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Need to Know Criteria and Classification Systems

There are many classification systems within orthopedics. Here are the systems that we have found are commonly discussed in fracture conference that would be good to be familiar with for your ortho trauma rotations.

Gustillo-Anderson Classification (For Open Fractures)

Type 1

Laceration <1cm in diameter

Type 2

Laceration >1cm <10cm without signs of high energy (Extensive soft tissue injury despite intact skin)

Type 3

>10cm soft injury (All high energy open fractures or those with gross contamination regardless of the size of the wound are type 3)

  • Type 3 A: Adequate soft tissue for coverage of fracture

  • Type 3 B: Inadequate soft tissue coverage, flap required

  • Type 3 C: Associated arterial injury requiring repair



Upper Extremity

La Fontaine’s Criteria (Predictors of distal radius fracture instability)

  •  dorsal angulation > 20 degrees

  •  initial radial shortening >5mm

  • associated ulnar fracture (more than just tip of ulnar styloid)

  • dorsal comminution >50% (most frustrating for holding reduction)

  •  palmar comminution

  •  intra-articular comminution

  • Osteoporosis

Distal Radius Surgical Indications

  • Open fractures

  • Articular margin fractures

  • Volar or dorsal comminution

  • Displaced intra-articular fractures >2mm

  • Instability factors (elderly can take alot of deformity with good outcomes)

  • Volar ulnar corner where the lunate articulates (Die-punch fractures)

  • Comminuted and displaced extra-articular fractures

  • Progressive loss of volar title and radial length following closed reduction and casting

  • External fixation for severe open fractures, highly comminuted fractures, medical unstable patients

(Orthobullets)


Neers Classification (Proximal humerus fractures)

  • Based on how many parts to the fracture there is

  • Always consider high vs. low energy

  • The more parts of a fracture the more likely there will be avascular necrosis (AVN)

  • A “part” is considered separate if there is displacement of >10mm or 45degrees of angulation (this is actually quite of bit of displacement and angulation)

  • 4 potential fracture “parts”

    • Humeral shaft

      • Fracture through Anatomic neck or Surgical neck

    • Greater Tuberosity

    • Lesser Tuberosity

    • Articular surface

  • Unique types

    • Fracture dislocation

      • Humeral head articular segment is not reduced with glenoid

      • Can include two part, three part or four part fractures

    • Head split (articular segment is split)


Surgical Indications

  • Greater tuberosity displaced >5mm

  • 2, 3, and 4-part fractures in younger patients (higher energy fracture mechanism

  • Head-splitting fractures in younger patients

  • Fracture dislocation

  • Open fractures

  • Reverse total shoulders are used when there is a high risk for AVN in more comminution such as 3 to 4 part fractures in the elderly. Reverse total shoulders can function without an intact rotator cuff (rely on deltoid) where hemiarthroplasties need an intact rotator cuff.


Treatment by fracture type

2 Part: Surgical Neck

Non operative, Sling, surgical indications controversial

2 Part: Greater Tuberosity

Non op and Sling if GT displaced <5mm

Operative if GT displaced >5mm

2 Part: Lesser Tuberosity

Non operative minimally or non-displaced. 

ORIF if large fragment, excision and rotator cuff repair if small

3 Part: Surgical neck and greater tuberosity

Non op 

  • minimally displaced greater tuberosity <5mm, articular segment <1cm and <45 deg

  • Poor surgical candidate

Operative

  • Young patient (perc pinning, IM fixation, locking plate)

  • Elerly (hemiarthroplasty (with rotator cuff repair/RCR) vs. reverse total shoulder)

3 Part: Surgical neck and Lesser tuberosity

Commonly Non operative

Operative

  • Young patient (perc pinning, IM or locking plate)

  • Elderly (hemi with RCR or reverse total shoulder)

4 Part: Valgus impacted fracture

Non op, institution specific. Low rate of AVN if posteromedial calcar intact

Operative technique, raise articular surface, fill defects, repair tuberosities

4 Part: Head-splitting

High AVN risk

Operative

  • Young

    • ORIF vs. hemi

  • Elderly

    • Hemi v. reverse total shoulder

(Orthobullets)

