1.3 Soft Tissue Injury

The (soft-tissue) injury—
a high priority consideration
AO Trauma Basic Principles Course

Learning objectives
• Describe the role of soft tissue in fracture healing

• Prioritize the management of soft-tissue injuries
• Apply the management options for fractures with different
degrees of soft-tissue injuries
• Outline the etiology, diagnosis, and treatment of compartment
syndrome
“The bone is a plant, with its roots in the soft tissue,
and when its vascular connections are damaged, it
often requires, not techniques of a cabinet maker, but
the patient care and understanding of a gardener.”
Girdlestone
A fracture involves:
• Skin
• Subcutaneous fat
• Muscle
• Periosteum
• Bone
Vascular anatomy of the skin
Angiosomes
• Represent discrete, but
interconnected, areas of
skin, which are supplied
by a named source
vessel
• Very similar to
dermatomes
Vasculature of the skin
Vascular supply to the skin is directly related to perforators that

come through muscle from named arteries
Blood supply to muscle
• Usually comes from named vessels

• Various patterns of vascular supply
• Single pedicle (proximal)
• Dominant pedicle and multiple minor pedicles
• Two dominant pedicles
• Segmental pedicles
Muscular blood supply
Single pedicle
• Gastroc, rectus femoris, tensor
fascia lata
Single major/multiple minor

• Vastus lateralis, soleus, brachioradialis,
gracilis
Double pedicle
• Gluteus maximus
Segmental pedicles
• Tibialis anterior, EHL, EDL, FHL, FDL
Blood supply to bone
Outer 1/3 of bone
• Supplied by periosteal vessels that arise from named arteries

which enter only at the sites of ligamentous or heavy fascial
attachment
• However, all of these vessels are thin-walled and probably
represent venules or capillaries
Blood supply to bone
Inner 2/3 of bone

• Supplied by nutrient
artery that then
divides into arterioles
which supply entire
endosteum
Extraosseus blood supply
• In fractures, the blood supply to the callus forms from the

ruptured periosteal capillaries (where they exist) and torn muscle
capillaries in the vicinity of the fracture
• Endosteal blood supply reconstitutes from endosteal arterioles
• Persists until medullary circulation regenerates
• May easily be disrupted by lack of stability at the fracture
• Cannot replace the intramedullary circulation
Role of soft tissue
• Skin is the primary barrier to infection

• Muscle
• Provides blood supply to skin
• Functions to provide locomotion
• Improves blood drainage from dependent areas
• Periosteum
• Provides blood supply to bone (outer 1/3)
• Provides osteoprogenitor cells to bone
How do we assess soft-tissue injuries?
Degree of bone injury implies level of injury to soft tissue

• Uncommon for severe fracture to have little soft-tissue injury
• Not uncommon for severe soft-tissue injury to have innocuous
bone injury
Assessment of soft-tissue injury
Mechanism of injury can also give clues

Fracture mechanisms of the diaphysis
• Torsion (skiing)
• Bending (indirect)
• Compression (fall from a height)
• Contusion (direct, bumper injury)
• Combinations
•
Low-energy fracture patterns
Medium-energy fracture patterns
B2
High-energy fracture patterns
Classification of closed fractures
Tscherne and Oestern, 1982
C0
• No, or no significant, soft-tissue trauma
• Simple fracture
• Indirect mechanism
CI
• Soft-tissue contusion
• Fracture pattern usually simple
C II
• Deep erosion
• Contusion—localized
• Tangential trauma
• Compartment syndrome possible
• Complex fracture (two levels)
• Direct mechanism
C III
• Deep erosion
• Contamination
• Contusion—diffuse
• Manifestation of compartment
syndrome
• Complex fracture
C IV
• Deep erosion
• Contamination
• Contusion
• Shear injury
• Manifestation of compartment syndrome
• Complex fracture
• Vascular injury with reconstruction
Open fracture classification
Gustilo
Type I • Low energy
• Minimal soft-tissue damage
• Wound < 1 cm
Type II • Higher energy
• Laceration > 1 cm
• No flaps/crushing minimal contamination
• Slight comminution
Type IIIA • High energy
• Adequate soft-tissue coverage despite flaps/lacerations
• Comminution/segmental fracture
Type IIIB • High energy
• Extensive soft-tissue stripping
• Inadequate cover
• Massive contamination
Type IIIC • Vascular injury requiring repair
Classification of open fractures
Gustilo-Anderson (Modified)
Type I
• No gross contamination
• “Inside-out”
Type II
• No gross contamination
• Small wound
• Little periosteal stripping
Classification of open fractures
Gustilo-Anderson (Modified)
Type III
• Large skin defect
• Skin defect that requires coverage (type IIIB)
• Large amount of periosteal stripping
• Vascular injury that requires repair (type IIIC)
• Gross contamination or prolonged delay in removing
contamination (> 6 hours)
• Shotgun, high-energy ballistic injury, most blast injuries, farm-
yard injury
Classification
Tips
Size matters, but not that much

