This document discusses different types of soft tissue injuries and classifications systems used to categorize them. It describes closed wounds like contusions and hematomas versus open wounds. Classification systems like Gustilo and Tscherne grade soft tissue damage and help determine appropriate treatment and prognosis. The goal is to effectively communicate injury severity and anticipate complications to improve patient outcomes.
3. The effective treatment of fractures depends
upon good soft tissue management
Fractures with a soft-tissue injury must be
considered as surgical emergencies
Evaluation of the fracture must determine the
extent of the softtissue injury, which will be a key
factor in management
4. Pathophysiology and
Biomechanics
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.
6. Type of force Type of injury
Sharp, pointed Stab wound
Blunt Contusion injury, cut
Extension, twist Laceration
Shear Degloving, wound defect, avulsions, abrasion
Combination of forces Wounds from blows, impaling, bites, and gunshot
Crushing Traumatic amputation, rupture, crush injury
Thermal Burns
7. Closed Wounds
Soft tissue is damaged but
skin is not broken
Characteristic closed
wound is a contusion.
8. Closed Wounds
If small blood vessels are
damaged, ecchymosis will
cover the area.
If large blood vessels are
torn, a hematoma will
appear.
Courtesy of Rhonda Beck
9. Open Wounds
Characterized by disruption in the skin
Potentially more serious than closed wounds
Vulnerable to infection
Greater potential for serious blood loss
17. Gustilo classification
Gustilo and Anderson developed their
classification on the basis of a retrospective and
prospective analysis of 1,025 open fractures.
They initially described three types.
18. Type I
Fractures with a clean wound of less than 1 cm in
size
Little or no contamination
Wound results from an inside-out perforation
The fracture pattern is simple
19. Type II
Skin laceration is longer than 1 cm
The surrounding tissues have minor or no signs of
contusion
No dead muscle present
The fracture instability is moderate to severe.
20. Type III
Extensive soft-tissue damage
Frequently with compromised vascularity with or
without severe wound contamination
The fracture pattern is complex with marked
fracture instability.
21. Because of the many different
factors occurring in this group,
Gustilo proposed three
subtypes.
22. Type IIIA
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
26. Open fracture grade I (Fr. O 1)
The skin is lacerated by a bone fragment from the
inside
There is no or minimal contusion of the skin
Simple fracture
Result of indirect trauma
27. Open fracture grade II (Fr. O 2)
Skin laceration with a circumferential skin or soft-
tissue contusion and moderate contamination
All open 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 is accompanied 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
Separation of all important anatomical structures,
especially the major vessels, with total ischemia
31. Closed fracture grade 0 (Fr. C 0)
No or minor soft-tissue injury
Simple fracture
Indirect trauma
Spiral fracture of the tibia in a skiing injury.
32. Closed fracture grade I (Fr. C 1)
Superficial abrasion or skin contusion
Simple or medium severe fracture types
The pronation-external rotation fracture
dislocation of the ankle joint
33. Closed fracture grade II (Fr. C 2)
Deep contaminated abrasions and localized skin
or muscle contusions
Direct trauma
Imminent compartment syndrome also belongs to
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 III (Fr. C 3)
Extensive skin contusion, destruction of muscle or
subcutaneous tissue avulsion (closed degloving)
Compartment syndrome and vascular injuries
The fracture types are complex
39. Hanover Fracture Scale
The scale considers every detail of the injury to the
involved extremity and forms a checklist
Fracture type
Skin condition
Underlying soft tissues
Vascularity
Neurological status
Level of contamination
Presence or absence of compartment syndrome
Time interval between injury and treatment
Bone loss represents bone fragments that have been
lost at the site of the accident
40. For the evaluation of soft tissues, the score
provides three different categories:
Size of the skin wound;
Area of skin loss;
Damage to deep soft tissues such as muscles and
tendons.
Due to different diameters and thickness at
different levels in the involved extremity, the
extent of soft-tissue damage is related to the
volume of the 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 status is
often difficult at the time of admission but
monitoring of reflexes allows a gross estimation of
possible neurological damage
The overall score guides general patient
management and local treatment.
Some of the category scores are valuable for
treatment decisions and estimation of possible
complications
44. AO soft-tissue grading system
System identifies injuries to the different
anatomical structures and assigns them to
different severity groups
The grading of the skin lesion is done separately
for open or closed fractures
The letters “O” and “C” designate these two
categories
Each is divided 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 Necrosis from contusion
46. Open skin lesions (IO)
IO 1 Skin breakage from inside out
IO 2 Skin breakage from outside in < 5 cm, contused
edges
IO 3 Skin breakage from outside in > 5 cm, increased
contusion, devitalized edges
IO 4 Considerable, full-thickness contusion, abrasion,
extensive open degloving, skin loss
IO5 Extensive degloving
56. Muscle And Tendon Lesions (MT)
Although there may be considerable damage to
a muscle envelope, there is rarely an injury to
tendons except in severe injuries
The involvement of the neurovascular system
always indicates a most severe injury
Muscle and tendon injuries as well as
neurovascular injuries are of high prognostic value
for the fate of the extremity
57.
58.
59. This system allows a 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/ic1-mt1-nv1
An open, complex, segmental tibial shaft fracture
with an open wound greater than 5 cm, muscle
defect, and tendon laceration. There is no nerve
injury but an injury of the peroneal artery. This
injury will be graded as 42-C2.3/io4-mt4-nv3.
61. Higher grades of the Gustilo classification of open
fractures and of the Tscherne 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
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.
64. The effective treatment of fractures depends
upon good management of the soft tissues
The surgeon must carefully evaluate the injury by
systematically examining each structure that
could be damaged
The possibility of compartment syndrome should
always be considered
Careful evaluation will allow the surgeon to
classify the fracture using one of the
comprehensive grading systems