Bado Classification (Monteggia fractures, ulnar shaft + radial head dislocation)



Type 1

Fracture of proximal or middle third ulna with anterior dislocation of the radial head (most common in young people)

Type 2

Fracture of proximal or middle third ulna with posterior dislocation of the radial head (70-80% of adult Monteggia frxs)

Type 3

Fracture of ulna metaphysis, distal to coronoid with lateral dislocation of the radial head

Type 4

Fracture of proximal or middle third ulna and radius with dislocation of the radial head in any direction

(Orthobullets)


Spine

Thoracolumbar Injury Classification and Severity Score (TLICS for Thoracolumbar Burst Fractures)


  • Injury morphology

    • Compression (+1 point)

    • Burst (+2 points)

    • Rotation/translation (+3 points)

    • Distraction (+4 points)

  • Neurologic status

    • Intact (0 points)

    • Nerve root (+2 points)

    • Incomplete spinal cord or conus medullaris injury (+3 points)

    • Complete spinal cord or conus medullaris injury (+2 points)

    • Cauda equina syndrome (+3 points)

  • Posterior ligamentous complex integrity

    • Intact (0 points)

    • Suspected/indeterminate (+2 points)

      • MRI shows some signal in interspinous ligaments

    • Disrupted (+3 points)

      • Widening of interspinous distance seen


  • <4 points = Non surgical management

  • 4 points = Non surgical or surgical management

  • > 4 points = Surgical management indicated


  • Operative Indication (Surgical decompression & stabilization)

    • Neurologic deficits with imaging evidence of cord/thecal sac compression

    • Unstable fracture pattern

      • Injury to Posterior Ligament Complex (PLC)

        • Supraspinous ligaments

        • Interspinous ligaments

        • Facet capsule ligament

        • Ligamentum flavum

      • Progressive kyphosis

      • Lamina fractures (controversial

      • TLICS score = 5 or higher 



Pelvis

Young-Burgess Classification (Pelvic Ring Injuries)

  • Anterior-posterior compression (APC) and lateral compression (LC) injuries need inlet outlet x-ray views to evaluate for pelvic ring injuries

  • Needs a pelvis CT 


APC 1

Symphysis widening <2.5cm

  • Non-op. Protected weight bearing

APC 2

Symphysis widening >2.5cm. Anterior SI joint diastasis. Sacrotuberous and spinous ligaments torn.

  • May need a pelvic binder in attempt to close down pelvic volume.

  • Anterior symphyseal plate or Ex fix

  • + or – posterior fixation

APC 3

Symphysis widening and disruption of anterior and posterior sacroiliac (SI) ligaments (SI dislocation). 

  • Sacrotuberous and spinous ligaments torn.

  • Associated with vascular injury.

  •  Needs a pelvic binder.

  • Anterior symphyseal multi-hole plate or ex fix

  • Posterior stabilization with plate or screws




LC 1

Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture

Can be subtle, if rami fracture, look for compression frx of sacrum on the same side

(Orthobullets)


  • Non-op for incomplete sacral fracture

  • Protected weight bearing for complete and comminuted sacral frx

  • Weight bearing as tolerated (WBAT) for simple, incomplete

LC 2

Rami fracture and ipsilateral posterior ilium fracture dislocation

(Orthobullets)

  • ORIF Ilium


LC 3

Ipsilateral compression and contralateral APC (windswept pelvis)

(Orthobullets)

  • Posterior stabilization with plate or SI screws






Vertical Shear

  • Posterior and superior directed force

  • Highest risk of hypovolemic shock

  • Needs ipsilateral traction pin

  • Binder may not be helpful, unless coupled with symphysis widening

(Orthobullets)


Letournel Classification (Acetabular Fractures)


