Oku trauma free download pdf

Although the score was found to be reliable, val- MedlineDOI idation studies were limited. Multiple generic instruments were tested for construct Bhandari M, Chiavaras MM, Parasu N, et al: Radiograph- validity and test-retest reliability among patients with ic Union Score for Hip substantially improves agreement proximal humerus fracture.

All instruments performed between surgeons and radiologists. MedlineDOI ceiling effect compared with other instruments. The RUSH score for assessing the healing of inter- J Bone Joint Surg impression of healing. Am ;81 9 MedlineDOI Concepts important to outcome studies such as validity and reliability were reviewed with variety of potential MedlineDOI tals. Soc Sci Med ;35 8 J Am a 2-year prospective study.

J Orthop Trauma ;27 1 : Geriatr Soc ;39 2 Laflamme GY, Rouleau DM, Leduc S, Roy L, Beaumont In patients with severe foot and ankle injuries, those who E: The Timed Up and Go test is an early predictor of func- underwent limb salvage requiring a flap or ankle fusion tional outcome after hemiarthroplasty for femoral neck had lower SIP scores than those initially treated with be- fracture.

J Bone Joint Surg Am ;94 13 Hung M, Stuart AR, Higgins TF, Saltzman CL, Kubiak The timed up-and-go test administered four days and three EN: Computerized adaptive testing using the PROMIS weeks after treatment of femoral neck fracture with hemi- physical function item bank reduces test burden with less arthroplasty was strongly correlated with the likelihood ceiling effects compared with the Short Musculoskele- of independent ambulation at two years.

J Orthop Trauma ;28 8 The PROMIS test required dramat- Current outcome instruments to assess physical activity, ically less time to administer and had less ceiling effect. J Hand Surg Am ;39 10 of methods for monitoring the results of medical care. JAMA ; 7 JAMA ; 15 Chapter 2. The number of trauma Patient Access to Emergency Care centers continues to increase, additionally straining the orthopaedists providing coverage at these institutions.

The number of patient visits to emergency departments Novel models for orthopaedic emergency coverage have across the country continues to increase at a concerning been developed to provide care, with varying results.

According to the Centers for Disease Control and Prevention, million emergency department visits were made in , and The strain on the medical system and on orthopaedic surgeons in particular becomes more tangible, and some call arrangements that worked in the past may no longer be sufficient to provide orthopaedic coverage.

The reasons cited for lack of coverage include result in substantial functional impairment. More than the interruption of family life and lifestyle, inadequate , adolescents and adults younger than 65 years compensation, and the disruption of the elective ortho- are hospitalized annually in the United States because of paedic practice. At the same time as thopaedic care. Patients flow through a rapidly evolving changes in health care access in this country are evolving, the availability of orthopaedic specialists is in decline.

Neiman or an immediate family member is a member of a speakers bureau or has made paid presentations on The Patient Protection and Affordable Care Act behalf of Medtronic, serves as an unpaid consultant to Access to orthopaedic specialty care in the outpatient the Orthopaedic Implant Company, and has stock or stock setting varies by region depending on many factors, in- options held in the Orthopaedic Implant Company.

Neither cluding the density of providers, the geographical loca- Dr. Mallon nor any immediate family member has received tion, and patient health insurance status.

The Patient anything of value from or has stock or stock options held Protection and Affordable Care Act, commonly called in a commercial company or institution related directly or the Affordable Care Act ACA , was signed into law in indirectly to the subject of this chapter.

Unlike must return to the emergency department, increasing elective surgery with its requisite preauthorization pro- the number of visits to the emergency department and cess, trauma surgery does not have a protocol for in- ultimately increasing costs. These patients are generally surance approval before intervention.

Theoretically, if a more successful in obtaining a specialty referral when higher percentage of the population is insured, trauma referred from an emergency department, partly because centers should benefit.

After the introduction of health care re- status. Moreover, mortality in Labor Act the state has declined since the implementation of health Emergency department visits have risen steadily over the care reform.

