fracture nomenclature robert h. belding md. why classify? as a treatment guide to assist with...

Fracture Fracture NomenclatureNomenclature

Robert H. Belding MDRobert H. Belding MD

Why Classify?Why Classify?

As a treatment As a treatment guideguide

To assist with To assist with prognosisprognosis

To speak a To speak a common language common language with others in order with others in order to compare resultsto compare results

As a Treatment GuideAs a Treatment Guide

If the same bone is If the same bone is broken, the broken, the surgeon can use a surgeon can use a standard treatmentstandard treatment

PROBLEM: fracture PROBLEM: fracture personality and personality and variation with variation with equipment and equipment and experienceexperience

To Assist with PrognosisTo Assist with Prognosis

You can tell the You can tell the patient what to patient what to expect with the expect with the resultsresults

PROBLEM: Does PROBLEM: Does not consider the not consider the soft tissues or soft tissues or other compounding other compounding factorsfactors

To Speak A Common LanguageTo Speak A Common Language

This will allow This will allow results to be results to be comparedcompared

PROBLEM: Poor PROBLEM: Poor interobserver interobserver reliability with reliability with existing fracture existing fracture classificationsclassifications

Interobserver Interobserver ReliabilityReliability

Different physicians agree Different physicians agree on the classification of a on the classification of a fracture for a particular fracture for a particular

patientpatient

Intraobserver Intraobserver ReliabilityReliability

For a given fracture, each For a given fracture, each physician should produce physician should produce

the same classificationthe same classification

LiteratureLiterature

94 patients with ankle 94 patients with ankle fracturesfractures

4 observers4 observers Classify according to Classify according to

Lauge Hansen and Lauge Hansen and WeberWeber

Evaluated the Evaluated the precision (observer’s precision (observer’s agreement with each agreement with each other)other)

Thomsen et al, JBJS-Br, 1991

LiteratureLiterature

Acceptable reliabilty Acceptable reliabilty with both systemswith both systems

Poor precision of Poor precision of staging, especialy PA staging, especialy PA injuriesinjuries

Recommend: Recommend: classification systems classification systems should have reliability should have reliability analysis before usedanalysis before used

Thomsen et al, JBJS-Br, 1991

LiteratureLiterature

100 femoral neck 100 femoral neck fracturesfractures

8 observers8 observers Garden’s Garden’s

classificationclassification

Classified Classified identical 22/100identical 22/100

Disagreement b/t Disagreement b/t displaced and displaced and non-displaced in non-displaced in 4545

Conclude poor Conclude poor ability to stage ability to stage with this systemwith this system

Frandsen, JBJS-B, 1988

Closed FracturesClosed Fractures

Fracture is not exposed to the Fracture is not exposed to the environmentenvironment

All fractures have some degree of soft All fractures have some degree of soft tissue injurytissue injury

Commonly classified according to the Commonly classified according to the Tscherne classificationTscherne classification

Don’t underestimate the soft tissue Don’t underestimate the soft tissue injury as this affects treatment and injury as this affects treatment and outcome!outcome!

Closed Fracture ConsiderationsClosed Fracture Considerations

The energy of the The energy of the injuryinjury

Degree of Degree of contaminationcontamination

Patient factorsPatient factors Additional injuriesAdditional injuries

Tscherne ClassificationTscherne Classification

Grade 0Grade 0– Minimal soft Minimal soft

tissue injurytissue injury– Indirect injuryIndirect injury

Grade 1Grade 1– Injury from Injury from

withinwithin– Superficial Superficial

contusions or contusions or abrasionsabrasions

Tscherne ClassificationTscherne Classification

Grade 2Grade 2 Direct injuryDirect injury More extensive soft More extensive soft

tissue injury with tissue injury with muscle contusion, muscle contusion, skin abrasionsskin abrasions

More severe bone More severe bone injury (usually)injury (usually)

Tscherne ClassificationTscherne Classification

Grade 3Grade 3– Severe injury to soft Severe injury to soft

tissuestissues– -degloving with -degloving with

destruction of destruction of subcutaneous subcutaneous tissue and muscletissue and muscle

– Can include a Can include a compartment compartment syndrome, vascular syndrome, vascular injuryinjury

Closed tibia fractureNote periosteal strippingCompartment sundrome

LiteratureLiterature

Prospective studyProspective study Tibial shaft Tibial shaft

fractures treated fractures treated by intramedullary by intramedullary nailnail

Open and closedOpen and closed 100 patients100 patients

Gaston, JBJS-B, 1999

LiteratureLiterature

What predicts What predicts outcome?outcome? Classifications Classifications used:used:– AOAO– GustiloGustilo– TscherneTscherne– Winquist-Hansen Winquist-Hansen

(comminution)(comminution)

All x-rays reviewed by All x-rays reviewed by single physiciansingle physician

Evaluated outcomesEvaluated outcomes

UnionUnion

Additional surgeryAdditional surgery

InfectionInfection

Tscherne classification Tscherne classification more predictive of more predictive of outcome than othersoutcome than others

Gaston, JBJS-B, 1999

Open FracturesOpen Fractures

A break in the skin A break in the skin and underlying soft and underlying soft tissue leading tissue leading directing into or directing into or communicating communicating with the fracture with the fracture and its hematomaand its hematoma

