Fracture ClassificationLisa K. Cannada MD Revised: May 2011 Created March 2004; Revised January 2006 & Oct 2008

History of Fracture Classification18th & 19th centuryHistory based on clinical appearance of limb aloneColles Fracture Dinner Fork Deformity

20th CenturyClassification based on radiographs of fracturesMany developedProblemsRadiographic qualityInjury severity

What about CT scans?CT scanning can assist with fracture classificationExample: Sanders classification of calcaneal fractures

Other Contributing Factors

The Soft TissuesFracture appears non complex on radiographsThe real injury

Patient VariablesAgeGenderDiabetesInfectionSmokingMedicationsUnderlying physiology

Injury VariablesSeverityEnergy of InjuryMorphology of the fractureBone lossBlood supplyLocationOther injuries

Why Classify?As a treatment guideTo assist with prognosisTo speak a common language with other surgeons

As a Treatment GuideIf the same bone is broken, the surgeon can use a standard treatmentPROBLEM: fracture personality and variation with equipment and experience

To Assist with PrognosisYou can tell the patient what to expect with the resultsPROBLEM: Does not consider the soft tissues or other compounding factors

To Speak A Common LanguageThis will allow results to be comparedPROBLEM: Poor interobserver reliability with existing fracture classifications

Interobserver ReliabilityDifferent physicians agree on the classification of a fracture for a particular patient

Intraobserver ReliabilityFor a given fracture, each physician should produce the same classification

Descriptive Classification SystemsExamplesGarden: femoral neckSchatzker: Tibial plateauNeer: Proximal HumerusLauge-Hansen: Ankle

Literature94 patients with ankle fractures4 observersClassify according to Lauge Hansen and WeberEvaluated the precision (observers agreement with each other)Thomsen et al, JBJS-Br, 1991

LiteratureAcceptable reliabilty with both systemsPoor precision of staging, especialy PA injuriesRecommend: classification systems should have reliability analysis before used

Thomsen et al, JBJS-Br, 1991

LiteratureClassified identical 22/100Disagreement b/t displaced and non-displaced in 45Conclude poor ability to stage with this system100 femoral neck fractures8 observersGardens classificationFrandsen, JBJS-B, 1988

Universal Fracture Classification

OTA ClassificationThere has been a need for an organized, systematic fracture classification Goal: A comprehensive classification adaptable to the entire skeletal system!Answer: OTA Comprehensive Classification of Long Bone Fractures

With a Universal Classification

ToTreatmentImplant optionsResultsYou go from x-ray.

To Classify a FractureWhich bone?Where in the bone is the fracture?Which type?Which group?Which subgroup?

Using the OTA ClassificationWhich bone?

Where in the bone?

Proximal & Distal Segment FracturesType AExtra-articularType BPartial articularType CComplete disruption of the articular surface from the diaphysis

Diaphyseal FracturesType ASimple fractures with two fragmentsType BWedge fracturesAfter reduced, length and alignment restoredType CComplex fractures with no contact between main fragments

Grouping-Type ASpiralObliqueTransverse

Grouping-Type BSpiral wedgeBending wedgeFragmented wedge

Grouping-Type CSpiral multifragmentary wedgeSegmentalIrregular

SubgroupingDiffers from bone to boneDepends on key features for any given bone and its classificationThe purpose is to increase the precision of the classification

OTA ClassificationIt is an evolving systemOpen for change when appropriateAllows consistency in researchBuilds a description of the fracture in an organized, easy to use manner

Classification of Soft Tissue Injury Associated with Fractures

Closed FracturesFracture is not exposed to the environmentAll fractures have some degree of soft tissue injuryCommonly classified according to the Tscherne classificationDont underestimate the soft tissue injury as this affects treatment and outcome!

Closed Fracture ConsiderationsThe energy of the injuryDegree of contaminationPatient factorsAdditional injuries

Tscherne ClassificationGrade 0Minimal soft tissue injuryIndirect injuryGrade 1Injury from withinSuperficial contusions or abrasions

Tscherne ClassificationGrade 2Direct injuryMore extensive soft tissue injury with muscle contusion, skin abrasionsMore severe bone injury (usually)

Tscherne ClassificationGrade 3Severe injury to soft tisues-degloving with destruction of subcutaneous tissue and muscleCan include a compartment syndrome, vascular injuryClosed tibia fractureNote periosteal strippingCompartment syndrome

LiteratureProspective studyTibial shaft fractures treated by intramedullary nailOpen and closed100 patients

Gaston, JBJS-B, 1999

LiteratureWhat predicts outcome? Classifications used:AOGustiloTscherneWinquist-Hansen (comminution)

All x-rays reviewed by single physicianEvaluated outcomesUnionAdditional surgeryInfectionTscherne classification more predictive of outcome than othersGaston, JBJS-B, 1999

Open FracturesA break in the skin and underlying soft tissue leading into or communicating with the fracture and its hematoma

Open FracturesCommonly described by the Gustilo systemModel is tibia fracturesRoutinely applied to all types of open fracturesGustilo emphasis on size of skin injury

Open FracturesGustilo classification used for prognosisFracture healing, infection and amputation rate correlate with the degree of soft tissue injury by GustiloFractures should be classified in the operating room at the time of initial debridementEvaluate periosteal strippingConsider soft tissue injury

Type I Open FracturesInside-out injuryClean woundMinimal soft tissue damageNo significant periosteal stripping

Type II Open FracturesModerate soft tissue damageOutside-in mechanismHigher energy injurySome necrotic muscle, some periosteal stripping

Type IIIA Open FracturesHigh energyOutside-in injuryExtensive muscle devitalizationBone coverage with existing soft tissue not problematicNote Zone of Injury

Type IIIB Open FracturesHigh energyOutside in injuryExtensive muscle devitalization Requires a local flap or free flap for bone coverage and soft tissue closurePeriosteal stripping

Type IIIC Open FracturesHigh energyIncreased risk of amputation and infectionMajor vascular injury requiring repair

245 surgeons12 cases of open tibia fracturesVideos usedVarious levels of training (residents to trauma attendings)Brumback et al, JBJS-A, 1994Literature on Open Fracture Classification

Literature on Open Fracture ClassificationInterobserver agreement poorRange 42-94% for each fractureLeast experienced-59% agreementOrthopaedic Trauma Fellowship trained-66% agreement

Brumback et al, JBJS-A, 1994

Thank You!lcannada@slu.edu

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