These reductions were most evident in the past 15 years since patients were guaranteed medical 1: General Topics. The goal is to deliver the emergency care physicians to evaluate and stabilize all pa- highest quality of care at the lowest possible cost. The tients regardless of their ability to pay, and hospitals must model developed to achieve this goal is the Accountable provide specialist care or arrange transfer when specialist Care Organization ACO , which is a network of phy- care is unavailable.

This requirement creates the potential sicians and hospitals created to share the burden of de- for abuse, because hospitals that do not have continuous livering care for a group of patients.

Another provision specialty coverage could transfer patients based on their of the ACA is the Independent Payment Advisory Board inability to secure an orthopaedic surgeon. Even when IPAB. This member panel has the task of slowing a particular hospital has busy and active orthopaedic the increases in health care spending.

The IPAB has the surgeons, the emergency department is forced to transfer authority to cut Medicare spending should its targets a patient to a facility with guaranteed coverage if the fail to be reached. Medicare cuts could limit access to orthopaedic surgeons are not required to take emergency musculoskeletal care and therefore is a potential concern. In some Additionally, the ACA shifts the burden of collect- instances, this arrangement has been shown to preferen- ing and reporting quality indicators to physicians, in- tially occur with underinsured patients.

The Alternative Solutions for Orthopaedic Call ACA attempts to fundamentally shift health care from a Coverage volume-centered payment system to a patient-centered, More orthopaedic emergencies are occurring, but fewer outcome-driven system. This paradigm shift could affect orthopaedic surgeons are willing to take call. Trauma patients have considerable orthopaedic call coverage. The American Association for variability in injury mechanisms and patterns.

Reporting the Surgery of Trauma has identified a shortage of cov- quality indicators will be the responsibility of physicians. With this shift has come a relative ma surgery, criteria exist for fellowships that include elec- shortage of specialty providers, including orthopaedic sur- tive training in basic orthopaedic procedures.

Currently, geons, who have not enrolled as providers in some of the 19 American Association for the Surgery of Traumaac- Medicaid plans. Therefore, when patients are referred to credited fellowships are available in the United States.

The an orthopaedic specialist for an acute or subacute injury, acute care surgery fellowship curriculum recommends their insurance status may still be a barrier to access. Chapter 2: Delivery of Orthopaedic Trauma Care. The American College of Surgeons ACS has estab- Like the positions of the internal medicine hospitalist lished high standards for trauma centers.

Only after these and subsequently the general surgery surgicalist, the posi- standards are met through the ACS process does a hospi- tion of the orthopaedic hospitalist has developed because tal become a verified trauma center. Currently, more than hospitals have engaged physicians and groups willing to ACS-verified trauma centers exist. Such level I trauma provide continuous orthopaedic coverage for all inpatient centers require orthopaedic trauma care to be overseen needs.

The predominant subspecialty group providing by an Orthopaedic Trauma Associationapproved and this service is the orthopaedic traumatologist, because fellowship-trained orthopaedic traumatologist.

Although priately serve the needs of the patient and the trauma still outnumbered by traditional call panels, these hos- community.

The allocation of trauma centers should be pitalist services are increasing in popularity across the based on the needs of the population rather than on the. They may cite patient need, but of coverage.

The orthopaedic trauma community is less may be motivated instead by issues of secondary gain, enthusiastic about this paradigm shift in treatment. Some including a reduction in the number of trauma patients surgeons even assert that the experienced trauma surgeon they would lose in transfer and an increase in the number is being replaced with young inexperienced surgeons at that they repatriate back into their medical systems. These the expense of not only the experienced surgeons but also organizations receive a share of public funds allocated the surrounding community.

Some surgeons think that for trauma care. Within orthopaedic trauma, it has been the orthopaedic surgeon has become commoditized, be- shown that a dedicated trauma center brings considerable cause hospital systems value price over experience. First, the central level I center sees fewer trauma patients, adversely affecting their training programs and Trauma System Models reducing the number of patients available to residents and Trauma hospitals in the United States were created ini- fellows.

Second, emergency department throughput may tially out of need, providing a network of centers spread be improved by the shift to other nearby centers, reduc- out geographically to meet the demands of patients re- ing the treatment time for injured patients in that center.

Over the decades, this system has In the newly established level II and III centers, similar evolved from a collection of independent centers into a opposing phenomena exist.

