G06 fracture classification
- 1. Fracture Classification Lisa K. Cannada, MD Emory University
- 2. Why Classify? • As a treatment guide • To assist with prognosis • To speak a common language with others in order to compare results
- 3. As a Treatment Guide • If the same bone is broken, the surgeon can use a standard treatment • PROBLEM: fracture personality and variation with equipment and experience
- 4. To Assist with Prognosis • You can tell the patient what to expect with the results • PROBLEM: Does not consider the soft tissues or other compounding factors
- 5. To Speak A Common Language • This will allow results to be compared • PROBLEM: Poor interobserver reliability with existing fracture classifications
- 6. Interobserver Reliability Different physicians agree on the classification of a fracture for a particular patient
- 7. Intraobserver Reliability For a given fracture, each physician should produce the same classification
- 8. Literature • 94 patients with ankle fractures • 4 observers • Classify according to Lauge Hansen and Weber • Evaluated the precision (observer’s agreement with each other) Thomsen et al, JBJS-Br, 1991
- 9. Literature • Acceptable reliabilty with both systems • Poor precision of staging, especialy PA injuries • Recommend: classification systems should have reliability analysis before used Thomsen et al, JBJS-Br, 1991
- 10. Literature • 100 femoral neck fractures • 8 observers • Garden’s classification • Classified identical 22/100 • Disagreement b/t displaced and non- displaced in 45 • Conclude poor ability to stage with this system Frandsen, JBJS-B, 1988
- 11. 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 • Don’t underestimate the soft tissue injury as this affects treatment and outcome!
- 12. Closed Fracture Considerations • The energy of the injury • Degree of contamination • Patient factors • Additional injuries
- 13. Tscherne Classification • Grade 0 – Minimal soft tissue injury – Indirect injury • Grade 1 – Injury from within – Superficial contusions or abrasions
- 14. Tscherne Classification • Grade 2 • Direct injury • More extensive soft tissue injury with muscle contusion, skin abrasions • More severe bone injury (usually)
- 15. Tscherne Classification • Grade 3 – Severe injury to soft tisues – -degloving with destruction of subcutaneous tissue and muscle – Can include a compartment syndrome, vascular injury Closed tibia fracture Note periosteal stripping Compartment sundrome
- 16. Literature • Prospective study • Tibial shaft fractures treated by intramedullary nail • Open and closed • 100 patients Gaston, JBJS-B, 1999
- 17. Literature What predicts outcome? Classifications used: – AO – Gustilo – Tscherne – Winquist-Hansen (comminution) All x-rays reviewed by single physician Evaluated outcomes Union Additional surgery Infection Tscherne classification more predictive of outcome than others Gaston, JBJS-B, 1999
- 18. Open Fractures • A break in the skin and underlying soft tissue leading directing into or communicating with the fracture and its hematoma
- 19. 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
- 20. Open Fractures • Gustilo classification used for prognosis • Fracture healing, infection and amputation rate correlate with the degree of soft tissue injury by Gustilo • Fractures should be classified in the operating room at the time of initial debridement – Evaluate periosteal stripping – Consider soft tissue injury
- 21. Type I Open Fractures • Inside-out injury • Clean wound • Minimal soft tissue damage • No significant periosteal stripping
- 22. Type II Open Fractures • Moderate soft tissue damage • Outside-in mechanism • Higher energy injury • Some necrotic muscle, some periosteal stripping
- 23. Type IIIA Open Fractures • High energy • Outside-in injury • Extensive muscle devitalization • Bone coverage with existing soft tissue not problematic Note Zone of Injury
- 24. Type IIIB Open Fractures • High energy • Outside in injury • Extensive muscle devitalization • Requires a local flap or free flap for bone coverage and soft tissue closure • Periosteal stripping
- 25. Type IIIC Open Fractures • High energy • Increased risk of amputation and infection • Major vascular injury requiring repair
- 26. Literature • Interobserver agreement poor – Range 42-94% for each fracture • Least experienced- 59% agreement • Orthopaedic Trauma Fellowship trained- 66% agreement Brumback et al, JBJS-A, 1994
- 27. Literature • 245 surgeons • 12 cases of open tibia fractures • Videos used • Various levels of training (residents to trauma attendings) Brumback et al, JBJS-A, 1994
- 28. OTA Classification • There 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
- 29. With a Universal Classification… To… Treatment Implant options Results You go from x-ray….
- 30. To Classify a Fracture • Which bone? • Where in the bone is the fracture? • Which type? • Which group? • Which subgroup?
- 31. Using the OTA Classification • Which bone? •Where in the bone?
- 32. Proximal & Distal Segment Fractures • Type A – Extra-articular • Type B – Partial articular • Type C – Complete disrution of the articular suface from the disphysis
- 33. 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 main fragments
- 34. Grouping-Type A 1. Spiral 2. Oblique 3. Transverse
- 35. Grouping-Type B 1. Spiral wedge 2. Bending wedge 3. Fragmented wedge
- 36. Grouping-Type C 1. Spiral multifragmentary wedge 2. Segmental 3. Irregular
- 37. 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
- 38. 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
- 39. Thank You! Department of Orthopaedics Return to General Index