fracture nomenclature robert h. belding md. why classify? as a treatment guide to assist with...
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Fracture Fracture NomenclatureNomenclature
Robert H. Belding MDRobert H. Belding MD
Why Classify?Why Classify?
As a treatment As a treatment guideguide
To assist with To assist with prognosisprognosis
To speak a To speak a common language common language with others in order with others in order to compare resultsto compare results
As a Treatment GuideAs a Treatment Guide
If the same bone is If the same bone is broken, the broken, the surgeon can use a surgeon can use a standard treatmentstandard treatment
PROBLEM: fracture PROBLEM: fracture personality and personality and variation with variation with equipment and equipment and experienceexperience
To Assist with PrognosisTo Assist with Prognosis
You can tell the You can tell the patient what to patient what to expect with the expect with the resultsresults
PROBLEM: Does PROBLEM: Does not consider the not consider the soft tissues or soft tissues or other compounding other compounding factorsfactors
To Speak A Common LanguageTo Speak A Common Language
This will allow This will allow results to be results to be comparedcompared
PROBLEM: Poor PROBLEM: Poor interobserver interobserver reliability with reliability with existing fracture existing fracture classificationsclassifications
Interobserver Interobserver ReliabilityReliability
Different physicians agree Different physicians agree on the classification of a on the classification of a fracture for a particular fracture for a particular
patientpatient
Intraobserver Intraobserver ReliabilityReliability
For a given fracture, each For a given fracture, each physician should produce physician should produce
the same classificationthe same classification
LiteratureLiterature
94 patients with ankle 94 patients with ankle fracturesfractures
4 observers4 observers Classify according to Classify according to
Lauge Hansen and Lauge Hansen and WeberWeber
Evaluated the Evaluated the precision (observer’s precision (observer’s agreement with each agreement with each other)other)
Thomsen et al, JBJS-Br, 1991
LiteratureLiterature
Acceptable reliabilty Acceptable reliabilty with both systemswith both systems
Poor precision of Poor precision of staging, especialy PA staging, especialy PA injuriesinjuries
Recommend: Recommend: classification systems classification systems should have reliability should have reliability analysis before usedanalysis before used
Thomsen et al, JBJS-Br, 1991
LiteratureLiterature
100 femoral neck 100 femoral neck fracturesfractures
8 observers8 observers Garden’s Garden’s
classificationclassification
Classified Classified identical 22/100identical 22/100
Disagreement b/t Disagreement b/t displaced and displaced and non-displaced in non-displaced in 4545
Conclude poor Conclude poor ability to stage ability to stage with this systemwith this system
Frandsen, JBJS-B, 1988
Closed FracturesClosed Fractures
Fracture is not exposed to the Fracture is not exposed to the environmentenvironment
All fractures have some degree of soft All fractures have some degree of soft tissue injurytissue injury
Commonly classified according to the Commonly classified according to the Tscherne classificationTscherne classification
Don’t underestimate the soft tissue Don’t underestimate the soft tissue injury as this affects treatment and injury as this affects treatment and outcome!outcome!
Closed Fracture ConsiderationsClosed Fracture Considerations
The energy of the The energy of the injuryinjury
Degree of Degree of contaminationcontamination
Patient factorsPatient factors Additional injuriesAdditional injuries
Tscherne ClassificationTscherne Classification
Grade 0Grade 0– Minimal soft Minimal soft
tissue injurytissue injury– Indirect injuryIndirect injury
Grade 1Grade 1– Injury from Injury from
withinwithin– Superficial Superficial
contusions or contusions or abrasionsabrasions
Tscherne ClassificationTscherne Classification
Grade 2Grade 2 Direct injuryDirect injury More extensive soft More extensive soft
tissue injury with tissue injury with muscle contusion, muscle contusion, skin abrasionsskin abrasions
More severe bone More severe bone injury (usually)injury (usually)
Tscherne ClassificationTscherne Classification
Grade 3Grade 3– Severe injury to soft Severe injury to soft
tissuestissues– -degloving with -degloving with
destruction of destruction of subcutaneous subcutaneous tissue and muscletissue and muscle
– Can include a Can include a compartment compartment syndrome, vascular syndrome, vascular injuryinjury
Closed tibia fractureNote periosteal strippingCompartment sundrome
LiteratureLiterature
Prospective studyProspective study Tibial shaft Tibial shaft
fractures treated fractures treated by intramedullary by intramedullary nailnail
Open and closedOpen and closed 100 patients100 patients
Gaston, JBJS-B, 1999
LiteratureLiterature
What predicts What predicts outcome?outcome? Classifications Classifications used:used:– AOAO– GustiloGustilo– TscherneTscherne– Winquist-Hansen Winquist-Hansen
(comminution)(comminution)
All x-rays reviewed by All x-rays reviewed by single physiciansingle physician
Evaluated outcomesEvaluated outcomes
UnionUnion
Additional surgeryAdditional surgery
InfectionInfection
Tscherne classification Tscherne classification more predictive of more predictive of outcome than othersoutcome than others
Gaston, JBJS-B, 1999
Open FracturesOpen Fractures
A break in the skin A break in the skin and underlying soft and underlying soft tissue leading tissue leading directing into or directing into or communicating communicating with the fracture with the fracture and its hematomaand its hematoma
