rigiditas pada fiksasi internal dan untuk menahan kekuatan yang membuat terjadinya redisplacement. Bagaimanapun juga, analisis yang cermat dari alat-alat yang digunakan ini memperlihatkan bahwa hanya satu yang paling efektif yaitu alat-alat yang memanfaatkan prinsip low angle fixation ditambah impaksi pada fragmen-fragmen saat dilakukan operasi. Ini digunakan sebagai multiple pin fixation dan untuk sliding nails.

Harus diakui bahwa ada beberapa displaced fracture yang tidak dapat dilakukan metode tadi untuk mengembalikan stabilitas pada sisi fracture. Displaced fracture ini lebih baik ditangani dengan operasi terbuka. Yang dilakukan dengan, pertama, menempatkan caput pada slight valgus dan telescopingcollum femur ke caput femur, dan kedua, membuang tulang penahan dari permukaan anterosuperior dari collum femur.

Alasan lain dilakukannya operasi terbuka untuk blind fixation adalah:

  • Pada beberapa instansi, memungkinkan untuk menempatkan fragmen capital pada posisi yang optimal sehubungan dengan fragmen distal dengan manuver manipulasi; hal ini telah banyak diobservasi pada operasi terbuka.
  • Usaha yang kuat dan berulang pada reduksi menyebabkan comminutif yang lebih besar pada collum femur.
  • Interposition pada bagian capsul fibrosa diantara fragmen-fragmen, mencegah terjadinya reduksi, hal ini lebih sering dari yang biasanya diharapkan.
  • Penglihatan letak fracture melalui insisi longitudinal pada bagian anterior kapsul tidak akan menyebabkan gangguan yang lebih jauh dari suplai pembuluh darah ke bagian caput femur.

Tata Laksana Berdasarkan Waktu

Penatalaksanaan fracturecollum femur juga dapat dibagi berdasarkan waktunya yaitu pada acute phase, recovery phase, dan maintenance phase.

Acute Phase (Fase Akut)

1.    Program Rehabilitasi

        Physical Therapy

Tujuan terapi ini adalah untuk meningkatkan penyembuhan, untuk mencegah timbulnya komplikasi dan mengembalikan fungsi. Tujuan utama terapi penanganan fracture adalah untuk mengembalikan pasien ke kondisi awal sebelum terjadinya fracture. Hal ini dapat dilakukan baik dengan operasi maupun tanpa operasi.Beberapa faktor harus dipertimbangkan dengan matang sebelum rencana terapi dilakukan.

Pada fracturecollum femur yang tidak rumit, penatalaksanaan pada seorang atlet harus difokuskan pada istirahat dan memperbaiki kesalahan-kesalahan pada waktu latihan (perbaiki training error). Mengubah salah satu faktor resiko juga penting untuk mencegah progresifitas dari fracture.

Physical therapy mungkin dapat digunakan untuk menunjang terapi sewaktu beristirahat dan membantu pasien mengubah program training untuk membantu penyembuhan.Seorang atlet dapat mengatur latihan fitness dan mobilitasnya pada ekstremitas yang masih berfungsi dengan baik dan melakukan latihan beban yang tidak menyebabkan ketegangan pada sendi panggul. Seorang ahli dapat mengevaluasi pasien dari cara berjalannya atau anatomi pasien yang abnormal yang mungkin menjadi faktor predisposisi untuk perkembangan fracture lebih lanjut. Beberapa pasien memerlukan orthotic untuk mencegah pronasi yang berlebihan, yang dapat meningkatkan tekanan pada collum femur.  Ahli juga memberikan edukasi kepada pasien selama proses rehabilitasi, dimana terapi maupun non-operatif telah dilakukan sebelumnya.

2.        Komplikasi Medis

Kondisi medis pasien harus dipertimbangkan sewaktu diperlukan terapi operatif.Bila terapi non-operatif yang dilakukan, pasien harus dimobilisasi secepat mungkin untuk menghindari komplikasi karena immobilisasi dalam waktu yang lama.

Banyak komplikasi yang berhubungan dengan displacedfracture atau terlambatnya penegakan diagnosis. Komplikasi yang terjadi meliputi delayed union, nonunion, refracture, osteonekrosis, dan nekrosis avaskular. Kegagalan fiksasi awal (dalam 3 bulan setelah operasi) terjadi sebanyak 12-24% dari displacedfracturecollum femur yang dilakukan fiksasi internal.

Pada penelitian jangka panjang pada pasien lanjut usia yang dilakukan fiksasi internal (internal fixation), Blomfeldt et al melaporkan bahwa komplikasi panggul sebesar 42% dan setelah dioperasi kembali sebesar 47% selama 48 bulan.

Pada tahun 1985, Stappaerts menemukan bahwa faktor yang paling penting berhubungan dengan gagalnya fiksasi adalah usia yang tua dan reduksi yang tidak akurat.

Pada tahun 1980, Scheck menekankan tentang pentingnya posterior comminution dari collum femur yang menyebabkan gagalnya fiksasi dan nonunion.

Selain itu, Heetveld et al pada tahun 2005 melaporkan bahwa tidak ada perbedaan antara pasien osteopeni dan osteoroporosis yang ditangani dengan internal fixation ketika dipertimbangkan untuk dilakukan arthroplasty.

