Aménager les villes : réduire les fractures sociales et spatiales
L'extension urbaine s'est ensuite poursuivie le long des axes de transports reliant la ville à sa périphérie. • L'étalement urbain s'est caractérisé par le
Journée magistère du mardi 10 mars 2015 « Les territoires de l
10 mars 2015 Fractures territoriales et fractures scolaires à Marseille ... urbaine et résidentielle à Marseille (dir E Dorier et S.
Fracture numérique: essai de définition et regard critique sur
21 sept. 2017 1.1 Quelques définitions de la fracture numérique ... pays (à l'intérieur même des sociétés entre les milieux urbains et périphériques y ...
Fractures et transitions : réconcilier la France
12 mars 2019 populations concernées peuvent participer à la définition de l'intérêt ... augmenté de 47 % dans les 13 plus grandes aires urbaines de ...
LA COVID-19 ACCELERATRICE ET AMPLIFICATRICE DES
24 oct. 2020 Chercheur affilié au Laboratoire de sociologie urbaine ... De la fracture numérique aux fractures numériques.
La VEBE à Nancy: de la couture à la fracture urbaine (1976-2021)
6 sept. 2022 La VEBE à Nancy: de la couture à la fracture urbaine (1976-2021). ... Le dictionnaire Robert pose comme définition à la couture ...
Untitled
14 déc. 2017 La définition de l'intérêt métropolitain ne concerne donc que : ... réduction des fractures urbaines du territoire métropolitain.
La nouvelle question urbaine
fracture urbaine » semble ainsi prendre la relève de celle de frac ture sociale. espaces publics disparaissent au profit d'une définition fonctionnelle.
E2.1 –Les fractures du lextrémité supérieure du fémur.
L'incidence de cette fracture est variable d'un pays à l'autre et d'une race à une autre. Les pays industrialisés les zones urbaines
Protocole dengagements réciproques renforcés entre lÉtat et la
nombreux partenaires dans la lutte contre les fractures urbaines et sociales. demandeurs d'emploi (définition Insee) était deux fois plus élevée dans ...
Fracture Classifications - Orthopaedic Trauma Association (OTA)
• Type I:all fractures with
Fracture Classification - Orthopaedic Trauma Association (OTA)
Builds a description of the fracture in an organized easy to use manner Classification of Soft Tissue Injury Associated with Fractures 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
Department of Radiology – University of Wisconsin School of
Department of Radiology – University of Wisconsin School of
Anatomical Sites of Fractures
Long bones are divided into different anatomical areas (Fig. 8.1) and fractures can occur in one or multiple of these sites. The long bone shaft is called the diaphysis with each end called an epiphysis, while an area between the epiphysis and diaphysis, the neck in long bones, is called the metaphysis. In children there is the presence of growth p...
Fracture Correlation with Joints
An articular fracture involves the joint surface and is typically described in relation to the percentage of the joint space that is disrupted [1]. Intra-articular fractures are a bone fracture that crosses into the joint surface. Hemarthrosis (Fig. 8.2), bleeding into the joint space, can be a consequence of intra-articular fractures. Hemarthrosis...
Fracture Types
There are a variety of terms that can be used to describe the types of fractures that occur. Fractures that circumferentially traverse the shaft of bone perpendicular to the axis are transverse fractures and can be with or without displacement [6]. Spiral fractures are produced by rotational or twisting forces, while compression fractures are crump...
Fracture Displacement
Fracture displacements refer to the position of the fractured bone in relation to the normal anatomic configuration. Fractures without any abnormal anatomic configuration are nondisplaced. Displaced fractures show a separation of the fragment(s) with a loss of anatomic position of the distal fragment with respect to the proximal fragment. The amoun...
Open Versus Closed Fractures
Closed fractures indicate a fracture area that does not visibly communicate externally to the body (e.g., intact skin pattern). Open fractures communicate externally to the body and the break in the skin pattern may be very subtle (Fig. 8.5) or an obvious open wound (Fig. 8.6). Open fractures are an urgent situation and evaluation should commence f...
Pediatric Considerations
Greenstick Fracture
What is a bone fracture?
The fracture is a portion of the bone on one side, while the opposing side of the same bone will have a buckled or bowed appearance. The fracture itself does not cross through the width of the bone. These typically occur in the long bones and require immobilization and casting as quickly as possible following confirmation.
What are the classifications of fractures?
The purpose of this chapter is to discuss the various classifications of fractures that are based on distinct characteristics such as the anatomic site, the visual appearance (open versus closed), the radiographic appearance (e.g., displaced, compressed, fragmented), and the positioning and alignment of fragments if present.
What is a diaphyseal fracture?