Bringing a severely injured coordinated network of hospitals offering different levels patient to a trauma center not fully prepared for complex of care. A major goal of the creation of the trauma cen- orthopaedic or other subspecialty care necessitates trans- ter network is to provide nationwide level I trauma care fer to a nearby level I or II hospital better equipped for within a minute transport time. Although the number these patients. The outcome for the patient can potentially of trauma centers has increased dramatically, most are be influenced for the better.

At the same time, some remote rural ar- ment time, which is beneficial for most injuries. Careful eas of the country still lack emergency coverage. Most patients are injured close to and work toward the goal within their local county med- home or work, and the impact on families is reduced ical societies.

Each state assigns a designation level de- when the hospitalized patients are nearby. Families can pending on the needs of the locale and the services the offer more support to the injured patient without having hospital is capable of providing.

At least 1, designated to travel long distances, which could preclude their ability. With the existence of additional Hospitals must exert substantial effort to develop these level II and III hospitals, patients often can be repatriat- systems and to coordinate drills, but they are required ed back to the lower level trauma centers for secondary to be aggressive about disaster and mass-casualty man- orthopaedic and other procedures as required later, when agement, because disasters are not uncommon.

PIPS includes a writ- resources. The system response at the state level. If the governor determines that includes regular internal peer review and regular external the local and state resources are insufficient, FEMA will review and integration with the local and regional trauma be notified. FEMA performs a preliminary assessment system efforts. PIPS uses a model called the Continuous and reports back to the governor.

The governor submits Process of Performance Improvement. The steps involved a letter asking the President to declare the event a disaster begin with recognizing an area of improvement through and uses the FEMA report as evidence to support the data collection and collation, assessing the area through request.

When the President declares a disaster, FEMA analysis, and then improving the area through modifi- determines which federal programs are most appropriate cation and instruction. Trauma centers must be able to to manage the disaster. An MCI declaration indicates authority to effect change, a trauma registry to collect that the number, severity, or diversity of injuries over- data, and assurance that specific PIPS core measures are whelms the local medical resources.

No numeric formula met within the trauma center. Quality improvement at exists for this designation, but a lower-level trauma facili- trauma centers is bound inextricably to the quality of care ty will be overwhelmed much sooner than a larger facility. The individual orthopaedic surgeons integrated into A disaster plan enables hospitals and local emergency a hospitals trauma system must participate in these pro- services to operate within a predictable chain of command grams, because it is necessary for all subspecialties to and provides organization, checklists, accountability, and improve care, not just for the trauma coordinators and a common language to ensure that outside assistance is medical directors.

Continuing education for the ortho- coordinated with internal resources. The plan should out- paedist is a career-long requirement for licensure and the line a protocol by which first responders triage patients, maintenance of board certification and hospital privileges, hospitals prepare for an influx of patients, and the local, but it must include education in trauma care to satisfy the state, and national governments can mobilize resources requirements of the ACS and PIPS.

The protocols may be unfamiliar to many orthopaedic surgeons until an MCI occurs, so the job of the local medical directors and chiefs of staff is to engage Disaster and Mass-Casualty Planning the local physicians during routine drills to familiarize According to the ACS, the surgical community has an them with the process. Overtriage is de- state, and federal government. As a result, trauma centers fined as treating too many patients with minor injuries are required to have hospital disaster plans and biannual and undertriage is defined as delaying the care of criti- drills that integrate local hospitals and emergency services.

Triage should begin at the scene, and hospitals is on call. At the state and national levels, broader resources and The Patient Protection and Affordable Care Act of requirements exist. A governor can mobilize the National will have a varying effect on access to ortho- Guard. An organization known as the National Disas- paedic care in the United States. The costs of emer- ter Medical System partners private organizations with gency orthopaedic care may decline, because fewer governmental entities.

FEMA is perhaps the best-known patients are expected to be uninsured, although federal agency that plays a role in disaster management. This development Surgeons to begin educating orthopaedic surgeons in may improve the coordination of disaster planning disaster response. Trauma centers hospital level.

If the availability of acute care orthopaedic Annotated References surgeons continues to decline, the already challenging task of providing proper care in this environment will 1.

