This document discusses the classification of soft tissue injuries associated with fractures. It describes several classification systems, including Tscherne, Gustilo-Anderson, and AO, that grade soft tissue injuries based on factors like wound size, contamination, and bone and muscle involvement. Proper classification of soft tissue injuries is important for determining fracture management and predicting healing to help standardize treatment protocols.

1. PRESENTED BY
DR.CH RAKESH SINGHA
PGT ORTHOPAEDICS, SMCH

2.  “Soft tissue” is a broad term that includes -
skin, subcutaneous tissue, fasciae, muscles,
tendons, ligaments, neurovascular structures
& other connective tissues.
 It holds very pivotal & undisputed role in the
overall orthopaedic management.

3.  Fractures with soft-tissue injury considered
as surgical emergencies.
 It needs a sophisticated management
protocol and an excellent grading system to
achieve uncomplicated healing with complete
restitution of function.

4.  Evaluation of fracture must determine the
extent of soft tissue injury, which will be a
key factor in management.
 This impinges upon the need of soft tissue
injury classification.
 A classification of the soft-tissue injury
should consider all essential factors and
guide treatment.

5.  It decreases complications by preventing
avoidable treatment errors
 For prognostic value of wounds
 To monitor and compare standardized
treatment protocols.

7. Tscherne classification of closed fractures:
In it, the fracture is labeled as open or closed by an “O” or a “C”.
Closed fracture grade 0 (Fr. C 0):
 no/minimal soft-tissue injury
 simple fracture pattern
 E.g., spiral fracture of the tibia
Closed fracture grade I (Fr. C 1):
 superficial abrasion or skin contusion
 simple or medium severe fracture pattern.
 E.g, pronation - fracture dislocation of the ankle joint: The soft-
tissue damage occurs through fragment pressure at the medial
malleolus.

8. Closed fracture grade II (Fr. C 2):
 deep contaminated abrasions, localized skin or
muscle contusions.
 transverse or complex fracture patterns.
 includes imminent compartment syndrome
Closed fracture grade III (Fr. C 3):
 extensive skin contusion or muscle destruction
 subcutaneous tissue avulsion (closed degloving)
 complex fracture pattern
 Includes compartment syndrome and vascular
injuries.

10. Tscherne classification of open soft-tissue injuries:
Open fracture grade I (Fr. O 1):
 skin laceration by bone fragment from inside
 No or minimal skin contusion
 Negligible contamination
 indirect trauma (type A1 and A2 fractures according to the AO
classification).
Open fracture grade II (Fr. O 2):
 skin laceration
 circumferential skin or soft-tissue contusion
 moderate contamination
 All direct trauma causing fractures (AO classification type A3,
type B and type C) are included in this group.

11. Open fracture grade III (Fr. O 3):
 extensive soft tissue damage
 Often additional major vessel and/or nerve injury
 Includes every open fracture with ischemia and severe
bone comminution
 Includes farming accidents, high-velocity gunshot
wounds, and compartment syndrome.
Open fracture grade IV (Fr. O 4):
 subtotal and total amputations
 Cases requiring revascularization can be classified as
grade III or IV open.

12.  AO has developed a more detailed and precise
grading system for fractures with soft-tissue
damage.
 The fracture is classified according to the AO/OTA
Fracture and Dislocation Classification
 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.

13.  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

16.  IO 1 Skin breakage from inside out
 IO 2 Skin breakage < 5 cm, contused edges
 IO 3 Skin breakage > 5 cm, increased contusion,
devitalized edges
 IO 4 Considerable, full-thickness contusion,
abrasion, extensive open degloving skin loss
 IO5 Extensive degloving

22. Gustilo classification of open fractures: Gustilo
and Anderson developed their classification
on the basis of a retrospective and
prospective analysis of 1,025 open fractures.
 Initially three types, but clinical application
led Gustilo, Mendoza, and Williams to extend
and subdivide the classification of the severe
(type III) injuries into subgroups A, B, and C.

24. Definition
 The body's natural process of restoring normal
function and structure after injury
 complex series of events that begins at the
moment of injury and can continue for months to
years
Phases of wound healing
Three phases:-
 Inflammatory or Exudative phase
 Proliferative phase
 Maturation and remodeling phase

28. Duration : Immediate to 2-5 days
Aim : to stop bleeding and to prevent further
injury
Characterized by :- Clotting cascade -
haemostasis →Platelets aggregation →
Vasoconstriction and vasodilatation → Increased
polymorphonuclear neutrophils → Increased
Macrophages

30.  After the inflammatory stage, the proliferative
stage lasts about 3 weeks (or longer, depending
on the severity of the wound)
 Aim: repair of wounded tissue
 Characterized by: Angiogenesis → Fibroplasia
and granulation tissue formation → Epithelization
→ Wound contraction

32.  It begins when the levels of collagen
production and degradation equalize
 can last for a year or longer.

33.  Healing by primary intention (Primary closure)
 Healing by secondary intention (Secondary
closure)
 Healing by tertiary intention (Delayed primary
closure)

34.  occurs when a wound is created aseptically
with minimal tissue damage
 E.g., Healing by the approximation of tissue
edges with suture, staples, wound sealant etc

39.  Occurs in wounds that are already infected
and are usually left open and allowed to heal
by epithelialization and wound contraction
 May be caused by infection, excessive
trauma, tissue loss, or inability to re-
approximate the tissue
 It is a slow process

45.  Wounds that are heavily contaminated and
are likely to develop an infection if closed
primarily may be left open for 3-5 days
 This allows the wound to be cleaned and
allows the body’s natural defenses to
decrease bacterial count
 The wound can then be closed and allowed to
heal, producing a wound with characteristics
similar to primary closure

46. Local factors affecting wound healing
 Infection
 Necrotic tissue
 Movement
 Hematoma formation
 Venous or lymph stasis
 Tissue ischemia
 Presence of foreign body
 Exposure to radiation
 Site of wound :over bones and joints
 Underlying disease: osteomyelitis, malignancy

47. Systemic factors affecting wound healing
 Ageing, obesity
 Nutritional status
 Vitamin deficiency (vit C, vit A)
 Diseases states: ○ Uremia ○ Jaundice ○
Diabetes ○ Malignancy ○
Immunosuppression
 Smoking
 Drugs: ○ Steroids ○ anti-neoplastics ○
NSAIDs ○ bisphosphonates

48.  Careful evaluation of the injury by systematically
examining each structure that could be damaged: the skin,
subcutaneous tissue, muscle and tendons, nerves, vessels,
and bones.
 Possibility of compartment syndrome should always be
considered
 Closed injuries may be associated with as much soft-
tissue damage as open injuries.
 Careful evaluation to classify fracture using one grading
system such as AO system or Hanover fracture scale.
 Guide decision making, allow clear communication, and
give an indication of potential complications and outcome.