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)

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

(Orthobullets)

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

(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 

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)

Lower Extremity

Pipkin Classification (Femoral Head Fractures)

(Link)

• 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

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

Intertrochanteric Femur Fractures

• Extracapsular femur fracture (heals better than intracapsular)

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)

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)

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

Gartner Classification (Supracondylar humerus fractures)

(Orthobullets)

Pediatric Tibial Shaft Fracture Parameters

(Link)