Soft tissue injury

pathophysiology and its influence on

fracture management

Erica Kholinne
dr. Ifran Saleh, SpOT (K) Spine
Point of discussions
 Introduction

 Pathophysiology and biomechanics

 Pathophysiological responses in
healing

 Diagnosis and treatment in closed soft

tissue injury
Introduction

 Fractures with soft  timing,

tissue injury  risks,
 need sophisticated
 benefits of the
management protocol
different treatment
 Excellent grading
system options, and

 Goal  consider both the

 Uncomplicated healing  local injury
 Complete restitution of  whole patient
function
Pathophysiology and biomechanics
 Condition of wound:
 Type of insult
 Force applied
 Direction of force
 Area of body affected
 Contamination of the wound
 General physical condition
Pathophysiological responses in healing

Basic concepts Healing process phases

1. Exudative /
injury inflammatory

Bleeding and tissue 2. Proliferative

destruction

Humoral dan cellular

mechanism
3. reparative
 Inflammatory phase

Injury occured
Trauma to Release cytokines
subendothelial • PDGF, TGF-β, EGF, FGF
• Aggregation of • Chemotactic effect
thrombocytes • Increase phagocytoses
• vasoconstriction • Macrophages,
neutrophil, lymphocytes,
fibroblast

Stop
Capacity of
phagocytosis limited !! bleeding
Inflammatory phase

Tissue debris PG Mast cells

Histamin
Hypoxia, acidosis, • Local hyperemia
tissue oedema • Endothelial
permeability↑
Proliferative & reparative phase
 Migration of fibroblast  proliferate
 secretion of collagen and other extracelluler matrix  fills defect
and produces new capillaries  wound edges pull together to
reduces defect  migration and mitosis of epithelial cells across
wound surface
Time table of healing
Diagnosis and treatment in closed soft
tissue injuries

 Open soft tissue injury ??

 Closed soft tissue injury  difficulty in

diagnosis  accessibility of the
subcutaneous soft tissue
 Diagnostic tool is not available to differentiate
viable or nonviable tissue
Pathophysiology of the soft-tissue injury
Classification of fractures with soft-tissue injury

 Open
• Gustilo/Anderson 1976

 Closed
• Oestern & Tscherne 1982
Gustilo and Anderson
classification
Type I wound 1 cm or less, quite clean,
minimal muscle contusion, simple
fracture patterns

Type II laceration > 1 cm long, without

extensive soft tissue damage, flaps
or avulsions, simple fracture or
obliq fracture

Type III extensive soft tissue damage

including muscles, neurovascular
structures, flaps or avulsion
IIIA adequate bone coverage, segmental
fracture
IIIB periosteal stripping and bone
exposure, with massive
contamination
IIIC vascular injury requiring repair
Tscherne classification of open fracture
OI
- Skin lacerated by a bone fragment from the inside
- No or little contusion of the skin
- Fractures are the result of indirect trauma
O II
- Skin laceration with soft tissue contusion
- Moderate contamination
- Any type of fracture
- Without injury to a major vessel or peripheral nerve
O III
- Extensive soft tissue damage
- Major vessel injury and/or nerve injury
- Severe bone comminution
O IV
- Subtotal or total amputation
- Separation of all anatomical surface especially the major vessel
 Oestern & Tscherne 1982
 no or minor soft tissue injury
C0  simple fracture type

 superficial abrasions or contusion

 fragment pressure from inside
CI  Simple or medium severe fracture type

 deep, contaminated abrasions

 local skin or muscle contusion
 Medium to severe fracture type
C II  threatening compartment syndrome

 extensive skin contusions

 destruction of the musculature
 Subcutaneous tissue avulsion
 manifest compartment syndromes
 severe vascular injury
C III  Severe and comminuted fracture type
Hannover
fracture scale
AO soft tissue grading system
Examples

 A simple, closed spiral midshaft

tibial shaft fracture with no
relevant lesions of skin,
muscle/tendons, nerves, and
vessels is graded : IC1-MT1-NV1

 A severe open complex irregular

distal tibial shaft fracture with
extensive skin and bone loss,
muscle and tendon damage, but
no neurovascular injury.
 This injury will be graded as :
IO4-MT5-NV1
Usage of classification

 Assist the surgeon with decision making

 Identify treatment options
 Anticipate problems
 Suggest the course of treatment
 Predict the outcome
 Enable an analysis and a comparison of similar cases
 Assist and facillitate documentation
Conclusion

 Gustillo anderson & Tscherne

 no longer sufficient
 not be able to meet the required objectives

 Hannover fracture scale

 AO system
Algorithm of treatment for fracture with
soft tissue injury
Thank You
Compartment Syndrome

 Elevated tissue pressure within a closed fascial

space
 Reduces tissue perfusion
 Results in cell death
 Pathogenesis
 Too much inflow (edema, hemorrhage)
 Decreased outflow (venous obstruction, tight
dressing/cast)
Treatment

 Conservative Tx with antiinflammatory medication can be

successful if the patient is willing to significantly reduce or
stop atheletic activities.
 Fasciotomy - depending on compartment affected
 Mubarak : Two/Double incisions technique
anterolateral & posteromedial incisions
Forearm Fasciotomy

 Volar-Henry approach
 Include a carpal tunnel
release
 Release lacertus fibrosus and
fascia
 Protect median nerve,
brachial artery and tendons
after release
Leg Anatomy

 4 compartments
 Lateral: Peroneus longus
and brevis
 Anterior: EHL, EDC, Tibialis
anterior, Peroneus tertius
 Posterior-Gastrocnemius,
Soleus, plantaris
 Deep posterior-Tibialis
posterior, FHL, FDL
Leg Fasciotomies

 Generous skin incisions

 medial
 lateral
 Release completely all
4 fascial compartments
 Beware of
neurovascular
structures to prevent
iatrogenic injury
 Anterolateral incision

Posteromedial incision
Medial Leg Lateral Leg

Gastroc-soleus

Flexor
digitorum
longus

Intermuscular
septum

Superficial peroneal nerve

Compartment syndrome

 Increase within a fascial or osteofascial

space of interstitial fluid pressure sufficient to
compromise microcirculation and
neuromuscular function.