3.       Intervensi Operatif

Keputusan untuk dilakukan terapi operatif ataupun nonoperatif dari fracturecollum femur dan jenis dari intervensi bedah itu tergantung dari banyak faktor. Konsultasi pada bagian ortopedi diperlukan.Fracture karena tekanan (tension fracture) biasanya bersifat tidak stabil dan memerlukan tindakan operatif stabilisasi. Fracturecollum femur tanpa displaced perlu distabilisasi dengan multiple parallel lag screws atau pin. Pengobatan fracture dengan displaced didasarkan atas usia dan aktivitas dari pasien tersebut. Pada kelompok pasien lansia, fungsi koqnitif premorbid, kemampuan berjalan, aktivitas pasien sehari-hari harus dipertimbangkan bila akan dilakukan tidak operatif.

Fracture kompresi (compression fracture) lebih stabil daripada fracture dengan tekanan (tension fracture), dan dapat diterapi secara non-operatif. Pengobatan untuk fracture tanpa displaced dapat dilakukan dengan istirahat total dan atau penggunaan tongkat sampai pergerakan pasif dari paha tidak terasa nyeri lagi dan pada foto x-ray menunjukkan adanya formasi kalus.

Fracture dengan displaced pada pasien usia muda merupakan emergensi ortopedik, penatalaksanaan ORIF (Open Reduction Internal Fixation) harus segera dilakukan. Prognosis kembalinya ke keadaan sebelum terjadinya fracture sangatlah sulit pada keadaan seperti ini. Pada pasien yang lebih tua, bisa dilakukan ORIF atau penggantian prostetik.

 

Gambar 4.25 Internal Fixation dengan Screw

Keputusan dalam pengambilan keputusan atas berbagai macam cara penatalaksanaan yang dapat dilakukan harus berdasarkan keputusan pasiennya sendiri.

Sejumlah penelitian pada tahun 2005 oleh Blomfeldt et al, memperlihatkan bahwa penggantian total hip pada pasien yang tua dengan fungsi koqnitif yang lebih tinggi dan gaya hidup yang lebih bebas dihubungkan dengan rendahnya angka komplikasi dan terapi operatif yang berkali-kali. Selain itu, kesehatan yang berhubungan dengan kualitas hidup lebih tinggi 2 tahun dan sama dengan 4 tahun bila dibandingkan dengan pasien yang diterapi dengan internal fixation.

Sebaliknya, tak satupun prosedur yang menguntungkan pasien dengan telah terjadi gangguan koqnitif berat.Penggantian prostetik ataupun fiksasi internal (internal fixation) dihubungkan dengan tingginya mortalitas dan menurunnya fungsi pada aktivitas sehari-hari.

Pada pasien dengan garis fracture yang berlebihan dan tidak terdapat displaced pada x-ray, terapi awal yang dilakukan adalah ambulasi non-weight-bearing dengan tongkat. Ahli harus melakukan x-ray film setiap 2-3 hari pada 1 minggu pertama untuk mendeteksi ada tidaknya extensi atau pelebaran garis fracture.

Bila nyeri tidak mereda atau bila terjadi pelebaran garis fracture, internal fixation harus dilakukan sebagai indikasi. Bila pasien dengan hasil scanning positif dan tidak terlihat garis fracture pada foto x-ray, penatalaksanaan awal diutamakan untuk menangani gejala yang dialaminya. Penatalaksaan dimulai dengan aktivitas non-weight-bearing atau partial-weight-bearing (berdasarkan gejala) dengan tongkat sampai gejala mereda.

4.       Konsultasi

Untuk fracture resiko tinggi yang memerlukan tindakan operatif, konsultasi dengan ahli ortopedik diperlukan.

Recovery Phase (Fase Penyembuhan)

1.       Program Rehabilitasi

           Physical Therapy

Bila gejala nyeri pada fracture yang stabil telah ditangani pada pengobatan fase akut, latihan kekuatan untuk stabilisasi panggul dan otot dapat dimulai. Tujuan utama adalah untuk memperbaiki dan mengembalikan gerakan (range of motion) dari panggul dan paha.

Bila pasien tidak merasa nyeri lagi, weight bearing dapat dilakukan.Ketika pasien telah mampu mentoleransi partial weight-bearing, aktivitas umum di luar rumah seperti berenang dan cycling boleh dilakukan. Foto x-ray dilakukan seminggu sekali sampai pasien dapat bergerak dengan full weight bearing tanpa rasa nyeri.

Latihan lari harus dilakukan dari yang paling ringan secara bertahap.Bila nyeri masih dirasakan, istirahat selama beberapa hari disarakankan, jarak tempuh juga harus dikurangi, dan latihan dilanjutkan lagi secara bertahap tergantung dari gejala yang masih ada pada pasien tersebut.

Tindakan bedah diindikasikan untuk pasien dengan fracture dan displaced yang jelas dan berlebihan. Biasanya, fiksasi dilakukan dengan plate and screw.Setelah operasi, pasien diistirahatkan sampai rasa nyeri mereda dan kemudian mulai dilatih sampai aktivitasnya dapat optimal dan kesembuhan terjadi.Bila plate sudah diangkat, rehabilitasi lebih lanjut tetap diperlukan. Pengangkatan plate tergantung dari usia dan aktivitas dari pasien. Beberapa pasien lebih suka weight bearing dengan tongkat.Pasien biasanya dibolehkan untuk melanjutkan kembali untuk running; walaupun boleh, disarankan untuk membatasi olahraga dan tidak melakukan olahraga yang berat.

