G06 FX Classification JTG Rev 2-3-10

8/12/2019 G06 FX Classification JTG Rev 2-3-10

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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

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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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Grade 2 Direct injury

More extensive softtissue injury withmuscle contusion, skinabrasions

More severe boneinjury (usually)


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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!

[email protected]


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G06 FX Classification JTG Rev 2-3-10

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