Rotondo MF, C. Chicago: American College of Surgeons. Accessed February 8, The evolution and expan- The ACS publishes a resource guide for trauma centers sion of high-quality trauma centers require surgeons to that includes guidelines required during the verification adapt and function in an evolving system to deliver excel- process.

Orthopaedic 2. Tables 1, complex data-gathering processes, internal and exter- 4, 14, It is incumbent on all orthopaedic surgeons to The Centers for Disease Control and Prevention provides do their part in serving their communities by cooperat- data on emergency department visits and compares them with prior years surveys. All orthopaedic surgeons must receive and DM: How do emergency department physicians rate maintain adequate training to remain proficient in the their orthopaedic on-call coverage?

J Orthop Trauma delivery of acute care and to develop an understanding ;26 1 MedlineDOI of their role in the trauma systems in which they practice.

The authors surveyed a small group of emergency depart- It is the physicians responsibility to serve the needs of ments and found that approximately one-half of the time, departments did not have adequate orthopaedic coverage the community in addition to the needs of the medical at night or on weekends. Patients deserve expert care irrespective of who.

It was intended to care surgery curriculum. J Trauma Acute Care Surg lower the uninsured rate by expanding insurance coverage ;78 2 , discussion Medline DOI and to reduce the costs of health care for individuals and The authors describe the origins of the Acute Care Surgery the government. Although its focus is on general surgical trauma and acute care 5.

Harris MB: Massachusetts health care reform and or- procedures, the curriculum lists desired cases including thopaedic trauma: Lessons learned. J Orthop Trauma extremity procedures such as reductions, placement of ;28 suppl10 :SS MedlineDOI traction, fasciotomies, and amputations.

The authors reviewed the experiences of three of the four level I trauma centers in Boston with the Massachusetts They found a dramatic reduction in employment horizons: Identification of career destina- the proportion of uninsured orthopaedic trauma patients, tions and opportunities.

J Orthop Trauma ;26 sup- as well as a reduction in the proportion of uncompensated pl1 :SS The authors identified multiple practice patterns currently available to the orthopaedist. J Orthop Trauma ;28 sup- J Orthop Trauma ;27 6 They MedlineDOI reviewed the effect these changes will have on orthopaedic The authors addressed the problems associated with hos- traumatologists.

Kamath GV: A regional assessment of Medicaid access to outpatient orthopaedic care: The influence of population Bray TJ: Orthopaedic Traumatology: More than a surgi- density and proximity to academic medical centers on calist: Modified with permission from American Acade- patient access.

J Bone Joint Surg Am ;96 18 :e J Orthop Trauma ;27 8 The authors selected orthopaedic practices and made fic- MedlineDOI titious appointments for a few specific problems. Differ- The author described his position regarding the changes in ences in wait time for an appointment were noted, based the delivery of orthopaedic care, warning of the potential on whether the fictional patient had Medicaid or private pitfalls associated with the surgicalist model.

Access to orthopaedic care was reduced sub- stantially for patients on Medicaid. Van Haitsma M: Patients who cant get an appointment go to the ER: Access to specialty care for publicly in- In examining specific mass-casualty incidents in the Unit- sured children. Ann Emerg Med ;61 4 Existing technology was reviewed and opportunities for In this study, children who were referred from a primary improvement were identified and explored. The more effective means to attain referral was cess to trauma centers in the United States.

JAMA through the emergency department. Arch Intern Med ; 11 Accessed on February 8, The authors reviewed more than 25, diagnoses and The ACS website contains periodic bulletins on relevant transfers from various hospitals over an 8-year period.

This bulletin explains They found that, for certain diagnoses, transfer was more that increasing the number of trauma centers should be. Prehosp Emerg Care ;18 3 The ;91 1 Level of evidence: III. Chan L: The effect of trauma center designation and trau- ma volume on outcome in specific severe injuries. Ann Joint Commission Resources, Inc. Injury ;45 3 MedlineDOI aging resources and establishing leadership roles within the hospital system.