Penguatan otot gluteus medius, otot-otot abduktor panggul sangatlah penting untuk stabilisasi setelah operasi.Otot penting lainnya meliputi m. iliopsoas; gluteus maximus; adductor magnus, longus dan brevis; quadricep; dan otot-otot tumit bagian belakang. Tujuan fungsionalnya yaitu untuk menormalkan pola dan cara berjalan pasien. Aktivitas olahraga tertentu kemudian boleh mulai dilakukan secara progresif dengan pengawasan pelatih.

Mengusahakan agar dalam kondisi yang baik selama rehabilitasi merupakan hal yang penting.Bila alat pelindung atau non-weight-bearing diperlukan, kemudian latihan tubuh bagian atas seperti upper body ergometer dapat digunakan.Bila partial weight-bearing ambulation diperbolehkan, latihan aquatic diperlukan juga, seperti renang atau berjalan di dalam air yang dalam.

Intervensi Bedah

Pasien dengan fracture yang jelas dan terdapat displaced pada sisi tekanan memerlukan intervensi bedah demi kesembuhannya. Umumnya, internal fixation diperlukan dengan menggunakan screw and plate.

Maintenance Phase (Fase Perawatan)

1.     Program Rehabilitasi

        Physical Therapy

Maintenance phase menggambarkan fase akhir dari proses rehabilitasi. Latihan kekuatan otot seperti latihan kondisi dinamik (eg. dengan large gym ball), ditambahkan pada penatalaksaan pasien.Selain itu, latihan olahraga spesifik harus ada didalamnya sehingga seorang dapat mempertahankan keseimbangan ototnya.

Tata Laksana Fracture Collum Femur yang Tidak Ditangani 4 – 6 Minggu

Umumnya caput femur dapat hidup dan ada absorbsi minimal pada collum femur. Tangani lesi ini seperti fracture yang baru saja terjadi. Bila terdapat absorbsi moderate dari collum femur, tangani lesi ini dengan osteotomi.Jangan mengganti caput femur dengan prostesis kecuali sudah menjadi pilihan terakhir.

Prereduction x-ray (Fully displaced fracture)

  1. Sudut normal collum femur ke fragmen capital di reduksi; caput pada posisi varus
  2. Fragmen distal dirotasikan ke sisi lateral
  3. Corpus femur digeser ke atas
  4. Fragmen distal ditempatkan anterior dari fragmen proximal
  5. The plane of fracture diletakkan distal dari caput femur

Postoperative x-ray

  1. Caput pada valgus yang sempit
  2. Collum disambungkan ke caput
  3. Fragmen-fragmen di fiksasi dengan 2 sudut tinggi atau 2 sudut rendah Knowles pins

Nonunion dari Collum Femur dengan caput yang viabel dan hanya absorbsi minimal pada Collum femur

Lesi ini sangat baik ditangani dengan osteotomi. Tujuan dilakukannya osteotomi harus ditujukan untuk union dari tulang; nonunion dari fracturecollum femur diikuti dengan osteotomi akan menghasilkan nyeri pada panggul. Dengan melakukan osteotomi, semua pergerakan pada sisi fracture harus dihilangkan; bila pergerakan terjadi, absorbsi dari collumakan terjadi, dan alat-alat yang digunakan untuk menstabilisasi fracture akan menembus caput. Jangan memilih prostesis untuk menggantikan caput femur kecuali hal ini sudah merupakan keputusan terakhir.

Prereduction x-ray

  1. Hanya terjadi absorbsi minimal pada collum femur
  2. Gambaran fracture hampir vertikal
  3. Caput femur di adduksi sesuai dengan collum femur

Postoperative x-ray (Following Angulation Osteotomy)

  1. Gambaran fracture saat ini hampir horisontal. (Pada weight bearing, stress merupakan compressing force pada sisi fracture dibandingkan dengan shearing force).
  2. Aksis dari corpus femur diletakkan di bawah caput femur, mengurangi daya ungkit pada sendi panggul.
  3. Sisi osteotomi dibawah trochanter minor.
  4. Ujung proximal dari alat ditempelkan tetapi tidak menembus caput femur terlalu jauh.
  5. DuaKnowles pins dimasukkan secara paralel satu sama lainnya melewati sisi fracture sebelum bladeplate diletakkan (Blount blade plate).
  6. Blade Plate is bent pada posisi yang tepat (dipastikan dengan foto rontgent) untuk meletakkan caput dan collum kira-kira paling sedikit 155o dari valgus
  7. Screw paling proximal ditempelkan pada fragmen proximal.

Tidak ada fiksasi interna yang dibutuhkan.Lesi ini juga dapat ditangani dengan high servical trochanteric osteotomy; osteotomi ini menghasilkan hasil yang baik dibandingkan dengan metode lainnya.

