Tindakan torakosentesis

Indikasi torakosentesis adalah :

(2)

1. efusi parapneumonik yang mengalami komplikasi atau empiema 2. mengurangi rasa sesak nafas 3. evaluasi dasar penyakit paru kronik Pada tindakan torakosentesis perlu diperhatikan : cara aspirasi cairan dengan terarah arum yang miring. dikeluarkan cairan !P sampai 1"""- 12"" ml sekali am#il lakukan monitoring dengan o$ymeter agar saturasi %&"'. Pasca torakosenstesis dapat hipoksemia ter adi aki#at reaksi paradoksal pada perluasan area dengan rasio ()* yang rendah+ dan edem paru unilateral aki#at reekpansi paru. dapat dilakukan aspirasi ulangan #ila ada indikasi+ namun #ila selalu ter#entuk cairan kem#ali perlu dipertim#angkan tindakan pleurodesis.

Thoracentesis
Overview

Background
,horacentesis (thoracocentesis) is a core procedural skill for hospitalists+ critical care physicians+ and emergency physicians. -ith proper training in #oth thoracentesis itself and the use of #edside ultrasonography+ providers can perform this procedure safely and successfully..1+ 2/ 0efore the procedure+ #edside ultrasonography can #e used to determine the presence and si1e of pleural effusions and to look for loculations. 2uring the procedure+ it can #e used in real time to facilitate anesthesia and then guide needle placement.

Indications
,horacentesis is indicated for the symptomatic treatment of large pleural effusions (see the images #elo3) or for treatment of empyemas. It is also indicated for pleural effusions of any si1e that re4uire diagnostic analysis..3/

Image of a 48-year-old woman with cancer and large left pleural effusion (2.5 liters were removed). The patient was tachypneic hypo!ic and reported

pleuritic chest pain. patient shown a#ove.

"hest radiograph after thoracentesis of the cancer

,ransudative effusions result from decreased plasma oncotic pressures and increased hydrostatic pressures. 5eart failure is #y far the most common cause+ follo3ed #y liver cirrhosis and nephrotic syndrome. !$udative effusions result from local destructive or surgical processes that cause increased capillary permea#ility and su#se4uent e$udation of intravascular components into potential spaces. 6auses are manifold and include pneumonia+ empyema+ cancer+ pulmonary em#olism+ and numerous infectious etiologies.

Contraindications
,here are no a#solute contraindications for thoracentesis. 7elative contraindications include the follo3ing:

$ncorrected #leeding diathesis "hest wall cellulitis at the site of puncture

Periprocedural Care

Patient Education/Informed Consent

0efore thoracentesis+ it is important to pay attention to the consent process and provide a focused set of risks and complications+ so that the patient is not surprised if he or she e$periences adverse effects..8/ 6onsent should #e o#tained from the patient or family mem#er. ,he reason the procedure is #eing performed (suspected diagnosis)9 the risk+ #enefits+ and alternatives of the procedure9 the risks and #enefits of the alternative procedure9 and the risk and #enefits of not undergoing the procedure. :llo3 the patient the opportunity to ask any 4uestions and address any concerns they may have. ;ake sure that they have an understanding a#out the procedure so they can make an informed decision. ,he patient should #e counseled a#out the risks of pneumothora$+ hemothora$+ lung laceration+ infection+ empyema+ damage to the intercostals+ or internal mammary vessels+ diaphragmatic in ury+ puncture of the liver or spleen+ damage to other a#dominal organs+ a#dominal hemorrhage+ ree$pansion pulmonary edema+ air em#olism+ cough+ pain+ and catheter fragment left in the pleural space. 2iscuss ho3 these risks can #e avoided or prevented (eg+ proper positioning+ ensuring that the patient remains as still as possi#le during the procedure+ ade4uate analgesia).

Equipment
<everal commercially availa#le medical devices are specifically designed for performing thoracentesis. <uch devices include the follo3ing:

%rrow-"lar&e Thoracentesis 'evice (Telefle! (edical )esearch Triangle *ar& +") %rgyle Tur&el ,afety Thoracentesis ,ystem ("ovidien (ansfield (%) "ritical "are Thoracentesis ,et ("oo& (edical -loomington I+)

If a commercial use-specific device is not availa#le+ all of the necessary e4uipment can #e o#tained from the supplies located in most inpatient settings+ critical care units (66=s)+ or emergency departments (!2s).