A fracture of the humeral shaft (diaphyseal segment) is defined as any humeral fracture in which the major fracture line does not extend to within one metaphyseal width (Müller box) of either the shoulder or elbow joint; this is consistent with the Arbeitsgemeinschaft für Osteosynthesefragen definition , and is illustrated in Fig. 2. ... ...
How are fractures evaluated and managed?
Evaluation and management of fractures on or off the field must always include consideration of the anatomical site, the proximity to articulations, and complexity of the fracture. This is often assessed by simple visual inspection (open versus closed) and subsequent imaging modalities (e.g., type, displacement).
CoreCurriculumV5
Fracture Classifications
Jaclyn M. Jankowski, DO
Jersey City Medical Center-RWJBarnabas Health
All images belong to Jaclyn Jankowski, DO unless otherwise indicatedCoreCurriculumV5
Objectives
•To understand the need for classification systems •To understand the evolution of classification systems •To look at the importance of soft tissue injury associated with fracturesCoreCurriculumV5
Why do we have classifications?
•Organize knowledge •Transfer information •Guide treatment •Estimate prognosis •Enhance education and communicationCoreCurriculumV5
History of Classification Systems
•Ancient Egypt •The Edwin Smith Papyrus classified injuries as: •"An ailment which I will treat" •"An ailment with which I will contend" •"An ailment not to be treated"CoreCurriculumV5
History of Classification Systems
•18 th and 19 thCentury
-Descriptive classifications based on appearance of limbCCO 1.O
CCO 1.O
"Dinner Fork Deformity"CoreCurriculumV5
History of Classification Systems
•20 thCentury
•The advent of radiographs created numerous classification systems •Brought about the ability to identify location, amount, and displacement of fracture lines •Not without problems as radiographic views and quality can be inconsistentCoreCurriculumV5
History of Classification Systems
•The last 40 Years •CT has allowed for further understanding and classification of intra-articular fracturesCoreCurriculumV5
History of Classification Systems
•Believe it or not there's more to consider than just bones! •X-rays or CT alone can underestimate the severity of the overall injury and don't consider patient statusCoreCurriculumV5
What makes a good classification?
•Inter-observer Reliability •Do different physicians agree on the classification of a particular fracture? •Intra-observer Reproducibility •For a given fracture, does the same physician classify it the same way at different times?CoreCurriculumV5
Types of Classification Systems
•Fracture-Specific •Universal •Soft Tissue Injury Associated with FractureCoreCurriculumV5
Examples of Fracture
-Specific DescriptiveClassifications
•Garden-guides management/surgical plan •Neer-assists describing fracture for communication •Schatzker-can predict associated injuries and prognosis •Lauge-Hansen-provides insight into mechanism •Sanders-an example of CT-based classificationCoreCurriculumV5
Garden Classification
I Valgus impacted or
incompleteII Complete
Non-displaced
III Complete
Partial displacement
IV Complete
Full displacement
** Portends risk of AVN andNonunion**
III IIIIVNon-Displaced
Displaced
Images courtesy of Frank Liporace, MD
CoreCurriculumV5
Garden Classification
Pros -Determining displaced vs nondisplaced is critical for dictating management -Classification has highest inter- and intra-observer reliability when compared to Pauwel"s and AO classifications Cons -Poor interobserver reliability between Types I and II -Classification based on AP radiograph only can underestimate degree of displacementKazley JM, Banerjee S, Abousayed MM, Rosenbaum AJ. (2018). Classifications in brief: Garden classification
of femoral neck fractures. Clin Orthop Relat Res. 476:441-445.CoreCurriculumV5
Neer Classification
•Based on anatomic segments of the proximal humerus •Considered to be a "part" if arbitrarily displaced 1 cm or angulated 45 o•Classification has good intraobserver reliability, but only moderate interobserver reliability, though still useful for communication purposes
Dirschl DR. In: Rockwood and Green's Fractures in Adults.8 th ed. Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta III P, eds. Wolters Kluwer Health; 2015. Bernstein J, Adler LM, Blank JE, Dlasey RM, Williams GR,Iannotti JP. (1996).
Evaluation of the Neer system of
classification of proximal humerus fractures with computerized tomographic scans and plain radiographs.Journal of Bone and Joint Surgery,
78-A(9): 1371-1375.
CoreCurriculumV5
Schatzker Classification
I: Lateral SplitII: Split DepressionIII: Lateral DepressionCoreCurriculumV5
Schatzker Classification
IV: Medial PlateauV: BicondylarVI: Metaphyseal-Diaphyseal DissociationCoreCurriculumV5
Study to compare the inter-observer reliability and intra-observer reproducibility of the Schatzker, AO, and Hohl and Moore classifications of tibial plateau fractures
Four observers at different points in their careers classified 50 tibial plateau fracturesSchatzker showed superior inter-observer reliability and intra-observer reproducibility compared to AO and Hohl and Moore
> though still not perfectSchatzker Classification
CoreCurriculumV5
Schatzker Classification
•Associated Injuries By Fracture Type •Schatzker II Lateral meniscal tears •Schatzker IV medial meniscal tears, ACL injury, vascular injury •Schatzker VI ACL injury, compartment syndromeBennet WF and Browner B. (1994). Tibial plateau fractures: A study of associated soft tissue injuries. J Orthop Trauma.
