Fracture Classifications

Jaclyn M. Jankowski, DO
Jersey City Medical Center-RWJBarnabas Health

All images belong to Jaclyn Jankowski, DO unless otherwise indicated Core Curriculum V5
 Objectives
• To understand the need for classification systems

• To understand the evolution of classification systems

• To look at the importance of soft tissue injury associated with

fractures

Core Curriculum V5
Why do we have classifications?
• Organize knowledge

• Transfer information

• Guide treatment

• Estimate prognosis

• Enhance education and communication

Core Curriculum V5
History of Classification Systems
• Ancient Egypt

• The Edwin Smith Papyrus classified

injuries as:
• “An ailment which I will treat”
• “An ailment with which I will
contend”
• “An ailment not to be treated”

Core Curriculum V5
 History of Classification Systems
• 18th and 19th Century
-Descriptive classifications based on appearance of limb

“Dinner Fork Deformity”

CCO 1.O

CCO 1.O

Core Curriculum V5
 History of Classification Systems

• 20th Century
• The advent of radiographs created numerous classification systems
• Brought about the ability to identify location, amount, and displacement of
fracture lines
• Not without problems as radiographic views and quality can be inconsistent

Core Curriculum V5
 History of Classification Systems
• The last 40 Years
• CT has allowed for further understanding and classification of
intra-articular fractures

Core Curriculum V5
 History of Classification Systems
• Believe it or not there’s more to consider than just bones!
• X-rays or CT alone can underestimate the severity of the overall
injury and don’t consider patient status

Core Curriculum V5
 What makes a good classification?

• Inter-observer Reliability
• Do different physicians agree on the classification of a particular
fracture?

• Intra-observer Reproducibility
• For a given fracture, does the same physician classify it the same way
at different times?

Core Curriculum V5
Types of Classification Systems

• Fracture-Specific

• Universal

• Soft Tissue Injury Associated with Fracture

Core Curriculum V5
Examples of Fracture-Specific Descriptive
Classifications
• Garden – guides management/surgical plan

• Neer – assists describing fracture for communication

• Schatzker – can predict associated injuries and prognosis

• Lauge-Hansen – provides insight into mechanism

• Sanders - an example of CT-based classification

Core Curriculum V5
 Non-Displaced
Garden Classification
I Valgus impacted or
incomplete
II Complete
I II
Non-displaced
III Complete
Displaced
Partial displacement
IV Complete
Full displacement
** Portends risk of AVN and
Nonunion**
III IV
Images courtesy of Frank Liporace, MD Core Curriculum V5
 Garden Classification
Pros Cons
-Determining displaced vs -Poor interobserver reliability
nondisplaced is critical for dictating between Types I and II
management
-Classification based on AP
-Classification has highest inter- radiograph only
and intra- observer reliability when  can underestimate
compared to Pauwel’s and AO degree of displacement
classifications

Kazley JM, Banerjee S, Abousayed MM, Rosenbaum AJ. (2018). Classifications in brief: Garden classification
of femoral neck fractures. Clin Orthop Relat Res. 476:441-445.
Core Curriculum V5
 Neer Classification
• Based on anatomic segments of
the proximal humerus

• Considered to be a ”part” if
arbitrarily displaced 1 cm or
angulated 45o

• Classification has good

intraobserver reliability, but
only moderate interobserver
reliability, though still useful for
communication purposes
Bernstein J, Adler LM, Blank JE, Dlasey RM, Williams GR,
Iannotti JP. (1996). Evaluation of the Neer system of
classification of proximal humerus fractures with
computerized tomographic scans and plain radiographs. Dirschl DR. In: Rockwood and Green’s Fractures in Adults. 8th ed. Court-Brown CM, Heckman JD, McQueen MM, Ricci

Journal of Bone and Joint Surgery, 78-A(9): 1371-1375. Core Curriculum V5

WM, Tornetta III P, eds. Wolters Kluwer Health; 2015.
 Schatzker Classification

I: Lateral Split II: Split Depression III: Lateral Depression

Core Curriculum V5
 Schatzker Classification

IV: Medial Plateau V: Bicondylar VI: Metaphyseal-Diaphyseal Dissociation

Core Curriculum V5
 Schatzker Classification
• Study to compare the inter-observer
reliability and intra-observer reproducibility
of the Schatzker, AO, and Hohl and Moore
classifications of tibial plateau fractures

• Four observers at different points in their

careers classified 50 tibial plateau fractures

• Schatzker showed superior inter-observer

reliability and intra-observer reproducibility
compared to AO and Hohl and Moore
--> though still not perfect

Core Curriculum V5
 Schatzker Classification

• Associated Injuries By Fracture Type

• Schatzker II  Lateral meniscal tears
• Schatzker IV  medial meniscal tears, ACL injury, vascular injury
• Schatzker VI  ACL injury, compartment syndrome

Bennet WF and Browner B. (1994). Tibial plateau fractures: A study of associated soft tissue injuries. J Orthop Trauma.
8(3):183-188.