Thoracentesis device - This typically consists of an 8-.rench catheter over an /8gauge 0.5-in. (/1-cm) needle with a 2-way stopcoc& and ideally a self-sealing valve ,elf-assem#led device if a thoracentesis device is unavaila#le - 3ptions include using an /8-gauge needle or a /2-gauge intravenous (I4) catheter connected to a 56-m7 syringe and then to a stopcoc& after the needle is removed from the 56-m7 syringe In8ection needle 9 22 gauge /.5 in. (2.8/ cm) In8ection needle 9 25 gauge / in. (2.54 cm) 7uer-7o& syringe - /6 m7 7uer-7o& syringe - 5 m7 7uer-7o& syringe - 56 m7 Tu#ing set with aspiration:discharge device %ntiseptic - "hlorhe!idine solution ;<i#iclens= is preferred 7idocaine - /> or 2> solution /6-m7 ampule ,pecimen cap for 56-m7 syringe ,pecimen vials or #lood tu#es 'rainage #ag or vacuum #ottle 'rape - 24 ? 26 in. with 4-in. fenestration with adhesive strip ,terile towels ,calpel - +o. // #lade %dhesive dressing - 0.5 ? 2.5 cm @auAe pad(s) - 4 ? 4 in.

Patient Preparation
Patient preparation includes ade4uate anesthesia and proper positioning.

Anesthesia
In addition to local anesthesia+ mild sedation may also #e considered. I( mida1olam or lora1epam can attenuate the an$iety that may #e associated 3ith any invasive procedure. :nalgesia is critically important+ in that pain is the most common complication of thoracentesis. >ocal anesthesia is achieved 3ith generous local infiltration of lidocaine. ,he skin+ su#cutaneous tissue+ ri# periosteum+ intercostal muscle+ and parietal pleura should all #e 3ell infiltrated 3ith local anesthetic. It is particularly important to anestheti1e the deep part of the intercostal muscle and the parietal pleura #ecause puncture of these tissues generates the most pain. Pleural fluid is often o#tained via aspiration during anesthetic infiltration of these deeper structures9 this helps confirm proper needle location.

Positioning
Patients 3ho are alert and cooperative are most comforta#le in a seated position (see the image #elo3)+ leaning slightly for3ard and resting the head on the arms or hands or on a pillo3+ 3hich is placed on an ad usta#le #edside ta#le. ,his position facilitates access to the posterior a$illary space+ 3hich is the most dependent part of the thora$. =nsta#le patients and those 3ho are una#le to sit up may #e supine for the procedure.

3ne option for proper positioning of patient. Basy access to the 0-1 ri# space along the posterior a!illary line.

,he patient is moved to the e$treme side of the #ed+ the ipsilateral hand is placed #ehind the head+ and a to3el roll is placed under the contralateral shoulder. ,his measure facilitates dependent drainage and provides good access to the posterior a$illary space.

Technique

Approach Considerations
Proper personnel resources should #e ensured+ appropriate e4uipment collected+ and diagnostic la#oratory studies preordered+ as necessary. ,he clinician should #ecome comforta#le 3ith the e4uipment availa#le at the facility. If necessary+ an unused kit or one from an a#orted procedure may #e opened to permit evaluation of the components. ,he clinician should like3ise #ecome comforta#le 3ith the ultrasound machine and learn ho3 to ad ust key functions such as depth and overall gain. :n$iolysis should #e considered and good local analgesia provided. ,horacentesis can #e fraught 3ith patient an$iety+ and pain is the most common complication. If mild sedation is

#eing considered+ intravenous (I() medications should #e administered to the patient in advance. ,he patient should #e positioned appropriately. ,horacentesis can #e performed 3ith the patient sitting upright and leaning over a ;ayo stand or 3ith the patient supine (via an a$illary approach).

Thoracentesis (Thoracocentesis)
,horacentesis is performed as follo3s..?/

Bedside ultrasonography
:fter the patient has #een positioned+ ultrasonography is performed to confirm the pleural effusion+ assess its si1e+ look for loculations+ and determine the optimal puncture site. !ither a curvilinear transducer (2-? ;51) or a high-fre4uency linear transducer (@.?-1 ;51) may #e used (see the image #elo3). ,he diaphragm is #rightly echogenic and should #e clearly identified. Its e$act location throughout the respiratory cycle should #e determined. It is important to select a ri# interspace into 3hich the diaphragm does not rise up at ende$halation.

$ltrasound image using curvilinear pro#e. Image shows chest wall and large volume of pleural fluid.

