Types of Wounds,

Soft Tissue Injuries

CLASSIFICATION
Introduction
 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
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.
Types of Wounds
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
Closed Wounds
 Soft tissue is damaged but
skin is not broken
 Characteristic closed
wound is a contusion.
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

Open Wounds

 Characterized by disruption in the skin

 Potentially more serious than closed wounds
 Vulnerable to infection
 Greater potential for serious blood loss
Crush Injuries
 An injury to the underlying
soft tissues and bones
 Caused by a body part
being crushed between
two solid objects

© Mark C. Ide
CONTUSION
CONTUSION
HEMATOMA
Soft Tissue
Injury
CLASSIFICATION
Classification

 Considers all essential factors and guides

treatment.
 Effectively decreases complications by
preventing avoidable treatment errors.
 Prognostic value.
 Monitor and compare standardized treatment
protocols.
Gustilo classification
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.
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
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.
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.
Because of the many different
factors occurring in this group,
Gustilo proposed three
subtypes.
Type IIIA

 High-energy trauma
 Adequate soft-tissue coverage of the fractured
bone, despite extensive soft-tissue laceration or
flaps
Type IIIB

 Extensive soft-tissue loss with periosteal stripping

and bone exposure
 Usually associated with massive contamination
Type IIIC

 Any open fracture associated with arterial injury

requiring repair
 Independent of the fracture type
Tscherne classification
OPEN SOFT-TISSUE INJURIES
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
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
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.
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
Tscherne classification
CLOSED FRACTURES
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.
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
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
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
Hanover Fracture Scale
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
 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
 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
Limitations

 Moderate interobserver reliability

 Grading of many different injuries into the same
subgroup
AO soft-tissue grading system
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
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
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

No Skin Lesion (IC 1)
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
 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.
Usage of classification systems
 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
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.
Conclusion
 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