8(3):183
-188.CoreCurriculumV5
Lauge-Hansen Classification
Supination External Rotation
Based on position of ankle and direction of force applied at time of injurySupination Adduction
CoreCurriculumV5
Lauge-Hansen Classification
Based on position of ankle and direction of force applied at time of injuryPronation AbductionPronation External Rotation
CoreCurriculumV5
Lauge-Hansen Classification
Pros -Provides understanding of mechanism for rotational ankle fractures -Enables interprofessional communication for rotational ankle fractures Cons -Found to have the lowest interobserver reliability when compared to the AO and Danis-Weber classifications
-Classification cannot be used for non -rotational ankle fractures Lopes da Fonseca L, Nunes IG, Nogueira RR, Martins GEV, Mesencio AC, Kobata SI. (2018).Reproducibility of the Lauge-Hansen,
Danis -Weber, and AO classifications for ankle fractures. Rev Bras Ortop. 53(1):101-106.CoreCurriculumV5
Sanders Classification
•CT-based classification looking at the widest part of the calcaneus: •Number articular fracture fragments •Location of fragments •Compare to x-ray-based Essex-Lopresti it provides increased insight: •Fracture pattern •Pre-op planning •PrognosisCoreCurriculumV5
Sanders Classification
•Type I:all fractures with <2mm displacement •Type II:two-part fractures of the posterior facet •Type III:three-part fractures of the posterior facet •Type IV:highly comminuted fracture with four or more fracture linesDirschl DR. In:
Rockwood and Green's Fractures in Adults.8
th ed. Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta III P, eds. Wolters Kluwer Health; 2015.CoreCurriculumV5
Cross-sectional study of 100 pre-op CT scans of patients with intra-articular calcaneus fractures operated on by a single surgeon
Researchers reported:
Good to excellent intra-observer reproducibilityModerate inter-observer reliability (which was better than what was previously reported in the literature).
Validity was reported to be fair
Sanders Classification
CoreCurriculumV5
Universal Classification System
CoreCurriculumV5
OTA/AO Classification
•Alphanumeric classification that can be applied throughout the skeleton, based on fracture location and morphology•Created in the 1960's and multiply updated to include classifications of the pelvis and acetabulum
CoreCurriculumV5
OTA/AO Classification
•Fracture Location •Which bone? •Each bone is assigned a specific numberCoreCurriculumV5
OTA/AO Classification
•Fracture Location •Which part of the bone? •1. Proximal end segment •2. Diaphyseal segment •3. Distal end segment 1 2 3CoreCurriculumV5
OTA/AO Classification
•Fracture Morphology •Diaphyseal segment •Type A: Simple fractures •spiral, oblique, transverse •Type B: Wedge fractures •spiral, bending, fragmented •Type C: Multifragmentary fractures •spiral wedge, segmented, irregularCoreCurriculumV5
OTA/AO Classification
•Fracture Morphology •End segment •Type A: Extra-articular •Type B: Partial articular •Type C: Complete articularCoreCurriculumV5
OTA/AO Classification
•Now have additional Subgrouping •Goal of Subgrouping: to increase the precision of the classification •Subgroups differ amongst each boneCoreCurriculumV5
OTA / AO Classification Subgrouping
•Complex and value not fully known (Example: Distal Femur)CoreCurriculumV5
But what about the soft tissues?
CoreCurriculumV5
Soft Tissue-Based Classifications
•Oesterne and Tscherne Classification •Gustilo-Anderson Classification •OTA Open Fracture ClassificationCoreCurriculumV5
Oesterne and Tscherne Classification
•Classification of soft tissue damage in the setting of a closed fractureGradeSoft Tissue InjuryBony Injury
Grade 0
Minimal soft tissue damage
Indirect injury to limb
Simple fracture pattern
Ex: low energy spiral fractures
Grade 1
Superficial abrasion/contusion
Mild fracture pattern
Ex: rotational ankle fracture-dislocations
Grade 2
Deep abrasion with skin or muscle
contusionDirect trauma to limb
Severe fracture pattern
Ex: segmental fractures
Grade 3
Extensive skin contusion or crush
Severe underlying muscle damage
Subcutaneous avulsion
Possible compartment syndrome
Severe fracture pattern
Ibrahim DA, Swenson A, Sassoon A, Fernando ND. (2017). Classifications in brief: The Tscherne Classification of soft
tissue injury. Clin Orthop Relat Res.475:560-564CoreCurriculumV5
Gustilo-Anderson Classification
•Type II: wound 1-10 cm, moderate soft tissue injury•Type IIIA: wound usually >10 cm, high energy, extensive soft-tissue damage, contaminated, but with adequate tissue for flapcoverage
•Type IIIB: extensive periosteal stripping, woundrequires soft tissue coverage (rotational or free flap)
•Type IIIC: vascular injury requiringvascular repair,regardless of degree of soft tissue injury **Appropriate classification can only be made intraoperatively**Kim PH and Leopold SS. (2012).