Nonunion dengan caput yang viabel dan ditandai dengan absorbsi sedang sampai komplet dari collum femur

Setiap keputusan harus dibuat untuk mencapai bony union dan menyelamatkan caput femur; bila berhasil, hasil panggul jauh lebih baik daripada hasil yang didapatkan dengan melakukan arthroplasti (seperti Colonna operation) atau hasil penggantian caput dengan prostesis.Diplacement osteotomy merupakan prosedur terbaik untuk menyelamatkan panggul; tetap harus dilakukan walaupun viabel dari caput femur diragukan.Walaupun pada x-ray memberikan informasi yang berharga untuk menentukan viabilitas dari caput femur, tidak ada yang menjamin bahwa nekrosis avaskular tidak berkembang pada beberapa bulan ke depan.

a.       McMurray Osteotomy

Gambar 4.26 McMurray Osteotomy – Prereduction dan Postoperative X-ray

b.     Cervical Trochanteric Osteotomy (Reich)

Gambar 4.27 Reich Osteotomy – Post Operative X-ray dan Imobilisasi

Nonunion dengan caput femur nonviabel dan absorbsi sedang atau komplet dari collum femur

Pada individu muda dan usia pertengahan, setiap pertimbangan harus dibuat untuk stabilisasi, menghilangkan nyeri, membuat pergerakan panggul positif. Pada kelompok ini, DePalma Arthroplasty dilakukan sebagai prosedur rekonstruksi.Pada individu yang lebih tua dimana kondisi umumnya baik, pilihan Colonna arthroplasty atau penggantian caput nonviabel dengan prostesis medullary metal. Pada usia lanjut, bila semua prosedur tadi diragukan, caput femur digantikan dengan prostesis metal.

Salvage Operation untuk pasien muda dan umur pertengahan

Preoperative x-ray

  1. Absorbsi komplit dari collum femur
  2. Caput femur menjadi pekat, menandakan nonviabel

Postoperative x-ray (DePalma Arthroplasty)

  1. Caput femur dibuang dan vitallium cup ditempatkan pada acetabulum
  2. Transverse osteotomy dilakukan 3½ inches dibawah ujung trochanter mayor
  3. Fragmen proximal miring ke arah medial dan ujung proximalnya diletakkan pada vitallium cup
  4. Fragmen-fragmen di fiksasi dengan Neufeld nail pada sudut 135o

Preoperative x-ray

  1.  Absorbsi komplit dari collum femur
  2. Caput femur kontras dan pekat dan sklerotik

 Postoperative x-ray

  1. Caput femur dipotong
  2. Penopang tulang dibuang dari bagian dalam trochanter mayor dan corpus femur segera diatas trochanter minor
  3. Prostetis medulary (DePalma) ditempatkan langsung diatas corpus femur dan dengan batas berlawanan dari bagian dalam dari trochaner mayor

Collona Arthroplasty

  1. Trochanter mayor diletakkan pada acetabulum
  2. Abduktor dari panggul ditarik ke bawah pada corpus femur
  3. Prosedur ini dilakukan bila dengan penggantian prostetis tidak berhasil.

Tata Laksana Fracture Intertrochanteric

Fracture intertrochanteric hampir selalu ditangani dengan internal fixation sejak awal penatalaksanaan, bukan karena fragmen-fragmennya mengalami kegagalan untuk menyatu kembali dengan terapi konservatif. Internal fixation dini ini dilakukan dengan tujuan:

  1. Untuk mendapatkan posisi fragmen tulang yang terbaik
  2. Agar pasien dapat segera mulai berjalan kembali secepat mungkin setelah trauma sehingga juga dapat mengurangi resiko timbulnya komplikasi akibat tirah baring yang terlalu lama

Terapi non-operatif merupakan pilihan yang tepat bagi pasien-pasien dengan kondisi fisik yang tidak memungkinkan untuk menjalani proses anestesi. Terapi yang digunakan ialah dengan melakukan traksi di tempat tidur hingga mencapai posisi di mana pasien merasa nyaman atau tidak terlalu nyeri lagi dan juga memungkinkan untuk mobilisasi yang baik.Metode ini memiliki tingkat keberhasilan yang cukup baik, tetapi sangat tergantung pada kualitas perawatan dan terapi fisik yang diberikan.

Pada reduksi fracture melalui tindakan operatif, dilakukan traksi dengan endorotasi, posisi ini dipastikan melalui pemeriksaan x-ray. Pemasangan screw dengan posisi yang tepat merupakan hal yang sangat penting, terutama pada tulang yang mengalami osteoporosis. Screw harus dipasang melalui collum femur agar berada tepat di tengah caput femur, dengan posisi tip sekitar 5 mm dari subchondral bone plate. Jika posisi fragmen yang tepat gagal dicapai melalui reduksi tertutup, maka perlu dilakukan reduksi terbuka dan manipulasi pada fragmen tersebut.Pada fragmen posteromedial yang besar mungkin diperlukan fiksasi tambahan.

Setelah operasi, latihan dapat dimulai pada hari setelah dilaksanakan operasi.Pasien dapat mulai melakukan mobilisasi dan weightbearing secara bertahap.

Tata Laksana Fracture Subtrochanteric

Pada fracture ini, traksi dapat dilakukan untuk mengurangi rasa nyeri dan perdarahan. Penanganan ini merupakan terapi sementara, sambil menunggu persiapan untuk menjalani operasi.