  • Elementary Types

    • Posterior wall

    • Posterior column

    • Anterior wall

    • Anterior column

  • Associated Types

    • Both column

    • Transverse + Posterior wall

    • T shaped

    • Anterior column or wall + Posterior hemitransverse

    • Posterior column + Posterior wall

(Link)


  • Non operative with protected weight bearing

    • Patient factors

      • High operative risk

      • Morbid obesity

      • Open contaminated wound

      • Late presenting >3 weeks

    • Fracture characteristics

      • Minimally displaced <2mm

      • <20% posterior wall fractures

        • May need exam under anesthesia to look for instability

      • Femoral head congruence with weight bearing roof (out of traction)

      • Both column fracture with secondary congruence of head and weight bearing roof (out of traction)

      • Displaced fracture with roof arc >45deg in AP and Judet views or >10mm on axial CT cuts


  • Operative Treatment Indications

    • Patient factors

      • <3 weeks from date of injury

      • Physiologically stable

      • Adequate soft-tissue envelope

      • No local infection

    • Fracture factors

      • Displacement of roof >2mm

      • Unstable fracture pattern (posterior wall >40-50%)

      • Marginal impaction

      • Intra-articular loose bodies

      • Irreducible fracture-dislocation

(Orthobullets)


Sacrum

Denis Classification (Pronounced like “Den-ee”)

  • Get a CT to evaluate

  • MRI if nerve injury suspected

  • L4 L5 transverse process fractures are associated with high energy trauma and other fractures of sacrum/pelvis

  • L5 nerve root (great toe extension and 1st web space) runs anterior to sacrum and is susceptible to injury with sacral fractures

(Link)



Zone 1

Fracture lateral to foramina

Zone 2

Fracture through foramina

  • Unstable vs. stable

  • With shear = highly unstable

Zone 3

Fracture medial to foramina into spinal canal

  • Highest rate of neuro deficit (60%), bowel, bladder, sexual dysfunction

Transverse

Higher incidence of nerve involvement.

(Orthobullets)

U-type

Spino-pelvic dissociation


Treatment


Non operative

<1cm displacement and no neuro deficit

Operative

  • Displaced fractures >1cm

  • Soft tissue compromise

  • Persistent pain after non-operative management

  • Displacement of fracture after non-operative management

  • Decompression if neurologic injury


Lower Extremity

Pipkin Classification (Femoral Head Fractures)

(Link)


Pipkin 1

Fracture below fovea, below the weight bearing portion

TTWB for 4-6 weeks, restrict adduction and internal rotation

Pipkin 2

Fx superior to fovea/ligamentum in weight bearing portion of femoral head

TTWB if good reduction, <1mm step off

  • No interposed fragments

  • Stable hip joint

ORIF if >1 mm step off

Pipkin 3

Type 1 or 2 with a femoral neck fracture

  • High incidence of AVN

ORIF

Pipkin 4

Type 1 or 2 with a posterior wall acetabular fracture

ORIF


  • ORIF for 

    • Pipkin 2 with >1mm step off, Pipkin 3 and 4

    • If performing loose body removal

    • Polytrauma

    • Irreducible fracture-dislocation

  • Arthroplasty in elderly for Pipkin 1, 2 (displaced), 3, and 4

  • Arthroscopy is an option for removal of loose bodies


Garden Classification (Elderly Femoral Neck fractures)

  • Used in low energy injury elderly patients, not high energy injuries in young patients

  • If fracture line is basicervical (at the base of the femoral neck near the trochanteric portion of the femur) then dynamic hip screw is an option

  • Femoral neck fractures are intracapsular (except basicervical) and don’t heal well due to blood supply disruption if displaced and synovial fluid getting in fracture site


Type 1

Incomplete, Valgus impacted

Closed reduction percutaneous pinning (CRPP) with screws in inverted triangle

Type 2

Complete, nondisplaced

CRPP with screws in inverted triangle

Type 3

Complete, partially displaced

  • Hemiarthroplasty in low demand


  • Total hip arthroplasty in higher demand and more active individual (<85 years)

