Soft tissue injury

classification of soft tissue injuries. gustilo anderson classification, tscheren classification, hanover fracture scale and ao soft tissue grading system, types of wounds. orthopedic open fracture classification for management of soft tissue injuries

1. Types of Wounds,
Soft Tissue Injuries

CLASSIHCATION

2. Introduction

3. > The effective treatment of fracturesdepends
upon good soft tissue management

> Fractureswith a soft-tissue injury must be
considered assurgical emergencies

» Evaluation of the fracture must determine the
extent of the softtissue injury, which willbe a key
factor in management

4. Pathophysiology and
Biomechanics

>

VIVE Y V

Type of insult and area of contact (blunt,
penetrating, crushed, etc);

Force applied;

Direction of force;

Area(s) of body affected;

Wound contamination;

General physical condition of the patient.

5. Typesof Wounds

6. Type of force
Sharp, pointed

Blunt

Extension, twist

Shear

Combination of forces

Crushing

Thermal

Contusion injury, cut

laceration

Degloving, wound defect, avulsions, abrasion

Wounds from blows, impaling, bites, and gunshot

Traumatic amputation, rupture, crush injury

Burs

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Courtesy of Rhonda Beck

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11. CONTUSON

Commonly described as a ‘bruise’

Capillaries beneath skin ruptured by a blunt blow
e.g. punch

Bleeding under skin
Blood leaking into tissues causes bruising

Skin occasionally splits

13. HEMATOMA

Force impacts on arteries
and veins close to skin

Bleeding (internal) &
swelling

Blood collects under the
skin

14. Soft Tissue
Injury

15. Classification

> Considersall essential factorsand guides
treatment.

> Effectively decreases complications b y
preventing avoidable treatment errors.

> Prognostic value.

> Monitorand compare standardized treatment
protocols.

16. Gustilo classification

17. Gustilo classification

> Gustilo and Anderson developed their
classification on the basisof a retrospective and
prospective analysis of 1,025 open fractures.

> They initially described three types.

18. Type |

> Fractureswith a clean wound of lessthan 1 cm in
size

> Little orno contamination
> Wound results from an inside-out perforation
> The fracture pattern issimple

19. Type Il

> Skin laceration islongerthan 1 cm

> The surrounding tissues have minor or no signs of
contusion

» No dead muscle present
> The fracture instability ismoderate to severe.

20. Type Ill

> Extensive soft-tissue damage

> Frequently with compromised vascularity with or
without severe wound contamination

» The fracture pattern iscomplex with marked
fracture instability.

21. Because of the many different
factorsoccurring in thisgroup,
Gustilo proposed three
subtypes.

22. Type IIA

> High-energy trauma

» Adequate soft-tissue coverage of the fractured
bone, despite extensive soft-tissue laceration or

flaps

23. Type IIIB

> Extensive soft-tissue loss with periosteal stripping
and bone exposure

> Usually associated with massive contamination

24. Type IIIC

> Any open fracture associated with arterial injury
requiring repair

> Independent of the fracture type

25. Tscherne classification
OPEN SOFT-TISSUE INJURIES

26. Open fracture grade | (Fr. O 1)

> The skin islacerated by a bone fragment from the
inside

> There isno or minimal contusion of the skin

> Smple fracture

> Result of indirect trauma

27. Open fracture grade Il (Fr. O 2)

> Skin laceration with a circumferential skin or soft-
tissue contusion and moderate contamination

> Allopen fractures resulting from direct trauma

28. Open fracture grade III (Fr. O 3)

> Extensive soft tissue damage
> Often with an additional major vessel and/ or
nerve injury

> Every open fracture that isaccompanied by
ischemia and severe bone comminution belongs
in this group.

29. Open fracture grade IV (Fr. O 4)

> These are subtotal and total amputations.
> Subtotal amputation

> Sparation of allimportant anatomical structures,
especially the major vessels, with total ischemia

30. Tscherne classification
CLOSED FRACTURES

31. Closed fracture grade 0 (Fr. C 0)

> No or minor soft-tissue injury

> Smple fracture

> Indirect trauma

> Spiral fracture of the tibia in a skiing injury.

32. Closed fracture grade | (Fr. C 1)

> Superficial abrasion or skin contusion
> Smple or medium severe fracture types

» The pronation-external rotation fracture
dislocation of the ankle joint

33. Closed fracture grade Il (Fr. C 2)

» Deep contaminated abrasionsand localized skin
ormuscle contusions

> Direct trauma

> Imminent compartment syndrome also belongsto
this group

> Transverse or complex fracture patterns

> The segmental fracture of the tibia from a direct
blow by a car fender

34. Closed fracture grade Ill (Fr. C 3)

> Extensive skin contusion, destruction of muscle or
subcutaneoustissue avulsion (closed degloving)

> Compartment syndrome and vascular injuries
» The fracture typesare complex

35. Hanover Fracture Scale

36. A Fracture type

Type A

Type B

Type c

Bone loss
<2cm
>2cm

B soft issues

Skin (wound, contusion)
No

< 1/4 circumference

Skin defect (loss)
No
< 1/4 circumference
1/2

jeep soft tissues (muscle, tendon,
igaments, joint capsule)

No

< 1/4 circumference

Amputation
No
ubtotal/total guillotine

Subtotal/total crush

37. € Ischemia /compartment syndrome Points

No o
Incomplete 10
Complete
< 4 hours 15
4-8 hours
> 8 hours
D Nerves

Palmar/plantar sensations

Yes o
Yes o
No 8

E Contamination Points.