Open Reduction dan Internal Fixation

Open reduction dan internal fixation merupakan terapi pilihan untuk menangani fracture ini. Ada dua jenis implant yang umum digunakan untuk melakukan fiksasi, yaitu:

  1. Sebuah intramedullary nail dengan proximal interlocking screw yang dapat diarahkan ke area caput femur
  2. Screw dan plate untuk panggul dengan sudut 95o

Pemilihan kedua jenis implant di atas didasarkan pada pertimbangan-pertimbangan sebagai berikut:

  • Intramedullary nail secara umum lebih kuatdan dapat mengatasi tekanan untuk durasi yang lebih lama, pada proses penyembuhan yang berjalan lambat. Implan ini lebih dipilih pada kasus fracture yang unstable atau comminuted.
  • Intramedullary nail juga merupakan pilihan untuk terapi fracture patologis. Full length nail harus digunakan karena mungkin masih terdapat sel tumor lainnya pada bagian distal os femur.

 

 

Gambar 4.26 Internal Fixation pada Fracture Subtrochanteric

Keterangan gambar 4.26:

(a)     Internal fixation dengan 95oscrew and plate device

(b)     Pemasangan intramedullary nail dengan proximal interlocking screw pada caput femur

(c)      Fiksasi dengan proximal femoral plate dan locking screw

Ada beberapa hal yang perlu diperhatikan untuk melaksanakan operasi pada fracture ini, antara lain:

  • Reduksi secara anatomis akan menghasilkan area yang lebih luas bagi kontak antarfragmen tulang dan mengurangi tekanan yang terjadi pada implan
  • Reduksi harus dilakukan dengan diseksi jaringan lunak yang seminimal mungkin
  • Penting untuk diperhatikan bahwa integritas korteks medial harus tetap dipertahankan, terutama pada penggunaan hip screw and plate device

Proximal interlocking screw dan intramedullary nail harus diarahkan ke caput femur jika garis fracture berada di atas trochanter minor. Jika fracture masuk ke fossa piriformis, maka intramedullary nail harus dimasukkan ke ujung trochanter mayor atau juga dapat digunakan 95o hip screw-and-plate device.

Setelah operasi, pasien diperbolehkan untuk partial weightbearing dengan menggunakan tongkat hingga proses penyatuan tulang berhasil dengan baik.

4.10             Tata Laksana Medikamentosa

Pada semua kasus fracture, penatalaksanaan nyeri harus diutamakan.Analgetik seperti acetaminophen atau NSAID (Non Steroid Anti Inflammatory Drugs)dapat diberikan pada fase akut dari fracture.Walupun demikian, penambahan penghilang nyeri mungkin diperlukan bila nyeri pasien tidak hilang hanya dengan pemberian acetaminophen atau NSAID. Pada kasus seperti ini, golongan opiate mungkin dapat digunakan, khususnya untuk mengatasi rasa nyeri yang hebat. Penyesuaian terhadap rasa nyeri harus dilakukan, terutama pada fase akut.

Analgetik

Kontrol terhadap rasa nyeri sangat penting pada pasien. Analgetik akan membuat pasien nyaman, napas yang tenang, dan mempunyai efek sedatif, yang bermanfaat bagi pasien dengan nyeri yang terus-menerus. Beberapa jenis analgetik yang dapat digunakan, antara lain:

a.       Acetaminophen

  • Diindikasikan untuk nyeri ringan sampai sedang. Merupakan obat pilihan untuk nyeri pasien yang hipersensitif terhadap aspirin atau NSAID, dengan gangguan gastrointestinal atas, atau pasien yang mengkonsumsi antikoagulan oral.
  • Dosis yang digunakan adalah 325-650 mg Per Oral setiap 4-6 jam atau 1000 mg 3 sampai 4x sehari; dosis tidak lebih dari 4 gram per hari.
  • Untuk pasien anak12 tahun: 325-650 mg per oral setiap 4 jam; tidak lebih dari 5x dalam 24 jam.
  • Kontraindikasi pada pasien yang hipersensitif; defisiensi G6PD (Glucose-6-Phosphate Dehydrogenase)
  • Interaksi obat. Rifampin dapat mengurani efek analgetik; digunakan bersama barbiturate, carbamazepine, hydantoins, dan isoniazid akan meningkatkan hepatotoksisitas.
  • Efek samping bersifat hepatotoksik terutama bila pasien alkoholism; nyeri hebat atau nyeri terus-terusan atau demam tinggi merupakan efek samping yang serius; acetaminophen terdapat pada beberapa produk OTC dan biasanya dikombinasikan sehingga dosis acetaminophen menjadi berlebihan atau bahkan dapat melebihi dosis maksimal.