;otion-mode (;-mode) ultrasonography can also #e used to determine the depth of the lung and the amount of fluid #et3een the chest 3all and the visceral pleura (see the image #elo3). Areely floating lung can #e seen as 3avelike undulations on the ;-mode tracing.

$ltrasound image in (-mode showing sinusoidal wave pattern. This is created #y the lung moving within the large pleural effusion during respiration. The depth of the lung and the amount of fluid #etween the parietal pleura (adherent to the chest wall) and visceral pleura (adherent to lung tissue) are easily measured with ultrasonography.

0edside ultrasonography is a useful guide for thoracentesis: It can determine the optimal puncture site+ improve the administration of local anesthetics+ and+ most important+ minimi1e the complications of the procedure..2/ ,he optimal puncture site may #e determined #y searching for the largest pocket of fluid superficial to the lung and #y identifying the respiratory path of the diaphragm (see the video #elo3). ,raditionally+ this is #et3een the @th and &th ri# spaces and #et3een the posterior a$illary line and the midline. 0edside ultrasonography can confirm the optimal puncture site+ 3hich is then marked.
4ideo clip of ultrasound using the linear pro#e. Image demonstrates 2 ri#s with their associated acoustic shadows ri# interspace pleural fluid and the presence of the diaphragm rising up into this ri# interspace.

Preparation of puncture site

<tandard aseptic techni4ue is used for the remaining steps of the procedure. <terile pro#e covers are availa#le and should #e used if thoracentesis is performed under real-time ultrasonographic guidance. : 3ide area is cleaned 3ith an antiseptic #acteriostatic solution..B/ 6hlorhe$idine solution is preferred for preparing the skin (see the image #elo3)9 it dries faster and is far more effective than povidone-iodine solution.

%pplication of chlorhe!idine solution.

: sterile drape is placed over the puncture site (see the first image #elo3)+ and sterile to3els are used to esta#lish a large sterile field 3ithin 3hich to 3ork (see the second image #elo3).

,terile drape with fenestration and adhesive strip placed over

puncture site with sterile towels draping a large wor& area. towels on the #ed creating a large sterile wor& space.

,terile

If the patient has loose skin or significant su#cutaneous tissue+ the puncture site can #e optimi1ed #y using 3-in. tape to pull the skin or su#cutaneous tissue out of the 3ay #efore marking the spot and cleaning the puncture site. ,he skin+ su#cutaneous tissue+ ri# periosteum+ intercostal muscles+ and parietal pleura should #e 3ell infiltrated 3ith anesthetic (lidocaine 1-2') (see the image #elo3). Infiltration can also #e guided #y real-time ultrasonography using a high-fre4uency linear transducer (@.?-1" ;51).

%dministering anesthesia to the s&in su#cutaneous tissue ri# periosteum intercostal muscle and parietal pleura.

Insertion of de ice or catheter and drainage of effusion

If a commercially availa#le device or a large intravenous catheter is #eing used+ the skin should #e nicked 3ith a Co. 11 scalpel #lade to reduce drag as the catheter is advanced through the skin (see the image #elo3).

+ic&ing the s&in with scalpel to reduce s&in drag as the catheter is advanced through the s&in.

-ith aspiration initiated+ the device is advanced over the superior aspect of the ri# until pleural fluid is o#tained (see the image #elo3). ,he neurovascular #undle is located at the inferior #order of the ri# and should #e avoided.

%dvancing the device over the superior aspect of the ri#.

;ost commercial devices have a marker at ? cm (see the image #elo3). :t this depth+ the hemithora$ is usually entered+ and the needle need not need #e advanced any further.

The 5-cm mar& is at the level of the s&in.

,he catheter is then fed over the needle introducer (see the first image #elo3). In most cases+ it can #e fed all the 3ay to the hu# (see the second image #elo3).

.eeding the catheter over the needle introducer.

The catheter is fed all the way to the hu#.

-ith either a syringe pump or a vacuum #ottle+ the pleural effusion is drained until the desired volume has #een removed for symptomatic relief or diagnostic analysis (see the image #elo3).

$se the manual syringe pump method or a vacuum #ottle. The syringe pump method (shown here) is more la#or intensive and can cause thum# neurapra!ia in the operator.