This cohort did not observe any benefit of volume or des-. Level of evidence: I. Chapter 3. Abstract need for orthopaedic trauma coverage exists at these centers, several barriers to access have developed. A singular rela- for musculoskeletal injuries, the rising practice overhead tionship exists between the orthopaedic traumatologist costs, and the declining number of orthopaedic surgeons and the facility in which he or she operates. The surgeon who are comfortable taking trauma call emphasize the relies on the facility to supply the platform from which continued need for orthopaedic specialists with advanced the craft of orthopaedic traumatology may be practiced, training in fracture care to be supported by the hospitals and the hospital relies on the orthopaedic traumatolo- and communities they serve.

Establishing and maintaining a career within for those completing fellowship training in orthopaedic the field of orthopaedic trauma requires the hospital traumatology.

American College of Surgeons ACS and the addition of a fellowship-trained orthopaedic traumatologist to the facility benefits the entire community. Patient survival Keywords: orthopaedic trauma; contract; practice rates increase, length of stay declines within trauma types; practice resources systems, 3,4 and transfer to hospitals farther away from family support can be avoided.

Hospitals benefit by more efficiently using the resources of orthopaedic trau- Introduction matologists rather than those of general orthopaedic Fracture care constitutes a considerable burden of disease surgeons. Given similar fracture cases, traumatologists within the United States. Trau- injuries to be complex enough to benefit from the services matologists are less likely to transfer patients from their of a physician with specialized training and interest in facilities and are more likely to treat fracture cases at the field of orthopaedic traumatology.

Although the rewarding financially. Trau- ma centers provide a platform for fracture surgeons to Dr. Murtha or an immediate family member serves as a practice a skill set that interests them and can provide board member, owner, officer, or committee member of support for the creation of a successful and sustainable the American Academy of Orthopaedic Surgeons.

Orthopaedic with increasingly complex injuries. Trauma centers are trauma surgeons and trauma facilities can form symbiotic designated level I to level IV, with level I facilities able to relationships through the creation and maintenance of an accept the most complex patients.

Regional trauma net- orthopaedic trauma service. In addition to providing a works are constructed, and trauma center designations high level of patient care, meeting the needs of the surgeon are determined by governmental bodies based on the and the hospital is a key goal of the professional relation- needs of the surrounding populations.

The hospitals trau- ship between these parties. Hospital goals typically are ma-level designation indicates the support services that financially driven. They include cost containment through are available within the facility as well as the training of the delivery of efficient care and maximizing revenue the orthopaedic traumatologist. The orthopaedic care of potential.

Hospitals also must establish and maintain trauma patients within level 1 facilities must be overseen trauma verification by the state or the ACS. When con- by an individual who has completed a fellowship in or- 1: General Topics.

Both parties include operating room availability, the presence of other must be willing work together. The professional rela- medical services, including plastic surgery, neurosurgery, tionship between the surgeon and the facility is created and vascular surgery, and the availability of radiology within a negotiated framework that is transparent and technicians, operating room staff, and therapy services. Longevity in orthopaedic trauma is the goal of every Opportunity for practice growth and the development surgeon and should be supported by the facility and the of a trauma niche or nontrauma focus should be consid- practice partners.

Burnout from the lack of general trau- ered when evaluating a practice opportunity. The needs ma surgeon and service line support and the creation of of the trauma facility, its relationship with local orthopae- a trauma model that lacks long-term vision can create dic practices, the trauma volume, projections for trauma an environment that is not sustainable.

A clear under- activations, and the numbers of specific injury types seen standing by the surgeon and the hospital of the essential will affect the feasibility of the development of a trauma elements required to maintain a well-functioning trauma niche or the growth of a nontrauma-related practice op- system is vital Table1.

Transparent, nonadversarial portunity. The cultivation of surgical interest beyond the negotiations facilitate the development of an agreement scope of the trauma practice can have a positive effect on between the surgeon and the hospital, which is critical the surgeons value to the hospital by augmenting the vol- to the long-term success of the relationship.

Strategies for ume of patients with health insurance the surgeon treats achieving career sustainability within the field of trauma at the facility. If the surgeon desires the development of should be considered from the beginning of the communi- a niche or nontrauma practice, the regional market con- cation process.

Although short-term goals are important, ditions for that type of practice must be considered. The a lack of vision for the future will ensure the lack of any practice environment, including the hospital and potential future, or one that is less than fulfilling for all parties and partners or local orthopaedic surgeons, must support the increases the chances of system collapse.

