Different Classifications of Fractures & Brief Management of Compound (Open) Fractures

1. Classification of Fractures
&
Management of Compound
Fractures
By Kevin J Ambadan

2. CLASSIFICATION
• Based on Relationship with the Environment
• Based on Displacement
• Based on Fracture Pattern
• Based on Etiology

3. Classification Based on
Relationship with Environment
1. CLOSED {Simple}
2. OPEN {Compound}

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

5. 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

7. Grade 3A
• Limited stripping of periosteum and soft tissue
from bone.
• Adequate soft tissue coverage for bone,
tendons and neurovascular bundle.

8. 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

9. 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

10. Classification: Based on Displacement
1. UNDISPLACED
2. DISPLACED

11. 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

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

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

14. Classification: Based on Pattern
1. Transverse
2. Oblique
3. Spiral
4. Comminuted
5. Segmental
6. Stellate

15. According to the Path of the # Line
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.

16. 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.

17. 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.

18. 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.

19. Anatomical Classification of Fractures
Avulsion Fracture:
A chip of bone is avulsed by the sudden and unexpected
contraction of a powerful muscle from its point of insertion,
Examples
1. ASIS Avulsion
2. JONE’S 5th MT base Avulsion

20. 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

21. Classification: Based on Etiology
1. TRAUMATIC
2. PATHOLOGICAL
– Tumors
– Bone cysts
– Osteomyelitis
– Osteoporosis
– Osteogenesis imperfecta
– Rickets

22. Salter-Harris Classification
• Only used for pediatric fractures that involve
the growth plate (physis)

23. Salter-Harris type I fracture
• Type I fracture is
when there is a
fracture across the
physis with no
metaphysial or
epiphysial injury

24. Salter-Harris type II fracture
• Type II fracture is
when there is a
fracture across the
physis which extends
into the metaphysis

25. Salter-Harris type III fracture
• Type III fracture is
when there is a
fracture across the
physis which extends
into the epiphysis

26. Salter-Harris type IV fracture
• Type IV fracture is
when there is a
fracture through
metaphysis, physis,
and epiphysis

27. Salter-Harris type V fracture
• Type V fracture is
when there is a crush
injury to the physis

28. Treatment of Compound
Fracture

29. 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

30. 4 Essentials of Treatment
• Antibiotic Prophylaxis
• Urgent Wound and Fracture Debridement
• Stabilization of the Fracture
• Early Debridement Wound Cover

31. 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

32. • 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.

33. 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

34. • 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

35. 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

36. • 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

37. Stabilization of Open Fractures
METHODS
1.PLASTER IMMOBILISATION
2.PINS & PLASTER
3.SKELETAL TRACTION
4.EXTERNAL FIXATION
5.INTERNAL FIXATION
6.HYBRID FIXATION

38. External Fixators
Method 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

39. Amputation
Indications:
• Vascular injury – no repair possible
• Functional outcome better with prosthesis
• Life saving to arrest bleeding
• Associated diseases (DM)

40. Thank You