Completion of procedure
,he catheter or needle is carefully removed+ and the 3ound is dressed. If there is any dou#t+ pleural fluid should #e sent for diagnostic analysis (see #elo3)9 in practice+ diagnostic analysis is almost al3ays necessary. ,he patient is repositioned as appropriate for his or her comfort and respiratory status. Ainally+ a procedure note is 3ritten+ commenting specifically on the descriptive characteristics of the pleural fluid.

!iagnostic Analysis of Pleural "luid

Pleural fluid is la#eled and sent for diagnostic analysis. If the effusion is small and contains a large amount of #lood+ the fluid should #e placed in a #lood tu#e 3ith anticoagulant so that it does not clot. ,he follo3ing la#oratory tests should #e re4uested:

p< level @ram stain culture "ell count and differential @lucose level protein levels and lactic acid dehydrogenase (7'<) level "ytology "reatinine level if urinothora! is suspected (eg after an a#dominal or pelvic procedure) %mylase level if esophageal perforation or pancreatitis is suspected Triglyceride levels if chylothora! is suspected (eg after coronary artery #ypass graft ;"%-@= especially if the inferior mesenteric artery ;I(%= was usedC mil&y appearance is not sensitive)

!$udative pleural fluid can #e distinguished from transudative pleural fluid #y looking for the follo3ing characteristics (e$udates have 1 or more of these characteristics+ 3hereas transudates have none):

.luid:serum 7'< ratio D 6.5 .luid:serum protein ratio D 6.5 .luid 7'< level within the upper two thirds of the normal serum 7'< level

Complications of Procedure
6omplication rates for thoracentesis performed #y e$perienced clinicians are not availa#le. 5o3ever+ data on complications that develop after thoracentesis performed #y residents learning the procedure are availa#le..@+ 1/ ;a or complications include the follo3ing:

*neumothora! (//>;8= ) <emothora! (6.8>) 7aceration of the liver or spleen (6.8>) 'iaphragmatic in8ury Bmpyema Tumor seeding

;inor complications include the follo3ing:

*ain (22>) 'ry tap (/2>) "ough (//>) ,u#cutaneous hematoma (2>) ,u#cutaneous seroma (6.8>) 4asovagal syncope
o

*eru#ahan *atologi atau *atofisiologi Tulang #ersifat terlalu rapuh namun cu&up mempunyai &e&uatan dan daya

tahan pegas untu& menahan te&anan tulang yang mengalami fra&tur #iasanya dii&uti &erusa&an 8aringan se&itarnya. .ra&tur ini suatu permasalahan yang &omple&s &arena pada fra&tur terse#ut tida& dilu&ai lu&a ter#u&a sehingga dalam mereposisi fra&tur terse#ut perlu pertim#angan dengan fi&sasi yang #ai& agar tida& tim#ul &ompli&asi selama reposisi. *enggunaan fi&sasi yang tepat yaitu dengan internal fi&sasi 8enis plate and screw. 'ila&u&an operasi terhadap tulang ini #ertu8uan mengem#ali&an posisi tulang yang patah &e normal atau posisi tulang sudah dalam &eadaan se8a8ar sehingga a&an ter8adi proses penyam#ungan tulang yang menurut (%ppley )onald /115). ,tadium penyem#uhan fra&tur melalui #e#erapa tahap antara lain dapat dilihat pada ta#elE Ta#el 2.5 Tahap-tahap atau proses penyem#uhan tulang
5ematoma ,ulang ,ulang patah Proliferasi <el-sel Dalsifikasi Earingan Donsolidasi 6allus yang 7emodeling ,ulang

mengenai pem#uluh darah ,er#entuk hematoma di sekitar pepatahan 5ematoma di#entuk aringan lunak di sekitarnya Permukaan tulang yang patah tidak mendapatkan supplay 0erlangsung selama28 am setelah ter adi perpatahan

periosteum dan endosteum paling menon ol pada tahap proliferasi Proliferasi dari sel-sel dalam periosteum yang menutupi fraktur+ sel-sel ini merupakan tum#uhnya osteo#last :kan melepaskan unsur-unsur intraseluler dan kemudian men adi fragmen lain 0erlangsung selama 3-8 hari

seluler yang keluar dari masing-masing fragmen yang sudah matang

#elum masak akan mem#entuk callus 0erlangsung

menyam#ung atau mem#entuk #aik dari luar maupun dari dalam canalis medularis. Fsteo#last

<el-sel mem#eri perlengkapan untuk osteo#last. 6ondo#last mem#entuk callus yang #elum masak dan mem#entuk endolan. :danya rigiditas pada fraktur 0erlangsung selama B-12 minggu

