Lecture 2 - VCS 80630 - Fall 2023 - Fracture Classification and Decision Making - S. Malek PDF

FRACTURE CLASSIFICATION Dr. Sarah Malek VCS 80630 – Small Animal Surgery Fall 2023 LEARNING OBJECTIVES • Be able to describe basic fracture configuration and classification schemes including articular fractures • Be able to describe a long bone fracture on radiographs using the classification sch...

FRACTURE CLASSIFICATION Dr. Sarah Malek VCS 80630 – Small Animal Surgery Fall 2023 LEARNING OBJECTIVES • Be able to describe basic fracture configuration and classification schemes including articular fractures • Be able to describe a long bone fracture on radiographs using the classification schemes described in this lecture • Be able to describe the Patient Fracture Assessment Score (PFAS) principles, components, and how to interpret the score HOW DO YOU CLASSIFY FRACTURES? FRACTURE DESCRIPTION Based on orthogonal radiographs of good quality • Location • Cortical involvement • Configuration • Displacement • Open versus closed • Etiology Consistency is more critical than sequence FRACTURE CLASSIFICATION FRACTURE LOCATION Long bone • Epiphysis, metaphysis, diaphysis Spine, skull, joint • • • • Complex anatomy Proper positioning Special views +/- computed tomography FRACTURE PATTERN CLASSIFICATION CORTICAL INVOLVEMENT Complete • Fractured through 4 cortices Incomplete • Fracture not through all 4 visible cortices • Fissures • Greenstick FRACTURE PATTERN CLASSIFICATION CORTICAL INVOLVEMENT Incomplete • Fissure • Crack from surface • Propagating from main fracture • Greenstick • Skeletally immature animals • Break through one side, bent on other FRACTURE CLASSIFICATION FRACTURE PATTERN General patterns • Classic patterns Anatomically-specific patterns FRACTURE PATTERN CLASSIFICATION General Patterns • Transverse • Oblique • Spiral • Comminuted • Segmental • Avulsion GENERAL FRACTURE PATTERNS Transverse • Fracture relatively perpendicular to long axis of bone • Can have interdigitating edges α < 30° GENERAL FRACTURE PATTERNS Oblique • Short versus Long • Length of fracture line < or > than 2x bone diameter α= 30°- 60° α >60° α > 30° GENERAL FRACTURE PATTERNS Spiral • Short • Long α >60° GENERAL FRACTURE PATTERNS Comminuted • More than two fragments • Fracture lines communicate • +/- Reconstructible COMMINUTED FRACTURES Degree of re-constructability determines fixation options Butterfly fragment GENERAL FRACTURE PATTERNS Segmental • Fracture lines do not communicate NAME FRACTURE CONFIGURATION 1. Transverse 2. Short oblique 3. Long oblique 4. Comminuted GENERAL FRACTURE PATTERNS Avulsion • Apophysis (at origin or insertion of tendon/ligament) • Strong distraction forces ANATOMICALLY-SPECIFIC PATTERNS Learn the S-H classification Close to physis +/- articular • Involving open growth plates • Salter-Harris classification • Specific classification for mature animals FRACTURE PATTERN CLASSIFICATION Salter-Harris Classification (I-VI) I. II. III. IV. Physis only Physis and metaphysis Physis and epiphysis All three areas involved V. Compressive physis VI. Compressed physis unilaterally • V and VI are not radiographically apparent V VI FRACTURE DESCRIPTION BASED ON DISPLACEMENT Based on orthogonal radiographs • Non-displaced • Minimally displaced • Displaced • How is the biggest distal segment displaced? • Proximal • Medial or lateral • Cranial or caudal FRACTURE CLASSIFICATION OPEN OR CLOSED Degree of • Soft tissue trauma • Contamination (organisms +/- foreign material) Modified Gustilo-Anderson classification FRACTURE CLASSIFICATION FRACTURE ETIOLOGY Forces acting on fractures • Compression • Tension • Torsion/Shear • Bending • Combination Why does it matter? • Determine how fracture occurred • Impacts the choice of repair method FRACTURE CLASSIFICATION BASED ON ETIOLOGY Traumatic versus pathologic • Significantly affects • Treatment options • Prognosis • Obtaining a complete history is key FRACTURE CLASSIFICATION BASED ON ETIOLOGY High energy versus low energy? Penetrating versus blunt force? Determine degree of: • Soft tissue trauma • Fracture instability Plupetstore.Com http://troopathon.com