Core Curriculum V5
 Lauge-Hansen Classification
Based on position of ankle and direction of force applied at time of injury

Supination External Rotation Supination Adduction

Core Curriculum V5
 Lauge-Hansen Classification
Based on position of ankle and direction of force applied at time of injury

Pronation External Rotation Pronation Abduction

Core Curriculum V5
 Lauge-Hansen Classification

Pros Cons

-Provides understanding of -Found to have the lowest

mechanism for rotational ankle interobserver reliability when
fractures compared to the AO and Danis-
Weber classifications
-Enables interprofessional
communication for rotational -Classification cannot be used for
ankle fractures non-rotational ankle fractures

Lopes da Fonseca L, Nunes IG, Nogueira RR, Martins GEV, Mesencio AC, Kobata SI. (2018). Reproducibility of the Lauge-Hansen,
Danis-Weber, and AO classifications for ankle fractures. Rev Bras Ortop. 53(1):101-106.

Core Curriculum V5
 Sanders Classification
• CT-based classification looking at the widest part of the calcaneus:
• Number articular fracture fragments
• Location of fragments

• Compare to x-ray-based Essex-Lopresti it provides increased insight:

• Fracture pattern
• Pre-op planning
• Prognosis

Core Curriculum V5
 Sanders Classification
• Type I: all fractures with <2mm displacement

• Type II: two-part fractures of the posterior

facet

• Type III: three-part fractures of the posterior

facet

• Type IV: highly comminuted fracture with four

or more fracture lines

Dirschl DR. In: Rockwood and Green’s Fractures in Adults. 8th ed. Court-Brown CM, Heckman JD, McQueen MM,
Ricci WM, Tornetta III P, eds. Wolters Kluwer Health; 2015.
Core Curriculum V5
 Sanders Classification

• Cross-sectional study of 100 pre-op CT scans of patients with intra-articular calcaneus

fractures operated on by a single surgeon

• Researchers reported:
• Good to excellent intra-observer reproducibility
• Moderate inter-observer reliability (which was better than what was previously
reported in the literature).

• Validity was reported to be fair

Core Curriculum V5
Universal Classification System

Core Curriculum V5
 OTA/AO Classification

• Alphanumeric classification that can be applied throughout the

skeleton, based on fracture location and morphology

• Created in the 1960’s and multiply updated to include

classifications of the pelvis and acetabulum

Core Curriculum V5
 OTA/AO Classification

• Fracture Location
• Which bone?
• Each bone is assigned a specific
number

Core Curriculum V5
 OTA/AO Classification
1

• Fracture Location
• Which part of the bone? 2
• 1. Proximal end segment
• 2. Diaphyseal segment
• 3. Distal end segment
3

Core Curriculum V5
 OTA/AO Classification

• Fracture Morphology

• Diaphyseal segment
• Type A: Simple fractures
• spiral, oblique, transverse
• Type B: Wedge fractures
• spiral, bending, fragmented
• Type C: Multifragmentary fractures
• spiral wedge, segmented, irregular

Core Curriculum V5
 OTA/AO Classification

• Fracture Morphology

• End segment
• Type A: Extra-articular
• Type B: Partial articular
• Type C: Complete articular

Core Curriculum V5
 OTA/AO Classification

• Now have additional Subgrouping

• Goal of Subgrouping: to increase the precision of the
classification
• Subgroups differ amongst each bone

Core Curriculum V5
OTA / AO Classification Subgrouping
• Complex and value not fully known (Example: Distal Femur)

Core Curriculum V5
But what about the soft tissues?