• Contamination, high-energy weapons, farm yard injuries are
automatically at least a type IIIA even if the wound is < 10 cm
AO soft-tissue classification
Integumentum closed (IC)

• IC 1 = no skin injury
• IC 2 = contusion without skin laceration
• IC 3 = local degloving
• IC 4 = extensive, closed degloving
• IC 5 = necrosis due to deep contusion
Rüedi, Border, Hanson, Tscherne

Integumentum open (IO)

• IO 1 = skin perforated from inside out
• IO 2 = skin perforation from outside < 5 cm
• IO 3 = local degloving, contusion > 5 cm
• IO 4 = loss of skin, deep contusion
• IO 5 = open degloving

Neurovascular injury (NV)

• NV 1 = no injury
• NV 2 = isolated nerve injury
• NV 3 = local vascular injury
• NV 4 = combined neurovascular injury
• NV 5 = sub/total amputation

Muscle and tendon injury (MT)

• MT 1 = no injury
• MT 2 = isolated (one group)
• MT 3 = two or more groups
• MT 4 = loss of muscle groups, tendon
• MT 5 = compartment/crush syndrome

Compartment syndrome
• Increasing volume in a nonexpandable space

• Increasing pressure > arteriolar pressure
• Hypoxia
• (Muscle) necrosis
• Critical pressure Pdiast - Pcomp < 30 mm Hg
• Decreasing arteriovenous difference
• Reperfusion can occur (AMP to hypoxanthine)
Compartment syndrome diagnosis is clinical
• Unrelenting, bursting pain

• Unreleased by analgesia
• Swollen compartment
• Passive stretch pain
• Sensory deficit?
• Pulses always palpable
Compartment pressure measurement
• Critical measurement is the difference between compartment

pressure and patient’s systolic pressure
• Invaluable in unconscious or anesthetized patients
• Trends are more useful than single readings
• NOT a substitute for clinical diagnosis
Compartment syndrome treatment
• Remove all compressing casts

• Lay the extremity flat
• Dermatofasciotomy > 30 mm Hg
• Lateral perifibular
• Bilateral
• Open all four compartments
Evaluation of muscle viability
• Color
• Contractility
• Consistency
• Capillary bleeding
Techniques for soft-tissue handling
Incisions
• “Minimally invasive” ≠ small incision
• If small incision does not allow adequate visualization, excessive
retraction is often used
• Proper placement of incision is more critical when using small
incisions
• Small incisions do not ensure that the surgeon does not strip the
bone
• Do not skive the skin—incise the skin perpendicular to the skin
Retraction
• Avoid retracting more than required to provide visualization
• Relax retraction whenever not needed
• Avoid self-retaining retractors when possible because they are
easily set and forgotten
Forceps
• Use a very gentle touch—do not squeeze tissue
• Use as a retractor
• Avoid the use of large forceps (eg, Smith-Peterson) on the skin
Dissection
• Avoid horizontal dissection planes whenever possible (especially
between the subcutaneous tissue and fascia)
• Gentle pressure on the skin edge may allow visualization of
bleeders which may then be specifically cauterized
• Sharp dissection with a knife should be used when possible
(rather than cutting with scissors which crushes soft tissues)
• Avoid multiple passes with scissors or scalpel through tissues
Bone exposure
• Preserve periosteum whenever possible
• Use least aggressive bone holding clamps as possible
• Pay attention
Take-home messages
• Soft tissue plays a critical role in preventing infection, supplying

vasculature to bone, and in function
• Soft-tissue injury must be appreciated when deciding how to
approach a fracture
• Soft tissue must not be further injured by careless surgical
dissection
• Compartment syndrome is a surgical emergency
• A high index of suspicion and early diagnosis is key to successful
treatment

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The (soft-tissue) injury—

a high priority consideration

AO Trauma Basic Principles Course

• Describe the role of soft tissue in fracture healing

Vascular supply to the skin is directly related to perforators that

• Usually comes from named vessels

Single major/multiple minor

Outer 1/3 of bone

• Supplied by periosteal vessels that arise from named arteries

Inner 2/3 of bone

• In fractures, the blood supply to the callus forms from the

• Skin is the primary barrier to infection

Degree of bone injury implies level of injury to soft tissue

Mechanism of injury can also give clues

Size matters, but not that much

Integumentum closed (IC)

Rüedi, Border, Hanson, Tscherne

Integumentum open (IO)

Rüedi, Border, Hanson, Tscherne

Neurovascular injury (NV)

Rüedi, Border, Hanson, Tscherne

Muscle and tendon injury (MT)

Rüedi, Border, Hanson, Tscherne

• Increasing volume in a nonexpandable space

• Unrelenting, bursting pain

• Critical measurement is the difference between compartment

• Remove all compressing casts

• Soft tissue plays a critical role in preventing infection, supplying

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