Open FracturesOpen Fractures
Commonly described by the Gustilo Commonly described by the Gustilo systemsystem
Model is tibia fracturesModel is tibia fractures Routinely applied to all types of open Routinely applied to all types of open
fracturesfractures Gustilo emphasis on size of skin Gustilo emphasis on size of skin
injuryinjury
Open FracturesOpen Fractures
Gustilo classification used for prognosisGustilo classification used for prognosis Fracture healing, infection and amputation Fracture healing, infection and amputation
rate correlate with the degree of soft rate correlate with the degree of soft tissue injury by Gustilotissue injury by Gustilo
Fractures should be classified in the Fractures should be classified in the operating room at the time of initial operating room at the time of initial debridementdebridement– Evaluate periosteal strippingEvaluate periosteal stripping– Consider soft tissue injuryConsider soft tissue injury
Type I Open FracturesType I Open Fractures
Inside-out injuryInside-out injury Clean woundClean wound Minimal soft tissue Minimal soft tissue
damagedamage No significant No significant
periosteal strippingperiosteal stripping
Type II Open FracturesType II Open Fractures
Moderate soft Moderate soft tissue damagetissue damage
Outside-in Outside-in mechanismmechanism
Higher energy Higher energy injuryinjury
Some necrotic Some necrotic muscle, some muscle, some periosteal strippingperiosteal stripping
Type IIIA Open FracturesType IIIA Open Fractures
High energyHigh energy Outside-in injuryOutside-in injury Extensive muscle Extensive muscle
devitalizationdevitalization Bone coverage Bone coverage
with existing soft with existing soft tissue not tissue not problematicproblematic
Note Zone of Injury
Type IIIB Open FracturesType IIIB Open Fractures
High energyHigh energy Outside in injuryOutside in injury Extensive muscle Extensive muscle
devitalization devitalization Requires a local Requires a local
flap or free flap for flap or free flap for bone coverage and bone coverage and soft tissue closuresoft tissue closure
Periosteal strippingPeriosteal stripping
Type IIIC Open FracturesType IIIC Open Fractures
High energyHigh energy Increased risk of Increased risk of
amputation and amputation and infectioninfection
Major vascular Major vascular injury requiring injury requiring repair repair
LiteratureLiterature
Interobserver Interobserver agreement pooragreement poor– Range 42-94% for Range 42-94% for
each fractureeach fracture Least experienced-Least experienced-
59% agreement59% agreement Orthopaedic Orthopaedic
Trauma Fellowship Trauma Fellowship trained-66% trained-66% agreementagreement
Brumback et al, JBJS-A, 1994
LiteratureLiterature
245 surgeons245 surgeons 12 cases of open 12 cases of open
tibia fracturestibia fractures Videos usedVideos used Various levels of Various levels of
training (residents training (residents to trauma to trauma attendings)attendings)
Brumback et al, JBJS-A, 1994
OTA ClassificationOTA Classification
There has been a need for an There has been a need for an organized, systematic fracture organized, systematic fracture classification classification
Goal: A comprehensive classification Goal: A comprehensive classification adaptable to the entire skeletal adaptable to the entire skeletal system!system!
Answer: OTA Comprehensive Answer: OTA Comprehensive Classification of Long Bone FracturesClassification of Long Bone Fractures
With a Universal With a Universal Classification…Classification…
To…To…
TreatmentTreatment
Implant optionsImplant options
ResultsResults
You go from x-ray….
To Classify a FractureTo Classify a Fracture
Which bone?Which bone? Where in the bone Where in the bone
is the fracture?is the fracture? Which type?Which type? Which group?Which group? Which subgroup?Which subgroup?
Using the OTA ClassificationUsing the OTA Classification
Which bone?Which bone? •Where in the bone?
Proximal & Distal Segment Proximal & Distal Segment FracturesFractures
Type AType A– Extra-articularExtra-articular
Type BType B– Partial articularPartial articular
Type CType C– Complete disruption Complete disruption
of the articular of the articular surface from the surface from the disphysisdisphysis
Diaphyseal FracturesDiaphyseal Fractures
Type AType A– Simple fractures with Simple fractures with
two fragmentstwo fragments Type BType B
– Wedge fracturesWedge fractures– After reduced, length After reduced, length
and alignment restoredand alignment restored Type CType C
– Complex fractures with Complex fractures with no contact between no contact between main fragmentsmain fragments
Grouping-Type AGrouping-Type A
1.1. SpiralSpiral
2.2. ObliqueOblique
3.3. TransverseTransverse
Grouping-Type BGrouping-Type B
1.1. Spiral wedgeSpiral wedge
2.2. Bending wedgeBending wedge
3.3. Fragmented Fragmented wedgewedge
Grouping-Type CGrouping-Type C
1.1. Spiral Spiral multifragmentarmultifragmentary wedgey wedge
2.2. SegmentalSegmental
3.3. IrregularIrregular
SubgroupingSubgrouping
Differs from bone to boneDiffers from bone to bone Depends on key features for any Depends on key features for any
given bone and its classificationgiven bone and its classification The purpose is to increase the The purpose is to increase the
precision of the classificationprecision of the classification
OTA ClassificationOTA Classification
It is an evolving systemIt is an evolving system Open for change when appropriateOpen for change when appropriate Allows consistency in researchAllows consistency in research Builds a description of the fracture in Builds a description of the fracture in
an organized, easy to use manneran organized, easy to use manner
Thank You!Thank You!