Trauma operat- ing room coverage by other orthopaedic surgeons can be negotiated. Referrals of patients whose orthopaedic Practice Selection needs fit the nontrauma interests of the traumatologist The orthopaedic traumatologist generally practices his or should be discussed with the hospital and the local or- her craft within a hospital system.

For this reason, the thopaedic practices. If the local orthopaedic surgeons are hospitals trauma-level verification and designation is an not aware of the nontrauma orthopaedic interests of the important consideration for the traumatologist. It will de- traumatologist, they may view an attempt to cultivate a termine the type of practice a physician can build within practice beyond the scope of trauma as an intrusion that that particular setting. A hospitals patient volume, injury could lead to an acrimonious relationship.

The adequacy of the trauma centers resources practice or academic practice models. Both types allow. Table 1 Orthopaedic Trauma Service Needs Hospital-based support staff OR staff with knowledge of orthopaedic equipment and use Radiology technicians with experience and training in the intraoperative use of the C-arm in orthopaedic cases Physician extenders who can see and treat emergency department patients, make rounds on inpatients, and assist in surgical cases during regular hours and when the surgeon is on call Floor nurses with orthopaedic background Oversight of ongoing training and evaluation of hospital staff Orthopaedic trauma room with staff available 24 hours a day, 7 days a week for urgent and emergent cases Orthopaedic OR available for nonemergent surgical cases 3 to 5 days a week without normal release constraints Continuing medical education support for physicians and staff.

Pri- experience and tend to have a shortsighted focus on fi- vate employment models include multispecialty groups, nancial remuneration and little else. Certainly, financial orthopaedic specialty groups, subspecialization of ortho- considerations play an important role in brokering an paedic traumatologists, and solo practice.

Remuneration agreement, but other factors must be taken into consid- within private practice typically involves a base salary eration. The professional service agreement between the with incentive pay based on a productivity metric, col- hospital or private practice and the trauma surgeon not lections, or a hybrid of both. Academic practice often has only can reward the surgeon financially, but it also can a similar pay structure with additional expectations and increase the likelihood that the job evolves into a healthy, financial incentives based on academic output, including long-term relationship that is beneficial for all parties.

The attainment of tenure, publication, teaching, committee physician has the greatest amount of leverage to obtain memberships, and administrative involvement. Each type demands during negotiations for the first contract. For of practice has its own benefits and pitfalls that must be this reason, careful consideration should be given to the considered carefully.

Nothing is guar- anteed unless it is put into writing; therefore, anything considered critical to the success of the trauma service Contract Structure line should be included in the contract. If deadlines and consequences for failure to. The surgeons professional, financial, and personal costs are Compensation agreements include salary, call stipend, high if the relationship fails.

Developed by the Orthopaedic Trauma Association OTA and published by AAOS, this new edition features chapters on computer-assisted surgery, new technologies, and the diagnosis and management of infection associated with fractures and nonunions.

Explore a completely new section on Nonunions, Malunions and Infections, as well as expanded coverage of pediatric trauma and new chapters on osteoporosis and pathologic bone, DVT prophylaxis in fracture patients, degloving injuries, management of traumatic nerve injuries, femoral neck fractures in the younger patient, and much more.

Whether you focus on orthopaedic trauma or rotate on trauma call, OKU s objective, evidence-based coverage of all aspects of orthopaedic trauma care will help you decide the best approach for every situation. The section editors have worked tirelessly to ensure that their authors have contributed to the common vision of the project as they synthesize large bodies of knowledge.

The authors of this text have done an outstanding job. Senior-level authors have assimilated background information and focused on updates in their given chapters. Even for those who keep current with the literature, this type of update provides a way to easily glean recent developments in areas ranging from orthopaedicrelated basic science to advances in surgical options.

Unlike the AA03 Comprehensive Orthopaedic Review test, which summarizes orthopaedic topics, OKU 12 has strived to focus on the key updates in the field. Whether you are in training and rotating on a service, preparing for your boards or recertification, or keeping up to date in the field, OKU 12 has much to offer.