Gustilo-Anderson classification. Clin Orthop Relat Res.470:3270
-3274.CoreCurriculumV5
OTA Classification of Open Fractures
•Assigns severity to five essential factors for treatmentEssential FactorSeverity
Skin1.Can be approximated
2.Cannot be approximated
3.Extensive degloving
Muscle1.No muscle in area/no appreciable necrosis
2.Loss of muscle; intact function, localized necrosis
3.Dead muscle, loss of function
Arterial1.No injury
2.Arterial injury without ischemia
3.Arterial injury with ischemia
Contamination1.None or minimal
2.Surface contamination
3.Imbedded in bone or deep tissues
Bone Loss1.None
2.Bone missing or devascularized, but still contact present between
proximal and distal segments3.Segmental bone loss
Orthopaedic Trauma Association: Open Fracture Study Group. (2010).A new classification scheme
for open fractures. J Orthop Trauma.24(8): 457-465CoreCurriculumV5
Reliabilityof Classification Systems
OTA Open Fracture Classification System appears superior to Gustillo- Anderson Classification System in both reliability and validity 86% overall interobserver agreement vs 60% for G-AJOT: 2013 vol 27; pp379-384
Interobserver RELIABILITYis different than VALIDITY If surgeons agree on a measurement pre-operatively (reliability"), that may not prove to be accurate intra-operatively (validity")JAAOS: 2002 vol 10; pp290-297
CoreCurriculumV5
Prospective study to determine if descriptive classifications of diaphyseal tibia fractures are predictive of prognosis Compared AO, Gustilo-Anderson, Tscherne, and Winquist-Hansen classifications and looked at union, need for future surgery, and subsequent infection Found that the Tscherne Classification was most predictive of final outcomeUse of Soft Tissue and Open
Fracture Classifications
CoreCurriculumV5
Summary
•Classifications are essential for communication, education, treatment guidelines, and as a prognostic tool •As imaging technology has advanced so have our fracture classifications•The soft tissue can't be ignored and classification systems taking the soft tissue envelope into consideration are essential for creating a complete
prognostic pictureCoreCurriculumV5
References
•Bennet WF and Browner B. (1994). Tibial plateau fractures: A study of associated soft tissue injuries. J Orthop Trauma. 8(3):183-188.
•Bernstein J, Adler LM, Blank JE, Dlasey RM, Williams GR, Iannotti JP. (1996). Evaluation of the Neer system of classification of proximal humerus fractures with computerized tomographic scans and plain radiographs. Journal of Bone and Joint Surgery, 78-A(9): 1371-1375.
•Dirschl DR. Chapter 2: Classification of fractures. In: Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta III P, eds. Rockwood and Green's Fractures in Adults.8
th ed. Wolters Kluwer Health; 2015:43-57.•Gaston P, Will E, Elton RA, McQueen MM, and Court-Brown CM. (1999).Fractures of the tibia. The Journal of Bone and Joint Surgery. British Volume, 81-B(1), 71-76.
•Ibrahim DA, Swenson A, Sassoon A, Fernando ND. (2017). Classifications in brief: The Tscherne Classification of soft tissue injury. Clin Orthop Relat Res.475:560-564.
•Kazley JM, Banerjee S, Abousayed MM, Rosenbaum AJ. (2018). Classifications in brief: Garden classification of femoral neck fractures. Clin Orthop Relat Res. 476:441-445.
•Kim PH and Leopold SS. (2012). Gustilo-Anderson classification. Clin Orthop Relat Res. 470:3270-3274.
•Lopes da Fonseca L, Nunes IG, Nogueira RR, Martins GEV, Mesencio AC, Kobata SI. (2018). Reproducibility of the Lauge-Hanses, Danis-Weber, and AO classifications for ankle fractures. Rev Bras Ortop. 53(1):101-106.
•Maripuri SN, Rao P, Manoj-Thomas A, and Mohanty K. (2008).The classification systems for tibial plateau fractures: How reliable are they? Injury, 39(10), 1216-1221.
•Orthopaedic Trauma Association: Open Fracture Study Group. (2010). A new classification scheme for open fractures. J Orthop Trauma.24(8): 457-465.
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