Rockwood, Green, and Wilkins' Fractures, 10e Package

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SECTION ONE • General Principles

PURPOSE AND APPLICATION OF FRACTURE CLASSIFICATION

Classification schemes should be considered a practical tool with applicable results, rather than a mental exercise, in order to help us treat fractures. Additionally, these systems continue to be fundamental to clinical research on fractures as it helps with grouping and descriptions. In short, it is important for fracture classification systems to provide a reproducible idea of what the fracture pattern entails, drive treatment options, provide information regarding prognosis, and/or be concise and easy to apply. The more of these characteristics a system can encompass, the more widespread its use is likely to be. The 2018 OTA/AO Fracture Compendium is a comprehensive, organized system developed with Delphi methodology. This alphanumeric frac ture system, originally developed by AO, was then expanded and refined by workgroups of the OTA and AO. Thus, an inter national universal classification has become a reality. Further advances in imaging modalities added information that was used as an aid to classify fractures. CT scanning is one such modality. Over the previous three decades, CT scans have become a routine part of assessment of many fractures. CT scans allowed clinicians to more fully appreciate the extent of an articular injury and have quickly become an important adjunct for preoperative planning. With the ability to reprocess CT-generated information to create three-dimensional represen tations of the fracture, the understanding of fracture anatomy and preoperative planning was further enhanced. CT gradually became incorporated into existing classifications, and in some areas, formal assessment by CT was recommended prior to assigning a classification category. AI may also provide the key to more accurate fracture cate gorization. Using AI, classification could occur as soon as imag ing data were uploaded and analyzed. Immediate treatment options, predictive analytics, and anticipated outcomes could conceivably be generated by the computer. In this hypotheti cal future, classification of fractures may become so rapid and instantaneous that it is no longer viewed as a process. This would allow cost-effectiveness, projected life-time costs of care, and disability to ultimately be linked to fracture classification in the future. COMMON LANGUAGE AND TERMINOLOGY Having an inclusive and universal system for classification of fractures provides a common language for healthcare provid ers and associated entities to discuss injuries. Broadly speaking, classifying fractures is a way to organize and transfer informa tion, discuss and guide treatment, link diagnosis with progno sis, and enhance learning and education. It helps clarify what to look for in characterizing a fracture, such as the important variables of displacement, the soft tissue anatomy and associ ated blood supply, and relevant biomechanics. Classification allows for a quick transition from the chaos of accidental injury to order, control, and rational decision mak ing. It provides categories and labels, making it easy to compare

Figure 5-1. Colles fracture. Note the dorsal angulation of the distal aspect of the radius.

injury, classified prior to the advent of radiographs, describes a unique fracture pattern and guided early treatment (Fig. 5-1). 8 Perhaps most importantly, the author really understood the fracture—without the benefit of radiographs—and fundamen tally appreciated its personality, biomechanics, and skeletal stability. Although most of us cannot conceive of the evaluation of fractures without radiographs, it was not until 1901 that William Conrad Roentgen was awarded the first Nobel Prize in physics for his work on x-ray imaging. In 1895, he discovered that the x-ray beam could pass through human tissue but was unable to pass through bone or metal, resulting in a method to project the images of bones on a film. 6 The impact that radio graphs have had on fracture care cannot be overstated. Radio graphs are still essential for determining management, whether it is an ankle fracture requiring a gravity stress view, a pelvic ring injury requiring inlet and outlet views, or an acetabular fracture requiring Judet views. 47 After the advent of radiography, fracture-specific classifica tions were described (and commonly named for their creators), many of which remain in usage today. For example, in 1961, Robert Symon Garden described the Garden classification of femoral neck fractures. 14,15 Joseph Schatzker’s description of tibial plateau fractures, based on a series of 94 radiographs, was published in 1979. 53 More recent classifications, such as the Sanders classification of calcaneus fractures, incorporate CT imaging findings in its criteria for classification. 52 Application of CT imaging is standard for evaluation of many articular frac tures and its indications continue to expand. Magnetic resonance imaging (MRI) can add additional infor mation about the concomitant state of adjacent soft tissue struc tures during the process of fracture classification. Application of MRI to fractures of the spine is well-known and has clear value for evaluation of the spinal cord, intervertebral discs, and the posterior longitudinal ligament. The role of MRI or other advanced imaging continues to evolve within fracture classifi cation and management due to technologic advancements and improved access, especially surrounding the elbow, knee, and posterior pelvis.