PRACTICE! Describe the fracture • Location • Cortical involvement • Configuration • Displacement • Open versus closed • Etiology CONSEQUENCES OF BAD DECISIONS… ❖ ❖ ❖ ❖ ❖ Poor decision making Technical errors Excessive soft tissue damage Prolonged operating time Breaks in aseptic technique ❖ Extra expense ❖ Loss of time ❖ Loss of function ❖ Infection ❖ Implant failure ❖ Other complications ❖ Additional surgery ❖ ❖ ❖ ❖ Permanent disability Loss of limb Failure to achieve fracture healing Death! PATIENT WITH ORTHOPEDIC INJURY Patient assessment • Initial exam and triage • Stabilize patient • Secondary exam • More thorough exam • Diagnostic imaging • Fracture classification and decision making CASE EXAMPLE: JACK • 7 year-old, intact male, mixed breed dog • Hit by car two hours ago • Day 1: Initial stabilization • Pain medications • Fluid therapy for shock • Splint on right forelimb • Day 2: Surgical stabilization of fracture • Outcome: Healed 3 months postop CASE EXAMPLE: DENALI • 3 year-old, male, mixed breed dog • Non-ambulatory in hind limbs • Paraplegic in hind limbs • Bilateral acetabular fractures Initial stabilization • Fluid therapy • Pain medications CASE EXAMPLE: DENALI • Secondary assessment • Radiographs of spine and thorax • Recheck neurological exam (T3-L3 lesion) • Diagnosis • Bilateral acetabular fractures • Comminuted T9-T10 spinal fractures • Prognosis: Guarded • Treatment options • Spinal fracture stabilization • Repair of acetabular fractures • Outcome: Owner decided euthanasia PATIENT FRACTURE ASSESSMENT SCORE PFAS A. Biological Factors (1-10) B. Mechanical Factors (1-10) C. Clinical Compliance Factors (1-10) • Grades (3-30) 1. Worst case scenario (PFAS 3) 2. Average case scenario 3. Best possible case scenario (PFAS 30) Used as a guide for complete fracture assessment PFAS CATEGORIES PFAS: BIOLOGICAL FACTORS • Risk of infection • Open or closed fracture • Low or high energy trauma • Local tissue health and blood supply • Systemic health • Age • Body condition score • Pre-existing conditions • Cancer, endocrinopathies, immunodeficiency PFAS: CLINICAL COMPLIANCE • Experience of surgeon • Owner compliance for after care instructions • Animal compliance for after care instructions PFAS: MECHANICAL FACTORS • Function and loads on affected bone • Bone function • Pre-existing conditions • Body weight • Body condition score • Number of injuries FRACTURE DECISION MAKING PATIENT FRACTURE ASSESSMENT SCORE • Value of facture classification • Guides treatment options • Predicts prognosis • Dictates follow up plans • Sets expectations when monitoring healing FRACTURE DECISION MAKING • If planning on stabilizing fracture • All forces causing instability at fracture site must be adequately neutralized FRACTURE DECISION MAKING • Should the fracture be reconstructed? • Anatomic reconstruction • Biological osteosynthesis • Fracture type and location dictates the approach FRACTURE DECISION MAKING Indications • Anatomic reconstruction • Articular • Linear and easy to reconstruct • Certain maxillofacial fractures for proper occlusion • Biological (functional) osteosynthesis • Preserve soft tissue and blood supply to bone • Preserve growth plates in juveniles • Comminuted to non-reconstructable fractures FRACTURE DECISION MAKING • What is the urgency to fix it? • Emergent – spine fractures, some open fractures • Urgent – many open fractures, articular fractures • Semi-urgent – pelvic, mandibular, closed long bone fractures FRACTURE DECISION MAKING • Is your plan for the fracture repair good for the patient • Does the owner understand risks, prognosis, potential complications? • Does the owner have $$ for the initial treatment AND follow up care with potential complications? TAKE HOME MESSAGES • Long bone fracture classification schemes are based on location, cortical involvement, configuration, displacement, presence of wound over fracture, and etiology. • Fracture classification schemes guide decision making process specific to each patient. • “Fracture assessment score” provides an overall view of the patient with a fracture to better guide therapeutic interventions.