I hope that this text will be of use to many. I would like to acknowledge my wife, Janie Merkel, and my two daughters, Julia and Jemma, for their support with all of my endeavors. I would also like to thank my parents, Betsy and Leonard Grauer, for setting me on my career path and always being there for me. And finally, I would like to thank Dr. Gary Friedlaender and all of my mentors, colleagues, residents, and students for keeping me on track and up to date. Chapter 1. Orthopaedic Research Alexander S.

Chapter 2. Leopold, MD. Chapter 3. Waddell, MD; William J. Chapter 4. Anderson, MD; S. Chapter 5. Chapter 7. Chapter 9. Coagulation and Blood Management Todd P. Pierce, MD; Vincent K. Scillia, MD; Michael A. Mont, MD. Chapter Musculoskeletal Biomechanics Marjolein C. Wright, PhD; Julia T. Chen, MS. Musculoskeletal Imaging Principles John A. Mintz, MD; O.

Kenechi Nwawka, MD. Bone and Calcium Metabolism Brian J. Kelopak mata dapat menutup dengan cepat untuk mengadakan perlindungan dari benda asing, dan mata dapat mentoleransi tabrakan kecil tanpa kerusakan. Walau demikian, trauma dapat merusak mata, terkadang sangat parah dimana terjadi kehilangan penglihatan, dan lebih jauh lagi, mata harus di keluarkan. Kebanyakan trauma mata adalah ringan, namun karena luka memar yang luas pada sekeliling struktur, maka dapat terlihat lebih parah dari sebenarnya.

Menurut data dari USEIR, rata-rata umur orang yang terkena trauma okuli perforans adalah pada umur 29 tahun, dan laki-laki lebih sering terkena dibanding perempuan. Pada penelitian ini ditemukan lebih dari setengah kasus disebabkan oleh trauma benda tajam. Manusia memiliki dua buah bola mata yang terletak di dalam rongga orbita yang dikelilingi tulang-tulang yang membentuk rongga orbita.

Selain itu juga terdapat jaringan adneksa mata yaitu : palpebra, sistem lakrimalis, konjungtiva, otot-otot ekstraokular, fasia, lemak,orbita, pembuluh darah dan sistem saraf.

Setiap kelopak terdiri dari bagian anterior dan bagian posterior. Pada kelopak mata terdapat bagian-bagian kelenjar seperti kelenjar sebasea, kelenjar Moll atau kelenjar keringat, kelenjar Zeis pada pangkal rambut, dan kelenjar Meibom pada tarsus. Otot seperti musculus orbikularis okuli yang berjalan melingkar di dalam kelopak mata atas dan bawah, dan terletak di bawah kulit kelopak. Sistem ekskresi mulai pada pungtum lakrimalis, kanalikuli lakrimal, sakus lakrimal, duktus nasolakrimal, dan berakhir di meatus nasi inferior.

Bermacam-macam obat mata dapat diserap melalui konjungtiva ini. Konjungtiva mengandung kelenjar musin yang dihasilkan oleh sel goblet.

Musin bersifat membasahi bola mata terutama kornea. Konjungtiva bulbi dan forniks berhubungan dengan sangat longgar dengan jaringan dibawahnya sehingga bola mata mudah bergerak. Anatomi Konjungtiva. Arteri oftalmika bercabang menjadi arteri retina sentralis, arteri siliaris posterior, dan beberapa arteri siliaris anterior.

Gambar 1. Pada kornea limbus itu menjadi substantia propria kornea stroma. Bagian luar kornea terdiri dari epitel stratified squamous non keratin, yang berubah pada epitel bulbar konjungtiva di limbus kornean dan dibentuk oleh satu lapisan sel endothelial. Membran Bowman berada antara epitel dan stroma dan membran descemet berada antara endothelium dan stroma.

Kekuatan bias kornea adalah sekitar 42 dioptri. Iris tidak memiliki epitel pada aspek anterior, sehingga stroma iris disusun secara radial ke tepi pupil. Iris tertipis terdapat pada bagian margin pupil dan dikelilingi oleh otot sfingter papillae diatur oleh persarafan parasimpatis melalui saraf oculomotor , yang menghasilkan kontraksi pupil miosis.