b.       Ibuprofen

  • Obat pilihan untuk pasien dengan nyeri ringan sampai sedang. Menghambat reaksi inflamasi dengan menurunkan sintesis prostaglandin.
  • Dosis dewasa 400-600 mg per oral setiap 4-6 jam selama gejala masih ada; tidak melebihi 3.2 gram/hari.
  • Dosis anak12 tahun: mengikuti dosis dewasa.
  • Kontraindikasi pada pasien yang hipersensitif; ulkus peptik, perdarahan dan perforasi saluran cerna, insufisiensi renal, atau resiko perdarahan.
  • Bila digunakan bersama aspirin akan meningkatkan efek kebalikan dari NSAID; dengan probenecid akan meningkatkan konsentrasi obat dan mungkin menjadi toksik; dapat menurunkan efek hidralazine, captopril, dan beta bloker; dapat menurunkan efek diuretik furosemide dan tiazid; dapat meningkatan PT (Protrombin Time) bila digunakan bersama antikoagulan (peringatkan pasien untuk mendeteksi gejala perdarahan); meningkatan efek toksik metrotrexate; level phenytoin akan meningkat bila digunakan terus-menerus.
  • Efek samping. Kategori D pada trisemester III kehamilan; Kategori B pada trisemester I dan II kehamilan; menyebabkan CHF, Hipertensi, dan menurunkan fungsi ginjal dan hati; menyebabkan abnormalitas antikoagulan atau selama terapi antikoagulan.

c.       Oxycodone

Analgesik dengan multipel aksi yang mirip morphine; dengan konstipasi minimal, spasme otot polos, dan depresi refleks batuk yang lebih ringan dibandingkan dengan pemberian morphine pada dosis yang sama.

  • Dosis dewasa: 5-30 mg per oral setiap 4 jam.
  • Dosis anak: 0.05-0.15 mg/kg per oral; Tidak melebihi 5 mg setiap 4-6 jam per oral.
  • Kontraindikasi pada pasien yang hipersensitif.
  • Interaksi obat. Phenothiazine menurunkan efek analgesik; toksisitas meningkat dengan pemberian bersama obat-obat depresi SSP.
  • Keamanan penggunaan selama kehamilan tidak tercatat.
  • Efek samping. Masa aktif meningkat pada pasien lansia; hati-hati pada penggunaan acetaminophen dan jangan melebihi 4000 mg dalam 24 jam karena dapat mengakibatkan hepatotoksik.

4.11 Komplikasi

4.11.1 Komplikasi Umum

Pasien yang mengalami fracture collum femur, yang sebagian besar merupakan orang lanjut usia, beresiko untuk mengalami komplikasi yang umum terjadi pada semua penderita fracture, di mana mereka mengalami proses imobilisasi yang cukup lama. Komplikasi umum tersebut ialah terjadinya deep vein thrombosis, emboli pulmonal, pneumonia, dan ulkus dekubitus akibat berbaring dalam jangka waktu yang lama secara terus menerus.

Walaupun saat ini penangan paska operasi sudah sangat berkembang, angka mortalitas pada orang lanjut usia masih mencapai 20%, yang terjadi dalam 4 bulan pertama setelah trauma. Pada pasien-pasien berusia lebih dari 80 tahun yang dapat bertahan hidup, hampir setengahnya tidak dapat berjalan seperti saat sebelum trauma.

4.11.2 Nekrosis Avaskular

Nekrosis caput femur akibat proses iskemik terjadi pada 30% pasien yang mengalami fracturedisplaced dan pada 10% pasien dengan fractureundisplaced. Komplikasi ini belum dapat didiagnosis atau diketahui pada saat awal terjadinya fracture.Setelah beberapa minggu setelah terjadinya fracture, melalui pemeriksaan bone scan, baru mulai tampak dan ditemukan adanya gangguan vaskularisasi tersebut.Pada pemeriksaan X-ray, perubahan vaskularisasi ini bahkan baru dapat terdeteksi beberapa bulan atau beberapa tahun setelah diagnosis fracture.

Nekrosis caput femur ini akan menimbulkan keluhan rasa nyeri dan hilangnya fungsi struktur tersebut yang bersifat progresif, yang semakin lama akan semakin memburuk jika tidak segera ditangani. Metode tata laksana yang dipilih pada pasien berusia lebih dari 45 tahun untuk mengatasi komplikasi ini ialah dengan total joint replacement. Sedangkan pada pasien dengan usia yang lebih muda, tata laksana yang akan digunakan masih menjadi kontroversi. Terapi core decompression tidak dapat digunakan pada kasus osteonekrosis traumatik ini, sedangkan terapi realignment atau rotational osteotomy dapat dilakukan pada pasien dengan segmen nekrosis yang relatif tidak terlalu luas.Terapi arthrodesis juga banyak dikemukakan sebagai salah satu pilihan terapi, tetapi pada prakteknya sangat jarang dilakukan.

4.11.3 Non-Union

Lebih dari 30% kasus fracture collum femur mengalami kegagalan untuk menyatu kembali dan resiko ini akan semakin meningkat pada fracture-fracture dengan displaced yang parah. Ada beberapa penyebab terjadinya komplikasi ini, antara lain karena suplai darah yang kurang baik, reduksi yang tidak sempurna, fiksasi yang tidak adekuat, dan adanya tardy healing yang merupakan ciri khas fracture intra-articular. Pada komplikasi non-union, pasien akan mengeluhkan rasa nyeri, tungkai yang mengalami fracture tampak lebih pendek dari tungkai yang sehat, dan mengalami kesulitan untuk berjalan. Hal ini dikonfirmasi melalui pemeriksaan X-ray yang juga menunjukkan hasil penyatuan tulang yang kurang baik atau tidak berhasil.