Type 4

Complete, fully displaced

  • Hemiarthroplasty in low demand


  • Total hip arthroplasty in higher demand and more active individual (<85 years)



Pauwels Classification (Young Femoral Neck Fractures based on verticality of fracture line)

  • Often used in higher energy young patients

  • Femoral neck fractures are intracapsular (except basicervical)

  • The more vertical the fracture line, the more shear forces pushing the fragments apart, less likely to heal

  • ORIF for displaced fractures in young patients most <65 years old

  • CRPP for most


Type 1

< 30 deg from horizontal

CRPP 

Type 2

30-50 deg from horizontal

CRPP vs. sliding hip screw

Type 3

>50 deg from horizontal (highest risk of nonunion and AVN)

Dynamic hip screw (DHS)

  •  If  DHS fails, valgus producing osteotomy and blade plate is an option



Intertrochanteric Femur Fractures

  • Extracapsular femur fracture (heals better than intracapsular)


Stable

  • Fracture line extends from Greater trochanter to lesser trochanter

  • No unstable characteristics

  • Dynamic hip screw (less commonly used)

  • Short or long intramedullary nail

    • Unstable

    • Reverse obliquity (frx line extends from proximal medial to lateral distal)

    • Lateral wall comminution or thin lateral wall

    • Posterior medial cortex comminution

    • Subtrochanteric extension

    • Long intramedullary nail



    Vancouver Classification (Fractures Around Arthroplasty Stems)

    (Orthobullets)

    • Vancouver classification has classifications for intraoperative fractures and post operative fractures, listed below are for postoperative fractures. 


    (Link)


    Type A

    Fracture in trochanteric region, associated with osteolysis.

    Greater troch fractures <2cm displacement – Non-op with partial weight bearing


    Greater troch fractures >2cm – ORIF with claw/cables

    Type B1

    Fracture around stem or just below it, with a well-fixed stem

    ORIF using cerclage cables and locking plates

    Type B2

    Fracture around stem or just below it, with a loose stem, but good proximal bone stock

    Revision of femoral component to long porous-coated cementless stem and fixation of the fractures fragment.

    Type B3

    Fracture around stem or just below it, with a loose stem, but poor quality proximal bone stock or severely comminuted

    Femoral component revision with proximal femoral allograft 

    or proximal femoral replacement

    Type C

    Fracture occurs well below the prosthesis

    ORIF with plate



    Schatzker Classification (Tibial plateau fractures)

    • Get a CT scan

    • Can remember the first three types with the boyfriend/girlfriend breakup analogy; you split, then you are split and depressed, then just depressed.

    (link)


    Type 1

    Lateral split

    Often low energy

    Non-op common vs. ORIF

    Type 2

    Lateral split-depressed

    Often low energy

    Non-op vs. ORIF

    Type 3

    Later pure depression

    Often low energy

    Non-op common vs. ORIF

    Type 4

    Medial plateau

    • Vascular injury is most common in this type due to common fracture-dislocation of the knee

    • Get an ankle brachial index ABIs

    • Watch for compartment syndrome

    ORIF

    Type 5

    Bicondylar

    • High energy fracture, be aware of vascular injury

    • Get an ankle brachial index ABIs

    • Watch for compartment syndrome

    ORIF

    Type 6

    Metaphyseal-diaphyseal disassociation

    • High energy fracture, be aware of vascular injury

    • Get an ankle brachial index ABIs

    • Watch for compartment syndrome

    ORIF +/- Nail



    Treatment


    Non operative

    • Knee immobilizer, non weight bearing commonly used in ED

    • Hinged knee brace, partial weight bearing 8-12 weeks, immediate passive ROM

      • Minimally displaced split or depressed fractures

      • Low energy fracture stable to varus/valgus alignment

      • Nonambulatory patients

    Operative

    • External fixation +/- limited open/percutaneous fixation of articular segment (screws hold the articular surface together while in the ex fix