Pada margin pupil, iris secara luas terhubung dengan badan siliar. Serabut otot dilatators berfungsi untuk kontraksi yang membuat pupil menjadi dilatasi mydriasis. Di sudut iridocorneal, humor aquous mengalir melalui celah-celah di ligamnetum pectinate dari iris trabecular meshwork ke dalam kanal Schlemm. Ini adalah lensa cembung ganda, dengan permukaan anterior kurang melengkung dari permukaan posterior.

Lensa shell, yang mengelilingi inti konsentris terletak di bawah kapsul lensa. Dengan konsistensi gelatin karena adanya asam hyaluronic, mucopolysaccharides, dan kolagen fibril. Selain arteri dan vena, juga membawa sekitar saraf siliar. Hal ini dipisahkan dari retina oleh Membran Bruch , yang mempunyai ketebalan 2 pM. Badan siliar ditutupi oleh bilaminar epithelium yang bertanggung jawab untuk produksi aqueous humor.

Ruang Anterior dan posterior bersama-sama mengandung sekitar 0,,3 ml aqueous humor, yang sebagian besar mengalir keluar di sudut iridocorneal. Bagian dari badan siliar adalah otot siliar , yang merupakan serat otot polos yang diatur secara meridional, sirkuler, dan radial diatur oleh persarafan parasimpatis melalui saraf oculomotorius yang dominan.

Kontraksi otot menyebabkan berkurangnya serat zonular sehingga terjadi peningkatan kelengkungan lensa dan terjadilah akomodasi. Bagian anterior tidak memiliki epitel sensorik dan mencakup badan siliar dan iris sebagai epitel bilaminar. Pusat arteri retina dan vena bersatu di pintu masuk saraf optikus disc optik atau papilla. Macula lutea titik kuning terdapat pada bagian lateral dengan fovea centralis di pusatnya yang merupakan situs maksimum ketajaman vi sual. Lapisan pigmen terdiri dari satu lapisan epitel isoprismatic retinal pigmen epitel.

Retina terdiri dari sel fotoreseptor dan sembilan lapisan yang diidentifikasi dari lapisan otak. Mereka adalah sel epitel sensorik primer Sekitar juta batang dan sel kerucut 6- 7 juta. Hanya ada sel kerucut dalam fovea centralis. Terdapat sel bipolar yang merupakan neuron kedua saraf optik yang berada di lapisan nukleus dalam yang berfungsi untuk mempertahankan kontak sinaptik dengan sel sensorik di lapisan plexiform luar dengan sel ganglion multipolar dari lapisan ganglion neuron ketiga di lapisan plexiform, dimana impuls sensorik disalurkan dalam serabut saraf unmyelinated ke disk optic.

Closed-globe injury merupakan suatu keadaan dimana dinding mata sklera dan kornea tidak memiliki luka yang sampai menembus seluruh lapisan- lapisan ini namun tetap menyebabkan kerusakan intraokuler, termasuk di dalamnya : - Contusio.

Merupakan jenis closed-globe injury yang disebabkan oleh trauma tumpul. Kerusakan yang timbul dapat ditemukan pada lokasi benturan atau pada lokasi yang lebih jauh dari benturan. Merupakan jenis closed-globe injury yang dicirikan dengan luka yang tidak sepenuhnya menembus lapisan sklera dan kornea partial thickness wound yang disebabkan oleh benda tajam maupun benda tumpul. Open-globe injury merupakan jenis trauma yang berkaitan dengan luka yang sampai menembus keseluruhan lapisan dinding dari sklera, kornea, atau keduanya.

Termasuk didalamnya ruptur dan laserasi dinding bola mata. Luka yang timbul disebabkan oleh peningkatan tekanan intraokuler secara tiba-tiba melalui mekanisme trauma inside-out. Luka yang dihasilkan merupakan akibat mekanisme luar ke dalam outside-in , termasuk di dalamnya : o Trauma penetrasi merujuk pada laserasi tunggal dari dinding mata yang disebabkan oleh benda tajam o Trauma perforasi merujuk pada dua laserasi pada dinding mata dengan ketebalan penuh satu masuk dan satu keluar yang disebabkan oleh benda tajam.