[PDF] Fracture Classification - Orthopaedic Trauma Association (OTA)





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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).

Fracture Classification

Lisa K. Cannada MD

Updated: 05/2016

History of Fracture

Classification

•18 th & 19 th century -History based on clinical appearance of limb alone

Colles Fracture Dinner Fork Deformity

20 th

Century

•Classification based on radiographs of fractures •Many developed •Problems -Radiographic quality -Injury severity

What about CT scans?

•CT scanning can assist with fracture classification •Example: Sanders classification of calcaneal fractures

Other Contributing Factors

The Soft Tissues

Fracture appears non

complex on radiographs

The real injury

Patient Variables

•Age •Gender •Diabetes •Infection •Smoking •Medications •Underlying physiology

Injury Variables

•Severity •Energy of Injury •Morphology of the fracture •Bone loss •Blood supply •Location •Other injuries

Why Classify?

•As a treatment guide •To assist with prognosis •To speak a common language with other surgeons

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

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

To Speak A Common

Language

•This will allow results to be compared •PROBLEM: Poor interobserver reliability with existing fracture classifications

Interobserver Reliability

Different physicians agree on

the classification of a fracture for a particular patient

Intraobserver Reliability

For a given fracture, each

physician should produce the same classification

Descriptive Classification

Systems

•Examples -Garden: femoral neck -Schatzker: Tibial plateau -Neer: Proximal Humerus -Lauge-Hansen: Ankle

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

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

Literature

•Classified identical

22/100

•Disagreement b/t displaced and non- displaced in 45 •Conclude poor ability to stage with this system •100 femoral neck fractures •8 observers •Garden's classification

Frandsen, JBJS

-B, 1988

Universal Fracture

Classification

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

With a Universal

Classification...

To...

Treatment

Implant options

Results

You go from x

-ray....

To Classify a Fracture

•Which bone? •Where in the bone is the fracture? •Which type? •Which group? •Which subgroup?

Using the OTA Classification

•Which bone? •Where in the bone?

Proximal & Distal Segment

Fractures

•Type A -Extra-articular •Type B -Partial articular •Type C -Complete disruption of the articular surface from the diaphysis

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

Grouping-Type A

1.Spiral

2.Oblique

3.Transverse

Grouping-Type B

1.Spiral wedge

2.Bending wedge

3.Fragmented wedge

Grouping-Type C

1.Spiral

multifragmentary wedge

2.Segmental

3.Irregular

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

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

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 •Don't underestimate the soft tissue injury as this affects treatment and outcome!

Closed Fracture Considerations

•The energy of the injury •Degree of contamination •Patient factors •Additional injuries

Tscherne Classification

•Grade 0 -Minimal soft tissue injury -Indirect injury •Grade 1 -Injury from within -Superficial contusions or abrasions

Tscherne Classification

•Grade 2 •Direct injury •More extensive soft tissue injury with muscle contusion, skin abrasions •More severe bone injury (usually)

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 syndrome

Literature

•Prospective study •Tibial shaft fractures treated by intramedullary nail •Open and closed •100 patients

Gaston, JBJS

-B, 1999

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

Open Fractures

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

Open Fractures

•Gustilo-Anderson •OTA-Open

Fracture

Classification

(OFC)

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

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

Type I Open Fractures

•Inside-out injury •Clean wound •Minimal soft tissue damage •No significant periosteal stripping

Type II Open Fractures

•Moderate soft tissue damage •Outside-in mechanism •Higher energy injury •Some necrotic muscle, some periosteal stripping

Type IIIA Open Fractures

•High energy •Outside-in injury •Extensive muscle devitalization •Bone coverage with existing soft tissue not problematic

Note Zone of Injury

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

Type IIIC Open Fractures

•High energy •Increased risk of amputation and infection •Major vascular injury requiring repair •245 surgeons •12 cases of open tibia fractures •Videos used •Various levels of training (residents to trauma attendings)

Brumback et al, JBJS-A, 1994

Literature on Open Fracture Classification

Literature on Open Fracture Classification

•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

New Lecture on the OTA

Open Fracture

Classification:

•For questions or comments, please send to ota@ota.org

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