      • Severe open fracture with marked contamination

      • Highly comminuted fractures where internal fixation not possible

      • Can bridge to ORIF if soft tissue injury/polytrauma

    • ORIF

      • Articular stepoff >3mm

      • Condylar widening >5mm

      • varus/valgus instability

      • All medial plateau fractures

      • All bicondylar fractures



    Weber Classification (Ankle fractures)

    • Pronounced “webber”

    • The system is based off where the fracture line on the fibula hits the tibio-talar joint

    • Start by looking at the fibula

    • Weber A the fracture line is below/distal to the level of the ankle joint

      • Stable

    • Weber B, the fracture line has a component at the level of the ankle joint

      • Get a gravity stress view xray to check for widening of the medial clear space (if there isn’t obvious widening already)

    • Weber C, the fracture line is above the ankle joint

      • Get a gravity stress view xray to check for widening of the medial clear space (if there isn’t obvious widening already)

      • Assume that there is a higher fibula fracture if there is widening of the medial clear space or an isolated medial malleolus fracture


    (Link)


    Lauge-Hansen (Ankle fractures)


    • Remember Sad, Ser, Pad,Per

      • It stands for the position the ankle was in for the injury to occur

    • Start by looking at the fibula, is it a high or low fibula fracture

    • Low fibula

      •  Supination adduction (SAD)

        • The SAD ankle has a vertical medial fracture

      • Supination external rotation (spiral fibula means there was a twisting component)

        • Commonly has a Weber B fibula fracture

    • High fibula

      • Pronation abduction

        • Look for ankle abduction and high fibula

      • Pronation external rotation

        • Look for spiral component and high fibula


     

    (Orthobullets)


    Non Operative indications for ankle fractures

    Short-leg walking cast/boot

    • Isolated nondisplaced medial mal fracture or tip avulsions

    • Isolated lateral mal fracture with <3mm displacement, no talar shift

    • Bimal fracture if elderly or unable to undergo surgery

    • Posterior mal <25% joint involvement <2mm step-off

    Operative indications for ankle fractures

    Open reduction internal fixation (plates and screws)

    • Any talar displacement

    • Displaced isolated lateral mal fractures

    • Displaced isolated medial mal fracture

    • Bimalleolar fractures

    • Bimalleolar equivalent fractures (lateral mal fracture with widening of medial clear space between talus and medial mal due to disruption of the deltoid ligament, often found on gravity stress views)

    • Posterior mall fracture with >25% or >2mm step off

    • Bosworth fracture dislocations

    • Open fractures

    • Malleolar nonunions


    (Orthobullets)



    Pediatrics


    Both Bone Forearm Fracture Criteria



    Angle

    Malrotation

    Bayonet Apposition

    0-10 years

    <15

    <45

    Yes, if <1cm short

    ≥ 10 years

    <10

    <30

    No

    Approaching skeletal maturity (<2y growth), 14-16 boys, 12-14 girls

    0

    0

    No



    Gartner Classification (Supracondylar humerus fractures)


    Type 1

    Nondisplaced, no medial comminution

    Posterior arm splint, then long arm cast 3-4 weeks

    Type 2

    Displaced, deformity in sagittal plane only (posterior hinge)

    CRPP

    Type 3

    Displaced in 2 or 3 planes (sagittal and coronal)

    CRPP, ORIF if needed based on inability to reduce fragment closed, may be interposed periosteum

    Type 4

    Complete periosteal disruption (only identified in operating room)

    CRPP or ORIF if needed

    Medial comminution

    Collapse of medial column, may look like a type 1. Leads to varus malunion and gunstock deformity

    CRPP

    Flexion type

    Fragment is flexed volarly instead of dorsally, caused by fall on the olecranon

    Treated with CRPP, more likely to require open reduction

    (Orthobullets)




    Pediatric Tibial Shaft Fracture Parameters


    Age

    Coronal Angulation

    Sagittal Angulation

    Shortening

    Cortical Overlap

    Rotation

    <8

    <10

    <10

    <1cm

    >50% overlap

    0 deg

    ≥ 8

    <5

    <10

    minimal

    >50% overlap

    0 deg

    (Link)


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