Open FracturesOpen Fractures

Commonly described by the Gustilo Commonly described by the Gustilo systemsystem

Model is tibia fracturesModel is tibia fractures Routinely applied to all types of open Routinely applied to all types of open

fracturesfractures Gustilo emphasis on size of skin Gustilo emphasis on size of skin

injuryinjury

Open FracturesOpen Fractures

Gustilo classification used for prognosisGustilo classification used for prognosis Fracture healing, infection and amputation Fracture healing, infection and amputation

rate correlate with the degree of soft rate correlate with the degree of soft tissue injury by Gustilotissue injury by Gustilo

Fractures should be classified in the Fractures should be classified in the operating room at the time of initial operating room at the time of initial debridementdebridement– Evaluate periosteal strippingEvaluate periosteal stripping– Consider soft tissue injuryConsider soft tissue injury

Type I Open FracturesType I Open Fractures

Inside-out injuryInside-out injury Clean woundClean wound Minimal soft tissue Minimal soft tissue

damagedamage No significant No significant

periosteal strippingperiosteal stripping

Type II Open FracturesType II Open Fractures

Moderate soft Moderate soft tissue damagetissue damage

Outside-in Outside-in mechanismmechanism

Higher energy Higher energy injuryinjury

Some necrotic Some necrotic muscle, some muscle, some periosteal strippingperiosteal stripping

Type IIIA Open FracturesType IIIA Open Fractures

High energyHigh energy Outside-in injuryOutside-in injury Extensive muscle Extensive muscle

devitalizationdevitalization Bone coverage Bone coverage

with existing soft with existing soft tissue not tissue not problematicproblematic

Note Zone of Injury

Type IIIB Open FracturesType IIIB Open Fractures

High energyHigh energy Outside in injuryOutside in injury Extensive muscle Extensive muscle

devitalization devitalization Requires a local Requires a local

flap or free flap for flap or free flap for bone coverage and bone coverage and soft tissue closuresoft tissue closure

Periosteal strippingPeriosteal stripping

Type IIIC Open FracturesType IIIC Open Fractures

High energyHigh energy Increased risk of Increased risk of

amputation and amputation and infectioninfection

Major vascular Major vascular injury requiring injury requiring repair repair

LiteratureLiterature

Interobserver Interobserver agreement pooragreement poor– Range 42-94% for Range 42-94% for

each fractureeach fracture Least experienced-Least experienced-

59% agreement59% agreement Orthopaedic Orthopaedic

Trauma Fellowship Trauma Fellowship trained-66% trained-66% agreementagreement

Brumback et al, JBJS-A, 1994

LiteratureLiterature

245 surgeons245 surgeons 12 cases of open 12 cases of open

tibia fracturestibia fractures Videos usedVideos used Various levels of Various levels of

training (residents training (residents to trauma to trauma attendings)attendings)

Brumback et al, JBJS-A, 1994

OTA ClassificationOTA Classification

There has been a need for an There has been a need for an organized, systematic fracture organized, systematic fracture classification classification

Goal: A comprehensive classification Goal: A comprehensive classification adaptable to the entire skeletal adaptable to the entire skeletal system!system!

Answer: OTA Comprehensive Answer: OTA Comprehensive Classification of Long Bone FracturesClassification of Long Bone Fractures

With a Universal With a Universal Classification…Classification…

To…To…

TreatmentTreatment

Implant optionsImplant options

ResultsResults

You go from x-ray….

To Classify a FractureTo Classify a Fracture

Which bone?Which bone? Where in the bone Where in the bone

is the fracture?is the fracture? Which type?Which type? Which group?Which group? Which subgroup?Which subgroup?

Using the OTA ClassificationUsing the OTA Classification

Which bone?Which bone? •Where in the bone?

Proximal & Distal Segment Proximal & Distal Segment FracturesFractures

Type AType A– Extra-articularExtra-articular

Type BType B– Partial articularPartial articular

Type CType C– Complete disruption Complete disruption

of the articular of the articular surface from the surface from the disphysisdisphysis

Diaphyseal FracturesDiaphyseal Fractures

Type AType A– Simple fractures with Simple fractures with

two fragmentstwo fragments Type BType B

– Wedge fracturesWedge fractures– After reduced, length After reduced, length

and alignment restoredand alignment restored Type CType C

– Complex fractures with Complex fractures with no contact between no contact between main fragmentsmain fragments

Grouping-Type AGrouping-Type A

1.1. SpiralSpiral

2.2. ObliqueOblique

3.3. TransverseTransverse

Grouping-Type BGrouping-Type B

1.1. Spiral wedgeSpiral wedge

2.2. Bending wedgeBending wedge

3.3. Fragmented Fragmented wedgewedge

Grouping-Type CGrouping-Type C

1.1. Spiral Spiral multifragmentarmultifragmentary wedgey wedge

2.2. SegmentalSegmental

3.3. IrregularIrregular

SubgroupingSubgrouping

Differs from bone to boneDiffers from bone to bone Depends on key features for any Depends on key features for any

given bone and its classificationgiven bone and its classification The purpose is to increase the The purpose is to increase the

precision of the classificationprecision of the classification

OTA ClassificationOTA Classification

It is an evolving systemIt is an evolving system Open for change when appropriateOpen for change when appropriate Allows consistency in researchAllows consistency in research Builds a description of the fracture in Builds a description of the fracture in

an organized, easy to use manneran organized, easy to use manner

Thank You!Thank You!