#ertahap dan #eru#ah-u#ah :danya aktivitas osteo#last men adi tulang le#ih kuat dan masa strukturnya #erlapis-lapis 0erlangsung setelah 12-18 minggu

menga#sor#si pem#entukan tulang yang le#ih. 0erlangsung selama 28 minggu sampai 1 tahun

Ta#el 2.5 Tahap-tahap atau proses penyem#uhan otot

Peradangan 7adang adalah mekanisme pertahanan diri pada otot yang terluka. 7eaksi radang menye#a#kan musnahnya agen yang mem#ahayakan dan mencegah penye#aran yang luas. 7adang uga Proliferasi ,er adinya per#aikan aringan epitelium dan aringan penghu#ung (connectifity). !pitelium adalah lapisan yang mem#entuk epidemis kulit dan lapisan permukan mukosa. Earingan penghu#ung adalah aringan yang terdapat pada aringan ekstra selular. Ai#rio#rasi akan #erguna pada daerah yang mengalami peradangan #emodeling ,er adi pem#entukan matrik aringan connective dan se#agai fase penguatan aringan parut+ aringan kolagen dilepaskan oleh fi#riosis serta aringan connective masih #ersifat lunak.

Ftot

menye#a#kan aringan yang cidera diper#aiki atau diganti yang #aru. ,anda-tanda radang: 0engkak (tumor)+ #er3arna kemerahan (ru#on)+ panas (kalor)+ gangguan gerak (fungsiolesi)

dengan mem#entuk fi#rin+ lalu akan mem#entuk aringan parut yang akan menyokong tensil strength untuk per#aikan. 2isaat yang #ersamaan sel endotel #aru #erkem#ang. <etelah #erlangsung selama @ hari degenerasi protein miofi#ril akan #erlangsung secara perlahan-lahan yang diikuti dengan serangan phagocytic. <el-sel otot yang mati akan #erpindah.

Frganisasi se a ar masih ter#entuk pada permukaan luka sehingga akan memelihara tensil strength. Camun kekuatan ma$imum dari aringan parut hanya @"' dari aringan normal.

Ta#el 2.0 Tahap-tahap atau proses penyem#uhan &ulit

#adang Pada 28 am pertama akan mengalami reaksi radang yang mendadak. 5al-hal di #a3ah merupakan ke adian hislogik yang ter adi 8G am pertama penyem#uhan luka. G am+ meluasnya area aringan yang mengalami nekrosis pada kedua sisi sayatan. 1B am epitelium yang terletak antara aringan yang masih hidup dengan aringan nekrotik mengalami pene#alan 28 am ke 2+ epitel yang #erasal dari aringan epitel yang masih hidup dan #erinvasi mendekatkan ke 2 u ungnya. 8" sampai 8G am kedua+ epitel terse#ut akan #ertemu dan mem#uang nekrotik dari Poliferasi <etelah 3-& hari epitel akan menutup kem#ali keratin dan meluasnya permukaan luka yang #erkem#ang. !pidermis yang #erhu#ungan dengan selokan #erkurang karena mutasi atau perpindahan+ dari fi#ro#ast dan terisi oleh aringan granulasi+ aringan granulasi tersusun dari epitelialossel. Ai#ro#last yang melepaskan collagen yang digunakan untuk pem#entukan #ekas luka dan kapiler mem#antu ter#entuknya aringan parut yang kemerahan. Earinan garnulasi akan ter#entuk #erdasarkan ter adinya luka. <e#elum permukaan epitel terse#ut ter#entuk+ aringan granulasi yang #aru Cicatrik ;erupakan fase pem#entukan aringan parut permanen aringan parut terse#ut akan #erkonstruksi dan pem#uluh darah yang terdapat didalamnya akan dilenyapkan+ sehingga aringan parut #eru#ah putih+ colagen men adi kuat+ #ekas luka tidak #isa dihilangkan. 0erlangsung #e#erapa minggu sampai #e#erapa #ulan

Dulit

lapisan aringan yang keraktiosa+ lalu keduanya #erga#ung dan menyatu di #a3ah luka dengan memutuskan hu#ungan pada luka yang #ertu uan mengeluarkan perompeng.

#erga#ung dengan fi#ro#last dan kapiler akan #erangsur pulih. >alu secara #erangsur-angsur akan ter adi konstruksi pada luka dipermukaan epitelium.