Metode terapi yang digunakan untuk mengatasi komplikasi ini sangat bergantung pada penyebab non-union ini terjadi dan dengan mempertimbangkan usia pasien. Pada pasien dengan usia yang relatif masih muda, ada tiga pilihan metode terapi yang dapat digunakan, antara lain:

  1. Jika garis fracture hampir vertikal dengan caput femur yang masih baik, dapat dilakukan subtrochanteric osteotomy dengan fiksasi internal untuk mengubah garis fracture agar sudutnya menjadi lebih horizontal.
  2. Jika terdapat masalah pada teknik reduksi atau fiksasi, tanpa adanya tanda-tanda nekrosis, dapat dilakukan pencabutan screw, reduksi fracture, memasang screw yang baru dengan cara yang tepat, dan memasang bone graft di sepanjang garis fracture. Bone graft dapat diambil misalnya dari segmen tulang fibula.
  3. Jika terjadi nekrosis pada caput femur tanpa adanya gangguan pada persendian, metode yang dapat dilakukan ialah dengan prosthetic replacement. Namun, jika disertai dengan gangguan pada persendian, makan harus dilakukan total replacement.

Sedangkan pada pasien lanjut usia, ada dua prosedur yang mungkin dapat dilakukan, yaitu:

  1. Jika nyeri yang timbul sangat berat dan mengganggu, maka caput femur, baik mengalami nekrosis avaskular ataupun tidak, harus segera diangkat dan diganti melalui prosedur total joint replacement.
  2. Jika pasien berusia sangat tua, tidak lagi menjalani aktivitas fisik secara aktif, dan nyeri yang timbul tidak terlalu berat, maka hanya dengan penggunaan raised heel dan stout stick atau elbow crutch biasanya sudah dapat mengatasi komplikasi ini.

4.11.4 Osteoartritis

Nekrosis avaskular yang terjadi pada caput femur, setelah beberapa tahun kemudian, dapat menyebabkan timbulnya osteoartritis sekunder pada panggul.Jika terdapat gangguan berat pada pergerakan sendi dan kerusakan telah meluas hingga permukaan articular, maka perlu dilakukan total joint replacement.

4.12 Pencegahan

Collum femur merupakan lokasi fracture tersering yang banyak terjadi pada orang lanjut usia. Fracture ini banyak terjadi pada orang ras Kaukasia, wanita lebih sering dari pada pria, usia dekade ketujuh dan kedelapan, dan pada orang yang menderita osteoporosis. Oleh karena itu, tingkat insidensi fracture collum femur dapat dijadikan sebagai salah satu parameter tingkat insidensi osteoporosis di suatu negara.

Adanya hubungan antara fracture collum femur dengan hilangnya massa tulang akibat osteoporosis post menopause meningkatkan usaha screening untuk osteoporosis sebagai salah satu bentuk pencegahan terjadinya fracture tersebut. Sebaliknya, trauma ini sangat jarang ditemukan pada orang-orang dengan massa tulang yang tinggi, seperti pada orang yang menderita osteoartritis.

Faktor resiko lainnya ialah adanya penyakit yang mengakibatkan kelemahan atau penurunan kekuatan pada tulang, seperti osteomalasia, diabetes mellitus, stroke, dan konsumsi alkohol. Selain itu, orang lanjut usia sering kali memiliki otot-otot yang lebih lemah dan keseimbangan yang kurang baik sehingga memiliki tendensi yang lebih tinggi untuk jatuh yang mungkin mengakibatkan fracture collum femur ini.

Pada orang dengan usia muda, fracture biasanya terjadi akibat jatuh dari ketinggian atau akibat kecelakaan lalu lintas yang menyebabkan hingga terlempar ke jalan. Pada pasien ini sering kali mengalami jejas multipel dan 20% di antaranya juga mengalami fracturecorpus femur.

Berdasarkan pengetahuan mengenai mekanisme terjadinya fracture collum femur tersebut, ada beberapa cara yang dapat dilakukan untuk mencegah terjadinya fracture ini, antara lain:

  • Screening dan terapi osteoporosis secara berkala.

Menurut WHO (1991), osteoporosis adalah penyakit yang ditandai oleh rendahnya massa tulang dan disertai kerusakan mikroarsitektur jaringan. Kelainan ini menyebabkan kerapuhan tulang sehingga terjadi peningkatan resiko fracture.

 

Gambar (A) Massa Tulang Normal, (B) Massa Tulang Osteoporosis

Kekuatan tulang sangat ditentukan oleh densitas tulang dan kualitas tulang.Densitas tulang dinyatakan dalam satuan gram mineral per area atau volume, sedangkan kualitas tulang dipengaruhi oleh struktur atau arsitektur tulang, proses turnover, akumulasi kerusakan (misalnya akibat mikrofracture), dan proses mineralisasi. Saat ini, tingkat densitas tulang telah dapat diukur secara kuantitatif melalui berbagai macam metode, tetapi untuk kualitas tulang belum dapat dinyatakan secara kuantitatif.

