Soft Tissue Injury in Fractures – Different Systems of Classification

Soft tissue injuries associated with fractures vary with the severity of the injury and often affect the treatment of underlying fractures.

A soft tissue injury may result in an open fracture or the fracture may remain closed along with significant soft tissue injuries.

A classification of the concomitant soft tissue injury offers the best support in choosing the appropriate management of fracture treatment.

Classification of concomitant soft tissue injuries is different for open and closed fractures.

Here are different classification systems for soft tissue injuries associated with fracture.

Gustilo and Anderson classification of Open Fractures

Gustilo and Anderson classification is for open fractures.

Gustilo type I

Fractures of this type have a clean wound of less than 1 cm in size with little or no contamination. The wound results from a perforation from the inside out by one of the fracture ends. Type I fractures are simple fractures, like spiral or short oblique fractures.

Gustilo type II

injuries have a skin laceration larger than 1 cm, but the surrounding tissues have minor or no signs of contusion. There is no dead musculature present and the fracture instability is moderate to severe.

Gustilo type III

open fractures have extensive soft-tissue damage, frequently with compromised vascularity with or without severe wound contamination, and marked fracture instability due to comminution or segmental defects. Because of the many different factors occurring in this group, Gustilo decided to form the subtypes III A, III B, and III C.

Gustilo type III A

usually results from high energy trauma, but there is still adequate soft tissue coverage of the fractured bone, despite extensive soft-tissue laceration or flaps.

Gustilo type III B

in contrast to the type III-A has an extensive soft-tissue loss with periosteal stripping and bone exposure. These injuries are usually associated with massive contamination.

Gustilo type III C

includes any open fracture associated with an arterial injury requiring repair, independent of the fracture type.

Tscherne classification of soft-tissue injuries for open Fractures

Grade I

•   Open fractures with a small puncture wound without skin contusion
•   Negligible bacterial contamination
•   Low-energy fracture pattern

Grade II

• Open injuries with small skin and soft tissue contusions
•  Moderate contamination
•  Variable fracture patterns

Grade III

•   Open fractures with heavy contamination
•   Extensive soft tissue damage
•   Often, associated with arterial or neural injuries

Grade IV

• Open fractures with incomplete or complete amputations

 Oestern and Tscherne classification of soft tissue injury in closed fractures

Grade 0

• Minimal soft tissue damage
• indirect injury to limb (torsion)
• simple fracture pattern

Grade 1

• Superficial abrasion or contusion
• mild fracture pattern

Grade 2

• Deep abrasion
• Sin or muscle contusion
• Severe fracture pattern
• Direct trauma to the limb

Grade 3

• Extensive skin contusion or crush injury
• Severe damage to underlying muscle
• Compartment syndrome
• Subcutaneous avulsion

Hannover fracture scale

The  Hannover group developed the Fracture Scale that attempts to improve the already available systems

This considers every detail of the injury to the involved extremity and is made up as a checklist that includes

• The fracture type according to the AO/OTA Fracture and Dislocation Classification
• bone loss
• skin laceration,
• the underlying soft tissues
• he vascularity
• the neurological status
• the level of contamination
• a compartment syndrome
• the time interval between injury and treatment
• the overall severity of the injury to the patient
• Amputation if present

These are added up to prove the total score.

Parameter	Finding	Points
AO-ASIF fracture type	type A (simple, with 2 pieces)	1
	type B (wedge, with 3 pieces)	2
	type C (complex, multifragmented)	4
bone loss	none	0
	< 2 cm	1
	>= 2 cm	2
skin wound or contusion	none	0
	< 0.25 circumference	1
	0.25 – 0.5 circumference	2
	0.5 – 0.75 circumference	3
	> 0.75 circumference	4
skin defect	none	0
	< 0.25 circumference	1
	0.25 – 0.5 circumference	2
	0.5 – 0.75 circumference	3
	> 0.75 circumference	4
deep soft tissues	none	0
	< 0.25 circumference	1
	0.25 – 0.5 circumference	2
	0.5 – 0.75 circumference	3
	> 0.75 circumference	6
amputation	none	0
	subtotal guillotine	20
	subtotal crush	30
ischemia or compartment syndrome	none	0
	incomplete	10
	complete, < 4 hours	15
	complete, 4 – 8 hours	20
	complete, > 8 hours	25
palmar or plantar sensation	yes	0
	none	8
finger or toe motion	yes	0
	none	8
foreign body	none	0
	single	1
	multiple	2
	massive	10
bacteriologic smear	negative	0
	aerobe, 1 morphotype	2
	aerobe, mixed	3
	anaerobe	2
	mixed aerobe and anaerobe	4
onset of treatment	(soft tissue score 0 to 2)	0
	soft tissue score > 2) and onset of treatment < 6 hours	0
	(soft tissue score) > 2 and onset of treatment < 6 hours	1
	(soft tissue score) > 2 and onset of treatment < 6 hours

The parameters are added up to create a total score.

Minimum score: 1 (if any fracture occurred), 2 (for a simple open fracture)

Maximum score: 108

The higher the score, the more severe the fracture.

Total Score	Corresponding Tscherne Open Fracture
2 to 3	O I
4 to 19	O II
20 to 69	O III
>= 70	O IV

The score supports injury management and therapy control. Partial scores, particularly “bone score” or the “soft-tissue score”, are valuable for treatment decisions and estimation of possible complications.