Ta#el 2.8 Tahap-tahap atau proses penyem#uhan 8aringan luna&

$aringan lunak <iklus perlukaan menye#a#kan reaksi dari aringan mengaki#atkan merusak sel karena trauma+ infeksi+ ischemia+ sekunder atau agen fisik. 7eaksi radang untuk memulai proses healing+ tetapi proses healing tidak ter adi sampai reaksi peradangan reda. 2engan dimulainya respon peradangan maka siklus perlukaan telah terlihat 2alam persendian dan struktur peri artikuler reaksi aringan mengarah kepada reaksi yang #erle#ihan+ synovial men adi hipertensi+ kadang hematrosis dan akhirnya proses ini tidak terle3ati akan ter adi degenerasi. Earingan lunak lainnya reaksi salah satunya adalah oedem dan kadang disertai hemorage. Peru#ahan ini mem#uat peradangan mengarah pada nyeri dan protektif spastik Pem#ekuan 2engan adanya luka yang diikuti pendarahan dan vasokontriksi pada pem#uluh darah. ;ekanisme pem#ekuan+ #iasanya selesai selama ? menit tetapi dapat memakan 28 sampai 3G am ,rom#oplastin+ trom#oplastin (plasma protein) men adi trom#in di#antu en1im trom#o plastin dan lonca trom#in serta fi#rinogen #erga#ung mem#entuk fi#rin yang akhirnya fi#rin #ersama platelest men adi #ekuan darah.

Peradangan

7econstitution of communty

2engan istirahat dan terapi yang adekuat akan mempercepat penanganan sehingga respon penyem#uhan dapat ter adi. 0erpengaruh terhadap per#aikan+ regenerasi+ hypertrophy+ pengurangan nyeri+ pengem#alian 7F;+ men adikan aringan normal+ per#aikan kekuatan+ per#aikan pola gerakan normal

Ta#el 2.1 Tahap-tahap atau proses penyem#uhan syaraf

%yaraf $aringan lunak Proses penyem#uhan neufi#ril #agian proksimal cidera menu u distal. Pem#entukan selu#ung myelin dari selu#ung chutan terus #erkem#ang+ neurofi#ril tum#uh di sekeliling protoplasma. Pertum#uhan ini ter adi 1 mm)hari. 0ila selu#ung myelin sem#uh sempurna maka fungsi syaraf akan pulih. ,anda a3alnya #ila disentuh akan terasa nyeri pada syaraf. Proses per#aikan syaraf tergantung dari: Pan ang luas yang mengalami cidera+ teknik pem#edahan+ lama 3aktu penyem#uhan

Bagaimana fraktur terjadi? Tulang #ersifat relatif rapuh namun cu&up mempunyai &e&uatan dan gaya pegas untu& menahan te&anan. .ra&tur dapat ter8adi a&i#atE /) peristiwa trauma tunggal 2) Te&anan yang #erulang-ulang atau 2) &elemahan a#normal pada tulang (fra&tur patologi&).

Fraktur akibat peristiwa trauma ,e#agian #esar fra&tur dise#a#&an oleh &e&uatan yang ti#a-ti#a dan #erle#ihan yang dapat #erupa pemu&ulan pemuntiran atau penari&an. -ila ter&ena &e&uatan langsung tulang dapat patah pada tempat yang ter&ena 8aringan luna& 8uga pasti rusa&. *emu&uan (pu&uran sementara) #iasanya menye#a#&an fra&tur melintang dan &erusa&an pada &ulit diatasnyaC penghancuran &emung&inan a&an menye#a#&an fra&tur &ominutif disertai &erusa&an 8aringan luna& yang luas (%ppley /115). -ila ter&ena &e&uatan yang tida& langsung tulang dapat mengalami fra&tur pada tempat tang 8auh dari tempat yang ter&ena &e&uatan ituC &erusa&an 8aringan luna& di tempat fra&tur mung&in tida& ada (%ppley /115).

Fe&uatan dapat #erupE /) pemuntiran yang menye#a#&an fra&tur spinalC 2) pene&u&an yang menye#a#&an fra&tur melintangC 2) pene&u&an dan pene&anan yang menga&i#at&an fra&tur yang se#agian melintang tetapi disertai fragmen &upu-&upu #er#entu& segitiga yang terpisahC (4) &om#inasi dari pemuntiran pene&u&an dan pene&anan yang menye#a#&an fra&tur o#li& pende& atau 5) penari&an dimana tendon atau ligament #enar-#enar menari& tulang sampai terpisah (%ppley /115).