This document discusses the classification and management of fractures, including compound fractures. It describes several classification systems for fractures based on their relationship to the environment, degree of displacement, fracture pattern, and etiology. It also discusses the Gustilo classification system for open fractures. For treatment of compound fractures, the document emphasizes the importance of antibiotic prophylaxis, debridement of the wound and fracture, stabilization of the fracture, and early wound coverage. It describes various methods of fracture stabilization, including external and internal fixation.

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