Densitas tulang sangat perlu untuk diukur secara berkala dan merupakan salah satu cara untuk mencegah terjadinya fracture yang mungkin dapat berakibat fatal. Cara pencegahan ini sangat penting untuk orang-orang lanjut usia, khususnya bagi para perempuan yang sudah memasuki fase post-menopause. Seiring bertambahnya usia, proses kehilangan massa tulang juga akan semakin meningkat.

Densitas tulang atau Bone Mineral Density (BMD) dapat diukur menggunakan suatu alat, yaitu Bone Densitometry.Berdasarkan nilai BMD tersebut, WHO mengklasifikasikan tingkat massa tulang sebagai berikut:

 

Kriteria

Normal

Nilai BMD < -1 SD di bawah nilai rata-rata

Osteopenia

Nilai BMD -1 s/d -2,5 SD di bawah nilai rata-rata

Osteoporosis

Nilai BMD > -2,5 SD di bawah nilai rata-rata

Osteoporosis Berat

Nilai BMD > -2,5 SD di bawah nilai rata-rata, disertai adanya ≥ 1 fracture karena osteoporosis

 

Contoh Hasil Pemeriksaan BMD pada Collum Femur

Pemeriksaan-pemeriksaan lain yang dapat dilakukan untuk mendeteksi resiko terjadinya fracture akibat osteoporosis ialah dengan cara biochemical melalui pemeriksaan laboratorium darah lengkap, tes fungsi ginjal, tes fungsi hati, kadar albumin, kadar fosfor, kadar hormone paratiroid, kadar 25-hidroksi vitamin D, pemeriksaan urin, dan sebagainya.

Membuat dan mengkonsultasikan rencana dan target latihan dengan dokter yang ahli di bidang tersebut. Hal ini perlu dilakukan untuk mencegah dan mengurangi resiko terjadinya fracture akibat latihan yang berlebihan dan tidak sesuai.

  • Diet tinggi kalsium dan mengkonsumsi suplemen kalsium.
  • Jika seseorang memiliki tingkat keseimbangan yang kurang baik, dapat dilakukan hal-hal berikut ini:
    • Menggunakan walker atau berjalan dengan bantuan tongkat untuk memperbaiki keseimbangan, sehingga megurangi resiko jatuh yang dapat menyebabkan fracture.
    • Menggunakan padded underwear untuk melindungi tulang panggul, sehingga mengurangi resiko terjadinya fracture jika mengalami kecelakaan kecil atau jatuh.
    • Meminimalkan resiko terjatuh di rumah, yaitu dengan cara:
      • Menggunakan karpet atau keset karet pada lantai agar tidak terlalu licin
      • Memasang handrails di kamar mandi, lorong, dan tempat-tempat lainnya sebagai pegangan saat berjalan.
      • Menyingkirkan barang-barang yang menghalangi jalan yang mungkin menyebabkan tersandung, seperti kabel-kabel yang melintas di lantai.
      • Menggunakan sepatu atau sandal dengan alas karet atau alas non-slip

4.13 Prognosis

Tergantung pada sifat fracturenya, seorang atlet dapat kembali ke keadaan sebelum terjadinya fracture tersebut.Displacedstress fracture pada fracturecollum femur dapat mengakibatkan kelumpuhan walaupun diterapi dengan baik. Diagnosis dan penatalaksanaan awal dapat mencegah terjadinya displaced pada fracture dan memperbaiki prognosis yang akan terjadi.

4.14 Edukasi

Pasien harus mendapatkan pengertian yang baik tentang diagnosis dan keuntungan serta kerugian dari pengobatan yang diterima. Melengkapi edukasi selama proses program rehabilitasi sangat penting bagi pasien untuk mendapatkan hasil yang optimal dan memungkinkan pasien kembali ke kondisi sebelum mereka mendapat cedera. Pasien harus peduli aktif terhadap diri mereka dan mengerti bahwa pentingnya kesembuhan diri mereka, dan diberikan instruksi terhadap program aktivitas di rumah mereka sesuai dengan porsi mereka. Edukasi terhadap pasien merupakan hal yang penting untuk mencegah rekurensi terhadap fracturecollum femur.

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その為、 あの人なんか臭う」と思われた一瞬で、 潔」な印象をレッテルを貼られてしまう です。「あなたお風呂入ってるの?」「 処したり努力してるの?」などヒドイ言 れようです。


しかし改善させる めには、臭う汗や体臭が出てしまう原因 打破しなければ知らなければダメだとい 事です。


そして次に、己の汗や 臭のパターンを知るという事です。

n
この2つの事を理解せずに、適当に色 な消臭・制汗商品を試してみても、無駄 なる可能性が大です。


お金を無 にしないためにも、初めに汗や体臭に関 ての正しい知識を身につけて、自分に合 たケアを見つけましょう!
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Hi there, I think your site could possibly be having browser compatibility problems.

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ganesh chaturthi | 13 Agustus 2017 - 09:55:01 WIB
Hi there just wanted to give you a quick heads up.

The words in your content seem to be running off the screen in Safari.
I'm not sure if this is a format issue or something to do with web browser compatibility but I thought I'd post to let you know.
The design and style look great though! Hope you get the issue solved soon. Kudos
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AFL Noyes FTS3 Fiber Optic Test | 13 Agustus 2017 - 13:42:34 WIB
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