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)
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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
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
| Operative
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3 Part: Surgical neck and Lesser tuberosity | Commonly Non operative | Operative
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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
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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 |
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 |
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APC 2 | Symphysis widening >2.5cm. Anterior SI joint diastasis. Sacrotuberous and spinous ligaments torn.
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APC 3 | Symphysis widening and disruption of anterior and posterior sacroiliac (SI) ligaments (SI dislocation).
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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 |
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LC 2 | Rami fracture and ipsilateral posterior ilium fracture dislocation |
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LC 3 | Ipsilateral compression and contralateral APC (windswept pelvis) |
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Vertical Shear |
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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
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
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Zone 3 | Fracture medial to foramina into spinal canal
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Transverse | Higher incidence of nerve involvement. |
U-type | Spino-pelvic dissociation |
Treatment | |
Non operative | <1cm displacement and no neuro deficit |
Operative |
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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
ORIF if >1 mm step off |
Pipkin 3 | Type 1 or 2 with a femoral neck fracture
| 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 |
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Type 4 | Complete, fully displaced |
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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)
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Intertrochanteric Femur Fractures
Extracapsular femur fracture (heals better than intracapsular)
Stable |
| Dynamic hip screw (less commonly used) Short or long intramedullary nail |
Unstable |
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Vancouver Classification (Fractures Around Arthroplasty Stems)
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 |
| ORIF |
Type 5 | Bicondylar |
| ORIF |
Type 6 | Metaphyseal-diaphyseal disassociation |
| ORIF +/- Nail |
Treatment | |
Non operative |
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Operative |
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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
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
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 |
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)