g06 fx classification jtg rev 2-3-10
TRANSCRIPT
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Fracture Classification
L isa K. Cannada M D
Revised: May 2011 Created March 2004; Revised January 2006 & Oct 2008
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History of Fracture Classification
18 th & 19 th century History based on
clinical appearanceof limb alone
Colles F racture Di nner F ork Deformity
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20 th Century
Classification basedon radiographs offractures
Many developed Problems
Radiographicquality
Injury severity
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What about CT scans?
CT scanning canassist with fractureclassification
Example: Sandersclassification of
calcaneal fractures
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Other Contributing Factors
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The Soft Tissues
Fracture appears non complexon radiographs The real injury
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Patient Variables
Age Gender
Diabetes Infection Smoking
Medications Underlying
physiology
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Injury Variables
Severity Energy of Injury
Morphology of thefracture
Bone loss
Blood supply Location Other injuries
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Why Classify?
As a treatment guide To assist with
prognosis To speak a common
language with othersurgeons
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To Assist with Prognosis
You can tell the patient what to expect
with the results PROBLEM: Does not
consider the softtissues or othercompounding factors
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To Speak A Common Language
This will allow resultsto be compared
PROBLEM: Poorinterobserverreliability withexisting fractureclassifications
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Interobserver Reliability
Different physicians agree on theclassification of a fracture for a
particular patient
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Intraobserver Reliability
For a given fracture, each physicianshould produce the sameclassification
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Descriptive Classification Systems
Examples Garden: femoral neck
Schatzker: Tibial plateau Neer: Proximal Humerus Lauge-Hansen: Ankle
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Literature
94 patients with anklefractures
4 observers Classify according to
Lauge Hansen and Weber Evaluated the precision
(observers agreementwith each other)
Thomsen et al, JBJS-Br, 1991
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Literature
Acceptable reliabilty with both systems
Poor precision of staging,especialy PA injuries
Recommend:classification systemsshould have reliabilityanalysis before used
Thomsen et al, JBJS-Br, 1991
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Literature Classified identical
22/100 Disagreement b/t
displaced and non-displaced in 45
Conclude poor ability
to stage with thissystem
100 femoral neckfractures
8 observers Gardens classification
Frandsen, JBJS-B, 1988
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Universal Fracture Classification
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OTA Classification
There has been a need for an organized,systematic fracture classification
Goal: A comprehensive classificationadaptable to the entire skeletal system!
Answer: OTA ComprehensiveClassification of Long Bone Fractures
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With a Universal Classification
To Treatment
Implant optionsResults
You go from x- ray.
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To Classify a Fracture
Which bone? Where in the bone is
the fracture? Which type? Which group?
Which subgroup?
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Using the OTA Classification Which bone? Where in the bone?
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Proximal & Distal SegmentFractures
Type A Extra-articular
Type B Partial articular
Type C Complete disruption of
the articular surfacefrom the diaphysis
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Diaphyseal Fractures
Type A Simple fractures with two
fragments
Type B Wedge fractures After reduced, length and
alignment restored
Type C Complex fractures with no
contact between mainfragments
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Grouping-Type A
1. Spiral
2. Oblique3. Transverse
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Grouping-Type B
1. Spiral wedge2. Bending wedge3. Fragmented wedge
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Grouping-Type C
1. Spiral
multifragmentarywedge
2. Segmental
3. Irregular
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Subgrouping
Differs from bone to bone Depends on key features for any given bone
and its classification The purpose is to increase the precision of
the classification
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OTA Classification
It is an evolving system Open for change when appropriate Allows consistency in research Builds a description of the fracture in an
organized, easy to use manner
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Closed Fractures
Fracture is not exposed to the environment All fractures have some degree of soft tissue
injury Commonly classified according to the
Tscherne classification Dont underestimate the soft tissue injury as
this affects treatment and outcome!
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Closed Fracture Considerations
The energy of theinjury
Degree ofcontamination
Patient factors Additional injuries
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Tscherne Classification
Grade 0
Minimal soft tissueinjury Indirect injury
Grade 1
Injury from within Superficial
contusions orabrasions
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Tscherne Classification
Grade 2 Direct injury
More extensive softtissue injury withmuscle contusion, skinabrasions
More severe boneinjury (usually)
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Tscherne Classification
Grade 3 Severe injury to soft
tisues -degloving with
destruction ofsubcutaneous tissueand muscle
Can include acompartmentsyndrome, vascularinjury
Closed tibia fracture Note periosteal stripping
Compartment syndrome
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Literature
Prospective study Tibial shaft fractures
treated byintramedullary nail Open and closed 100 patients
Gaston, JBJS-B, 1999
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Literature
What predicts outcome? Classifications used:
AO Gustilo Tscherne Winquist-Hansen
(comminution)
All x-rays reviewed by single physician
Evaluated outcomesUnionAdditional surgeryInfection
Tscherne classification more predictive of outcome thanothers
Gaston, JBJS-B, 1999
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Open Fractures
A break in the skin
and underlying softtissue leading into orcommunicating withthe fracture and its
hematoma
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Open Fractures
Commonly described by the Gustilo system Model is tibia fractures Routinely applied to all types of open
fractures Gustilo emphasis on size of skin injury
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Open Fractures
Gustilo classification used for prognosis Fracture healing, infection and amputation rate
correlate with the degree of soft tissue injury byGustilo Fractures should be classified in the operating
room at the time of initial debridement Evaluate periosteal stripping Consider soft tissue injury
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Type I Open Fractures
Inside-out injury Clean wound
Minimal soft tissuedamage
No significant periosteal stripping
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Type II Open Fractures
Moderate soft tissuedamage
Outside-in mechanism Higher energy injury Some necrotic muscle,
some periostealstripping
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Type IIIA Open Fractures
High energy Outside-in injury
Extensive muscledevitalization
Bone coverage withexisting soft tissue not
problematic Note Zone of Injury
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Type IIIB Open Fractures
High energy Outside in injury
Extensive muscledevitalization Requires a local flap
or free flap for bone
coverage and softtissue closure Periosteal stripping
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Type IIIC Open Fractures
High energy Increased risk of
amputation andinfection Major vascular injury
requiring repair
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245 surgeons 12 cases of open tibia
fractures Videos used Various levels of
training (residents totrauma attendings)
Brumback et al, JBJS-A, 1994
Literature on Open Fracture Classification
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Thank You!
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