Classification of Fractures&

Management of Compound Fractures

By Kevin J Ambadan

CLASSIFICATION

• Based on Relationship with the Environment• Based on Displacement• Based on Fracture Pattern • Based on Etiology

Classification Based on Relationship with Environment

1. CLOSED {Simple}2. OPEN {Compound}

Open Fractures

• A break in the skin and underlying soft tissue leading to a communicating fracture hematoma

Gustilo Classification

• The Gustillo classification is used to classify open fractures.

• Three grades that try to quantify the amount of soft tissue damage associated with the fracture

Grade 1 — <1cm wound, min soft t/s injury Grade 2 — >1cm wound, mod soft t/s inury Grade 3 — >10cm wound, severe muscle devitalization Subgrades A,B,C

Grade 3A

• Limited stripping of periosteum and soft tissue from bone.

• Adequate soft tissue coverage for bone, tendons and neurovascular bundle.

Type 3B• Extensive stripping of soft tissue and

periosteum from bone. • Requires a local flap or free tissue transfer

Type 3C

• A major vascular injury requiring repair

Muller’s (AO/OTA) Classification• Each long bone has 3 segments

Proximal, Diaphyseal and Distal

• Diaphyseal Fractures:– Simple– Wedge– Complex

• Proximal & Distal– Extra-Articular– Partial Articular– Complete Articular

Classification: Based on Displacement

1. UNDISPLACED2. DISPLACED

Displacement - Translation

• Translation is sideways motion of the fracture - usually described as a percentage of movement when compared to the diameter of the bone -- ----------direction of distal fragment decides

Displacement - Angulation

• Angulation is the amount of bend at a fracture described in degrees. Described with respect to the apex of the angle .

Displacement - Shortening

• Shortening is the amount a fracture is collapsed/ shifted proximally, expressed in centimeters.

Classification: Based on Pattern

1. Transverse2. Oblique3. Spiral4. Comminuted5. Segmental6. Stellate

Transverse Fracture A fracture in which the # line is perpendicular to the long axis of the bone .

Oblique Fracture A fracture in which the # line is at oblique angle to the long axis of the bone.

According to the Path of the # Line

Spiral Fracture A severe form of oblique fracture in which the # plane rotates along the long axis of the bone. These #s occur secondary to rotational force.

According to the Path of the # Line

Anatomical Classification of Fractures

Comminuted Fracture : The bone is broken into many fragments.

Stellate Fracture: This # occurs in the flat bones of the skull and in the patella, where the fracture lines run in various directions from one point.

Anatomical Classification of Fractures

Impacted Fracture: This # where a vertical force drives the distal fragment of the fracture into the proximal fragment.

Depressed Fracture: This # occurs in the skull where a segment of bone gets depressed into the cranium.

Avulsion Fracture: A chip of bone is avulsed by the sudden and unexpected contraction of a powerful muscle from its point of insertion, Examples1. ASIS Avulsion2. JONE’S 5th MT base Avulsion

Anatomical Classification of Fractures

Stress Fracture : • It is a fracture occurring at a site in the bone subject to

repeated minor stresses over a period of time.

Birth Fracture: • It is a fracture in the new born children due to injury during birth

Anatomical Classification of Fractures

Classification: Based on Etiology

1. TRAUMATIC2. PATHOLOGICAL – Tumors– Bone cysts– Osteomyelitis– Osteoporosis– Osteogenesis imperfecta– Rickets

Salter-Harris Classification• Only used for pediatric fractures that involve

the growth plate (physis)

Salter-Harris type I fracture

• Type I fracture is when there is a fracture across the physis with no metaphysial or epiphysial injury

Salter-Harris type II fracture

• Type II fracture is when there is a fracture across the physis which extends into the metaphysis

Salter-Harris type III fracture

• Type III fracture is when there is a fracture across the physis which extends into the epiphysis

Salter-Harris type IV fracture

• Type IV fracture is when there is a fracture through metaphysis, physis, and epiphysis

Salter-Harris type V fracture

• Type V fracture is when there is a crush injury to the physis

Treatment of Compound Fracture

Aim• To convert contaminated wound into clean wound • To convert the open # into a closed one.• To establish a union in a good position• To prevent pyogenic and clostridial infection.

Order of Priority• Patient• Limb• Wound• Fracture

4 Essentials of Treatment

• Antibiotic Prophylaxis• Urgent Wound and Fracture Debridement• Stabilization of the Fracture• Early Debridement Wound Cover

Sterility and Antibiotic Cover

• In most cases, Co-amoxiclav or Cefuroxime (or Clindamycin in case of penicillin allergy) is given ASAP

• At time of debridement, Gentamycin is added to a second dose of the 1st antibiotic given

• Wounds of Gustilo Grade 1 fractures can be closed at time of debridement; Antibiotic prophylaxis for up to 24hrs

• Grade 2 and 3A fractures, delayed closure after ‘second look’ is sometimes preferred

• Grade 3B & C, delayed cover is usually practiced.

• Total period of antibiotics is up to 72hrs.

Debridement

• Thorough irrigation of wound with copious amounts of NS to remove all foreign material in wound, followed by excision of dead tissue

• Tourniquet may be used to provide bloodless field, but it can cause ischemia and make it difficult to identify devitalized structures

• Principles observed during debridement:– Wound margin excision– Wound extension– Delivery of fracture– Removal of devitalized tissue– Wound cleansing

• Uncontaminated wound in Grade 1 or 2 can be sutured

Fracture Stabilization

• Important in reducing risk of infection and assisting recovery of soft tissues

• Method of fixation depends on– Degree of contamination– Length of time from injury to operation– Extent of soft tissue damage

• If there is no contamination and definitive wound cover can be achieved at time of debridement, all open #s can be treated as closed injury

• Internal or external fixation may be appropriate depending on individual characteristics of fracture and wound.

• If wound cover is delayed, then external fixation is safer; however fixator pins should be inserted away from potential flaps

• Internal fixation can be used at time of definitive wound cover as long as – delay to wound cover is < 7 days– No visible wound contamination– Internal fixation can control the # as well as

external fixator

Stabilization of Open Fractures METHODS

1.PLASTER IMMOBILISATION

2.PINS & PLASTER

3.SKELETAL TRACTION

4.EXTERNAL FIXATION

5.INTERNAL FIXATION

6.HYBRID FIXATION

External FixatorsMethod of choice in most open fractures

Advantages:• Easily applied • Good skeletal & soft tissue stability• Anatomical reduction.• No additional trauma• Risk of infection is comparatively less.• Allows wound inspection & wound dressing.• Assist in restoring the limb to length until definitive fixation• Allows transportation• Better nursing care

Amputation

Indications:

• Vascular injury – no repair possible

• Functional outcome better with prosthesis

• Life saving to arrest bleeding

• Associated diseases (DM)

Thank You