Foreign bodies

None o
Single 1
Multiple 2
Massive 10

F Bacteriological smear Points

Aerobe 1 germ 2

Aerobe > 1 germ 3

Anaerobe 2

Aerobe/anaerobe 4

G Onset of treatment Points

(Only if soft-tissue score > 2)

6-12 hours 1

> 12 hours 3

38. Classification Classification Total C-G

Fr O1 Fr © 3 points
Fr. C
Fr.
Fr.

39. Hanover Fracture Scale

> The scale consdersevery detail of the injury to the
involved extremity and formsa checklist

Fracture type

Skin condition
Underlying soft tissues
Vascularity
Neurological status
Levelof contamination

A wae ¥ V

Presence or absence of compartment syndrome
> Time interval between injury and treatment

> Bone lossrepresents bone fragmentsthat have been
lost at the site of the accident

40. > Forthe evaluation of soft tissues, the score
providesthree different categories:
> Size of the skin wound;
> Area of skin loss;
> Damage to deep soft tissuessuch asmusclesand
tendons.

» Due to different diametersand thicknessat
different levelsin the involved extremity, the
extent of soft-tissue damage isrelated to the
volume ofthe soft-tissue envelope

» The three different categories of soft-tissue
damage allow evaluation of both superficial and
deep injury

41. The category Amputation evaluates the
mechanism of injury and the possibility of
replantation

An exact evaluation of the neurological statusis
often difficult at the time of admission but
monitoring of reflexesallowsa grossestimation of
possible neurological damage

The overall score guidesgeneral patient
management and local treatment.

Some of the category scoresare valuable for
treatment decisionsand estimation of possible
complications

42. Limitations

> Moderate interobserver reliability

> Grading of many different injuriesinto the same
subgroup

43. AO soft-tissue grading system

44. AO soft-tissue grading system

> System identifies injuriesto the different
anatomical structuresand assignsthem to
different severity groups

» The grading of the skin lesion isdone separately
foropen orclosed fractures

> The letters“O” and “C” designate these two
categories

» Each isdivided into 5 severity groups

45. Closed skin lesions (IC)

IC 1 No skin lesion

IC 2 No skin laceration, but contusion
IC 3 Circumscribed degloving

IC 4 Extensive, closed degloving

IC5 Necrosisfrom contusion

46. Open skin lesions (IO)

101 Skin breakage from inside out
[Skin breakage from outside in <5cm, contused

10 2 edges a É

103 Skin breakage fro outs > I > 5cm, increased
contuson, vita lize

104 Considerable, full hieknessg, pntugon, abrasion,
extensive open glo vna, kn loss

105

Extensive degloving

47. No Skin Lesion (IC 1)

48. AO soft-tissue classification: no skin laceration, but contusion (IC 2).

49. AO soft-tissue classification: circumscribed gegloving (IC 3).

50. AO soft-tissue classification: extensive, closed degloving (IC 4).

51. A

AO soft-tissue classification:

necrosis from contusion (IC 5).

52. ur

AO soft-tissue classification: skin breakage from inside out (IO 1).

53. AO soft-tissue classification: skin breakage from outside in < 5 cm, contused edges (IO 2).

54. AO soft-tissue classification: skin breakage from outside in > 5 cm, increased contusion,
devitalized edges (IO 3).

55. AO soft-tissue classification: considerable, full-thickness contusion, abrasion, extensive open

degloving, skin loss (IO 4).

56. Muscle And Tendon Lesions (MT)

> Although there may be considerable damage to
a muscle envelope, there israrely an injury to
tendonsexcept in severe injuries

» The involvement of the neurovascular system
alwaysindicatesa most severe injury

» Muscle and tendon injuries as well as
neurovascular injuries are of high prognostic value
forthe fate of the extremity

57. MT 1 No muscle injury MT 4 Muscle defect,
tendon laceration,
extensive muscle
contusion

MT2 Circumscribed MT5 Compartment

muscle injury, one syndrome /crush
compartment only syndrome with wide
injury zone

MT3 Considerable muscle

injury,
two compartments

58. No neurovascular NVA
injury

NVI

Extensive segmental
vascular injury

NV 2 Isolated nerve injury NVS

Combined neurovas-
cular injury, includ
ing subtotal oreven
total amputation

1/2
N

Localized vascular
injury

59. >

>

This system allowsa comprehensive description of
the entire injury complex

A simple, closed spiral tibial midshaft fracture from
skiing with no injury of skin, muscles, tendons,
nerves, or vessels is graded: 42-A1.2/ic 1-mt1-nv1

An open, complex, segmental tibial shaft fracture
with an open wound greater than 5cm, muscle
defect, and tendon laceration. There isno nerve
injury but an injury of the peroneal artery. This
injury willbe graded as 42-C2.3/i04-mt4-nv3.

60. Usage of classification systems

61. > Higher gradesof the Gustilo classification of open
fractures and ofthe Tscheme classification of
closed fractures are most challenging from the
therapeutic point of view

» These injuries have the highest complication rates
and can cause severe disability of the patient

62. Objectives of classification systems

VZVZVZVZY VY VV

Facilitate communication;

Assist decision making;

Identify treatment options;
Anticipate problems;

Suggest treatment method;
Predict the outcome;

Enable comparison with similar cases;
Assist documentation and audit.

63. Conclusion

64. The effective treatment of fracturesdepends
upon good management of the soft tissues

The surgeon must carefully evaluate the injury by
systematically examining each structure that
could be damaged

The possbility of compartment syndrome should
alwaysbe consdered

Careful evaluation will allow the surgeon to
classify the fracture using one of the
comprehensive grading systems