Core Curriculum V5
Soft Tissue-Based Classifications

• Oesterne and Tscherne Classification

• Gustilo-Anderson Classification

• OTA Open Fracture Classification

Core Curriculum V5
 Oesterne and Tscherne Classification
• Classification of soft tissue damage in the setting of a closed fracture
Grade Soft Tissue Injury Bony Injury
Grade 0 Minimal soft tissue damage Simple fracture pattern
Indirect injury to limb
Ex: low energy spiral fractures

Grade 1 Superficial abrasion/contusion Mild fracture pattern

Ex: rotational ankle fracture-dislocations

Grade 2 Deep abrasion with skin or muscle Severe fracture pattern

contusion
Direct trauma to limb Ex: segmental fractures

Grade 3 Extensive skin contusion or crush Severe fracture pattern

Severe underlying muscle damage
Subcutaneous avulsion
Possible compartment syndrome

Ibrahim DA, Swenson A, Sassoon A, Fernando ND. (2017). Classifications in brief: The Tscherne Classification of soft
tissue injury. Clin Orthop Relat Res. 475:560-564.
Core Curriculum V5
 Gustilo-Anderson Classification
• Type I: wound ≤1 cm, minimal contamination or muscle damage

• Type II: wound 1-10 cm, moderate soft tissue injury

• Type IIIA: wound usually >10 cm, high energy, extensive soft-tissue damage,
contaminated, but with adequate tissue for flap coverage

• Type IIIB: extensive periosteal stripping, wound requires soft tissue coverage (rotational
or free flap)

• Type IIIC: vascular injury requiring vascular repair, regardless of degree of soft tissue injury
**Appropriate classification can only be made intraoperatively**

Kim PH and Leopold SS. (2012). Gustilo-Anderson classification. Clin Orthop Relat Res.
470:3270-3274. Core Curriculum V5
 OTA Classification of Open Fractures
• Assigns severity to five essential factors for treatment
Essential Factor Severity
Skin 1. Can be approximated
2. Cannot be approximated
3. Extensive degloving
Muscle 1. No muscle in area/no appreciable necrosis
2. Loss of muscle; intact function, localized necrosis
3. Dead muscle, loss of function
Arterial 1. No injury
2. Arterial injury without ischemia
3. Arterial injury with ischemia
Contamination 1. None or minimal
2. Surface contamination
3. Imbedded in bone or deep tissues
Bone Loss 1. None
2. Bone missing or devascularized, but still contact present between
proximal and distal segments
3. Segmental bone loss

Orthopaedic Trauma Association: Open Fracture Study Group. (2010). A new classification scheme
for open fractures. J Orthop Trauma. 24(8): 457-465. Core Curriculum V5
Reliability of Classification Systems
• OTA Open Fracture Classification System appears superior to Gustillo-
Anderson Classification System in both reliability and validity
• 86% overall interobserver agreement vs 60% for G-A
• JOT: 2013 vol 27; pp379-384
• Interobserver RELIABILITY is different than VALIDITY
• If surgeons agree on a measurement pre-operatively (“reliability”),
that may not prove to be accurate intra-operatively (“validity”)
• JAAOS: 2002 vol 10; pp290-297

Core Curriculum V5
Use of Soft Tissue and Open
Fracture Classifications
• Prospective study to determine if descriptive classifications of diaphyseal
tibia fractures are predictive of prognosis

• Compared AO, Gustilo-Anderson, Tscherne, and Winquist-Hansen

classifications and looked at union, need for future surgery, and
subsequent infection

• Found that the Tscherne Classification was most predictive of final

outcome
Core Curriculum V5
 Summary

• Classifications are essential for communication, education, treatment

guidelines, and as a prognostic tool

• As imaging technology has advanced so have our fracture classifications

• The soft tissue can’t be ignored and classification systems taking the soft
tissue envelope into consideration are essential for creating a complete
prognostic picture

Core Curriculum V5
 References
• Bennet WF and Browner B. (1994). Tibial plateau fractures: A study of associated soft tissue injuries. J Orthop Trauma. 8(3):183-
188.
• Bernstein J, Adler LM, Blank JE, Dlasey RM, Williams GR, Iannotti JP. (1996). Evaluation of the Neer system of classification of
proximal humerus fractures with computerized tomographic scans and plain radiographs. Journal of Bone and Joint Surgery, 78-
A(9): 1371-1375.
• Dirschl DR. Chapter 2: Classification of fractures. In: Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta III P, eds.
Rockwood and Green’s Fractures in Adults. 8th ed. Wolters Kluwer Health; 2015:43-57.
• Gaston P, Will E, Elton RA, McQueen MM, and Court-Brown CM. (1999). Fractures of the tibia. The Journal of Bone and Joint
Surgery. British Volume, 81-B(1), 71–76.
• Ibrahim DA, Swenson A, Sassoon A, Fernando ND. (2017). Classifications in brief: The Tscherne Classification of soft tissue injury.
Clin Orthop Relat Res. 475:560-564.
• Kazley JM, Banerjee S, Abousayed MM, Rosenbaum AJ. (2018). Classifications in brief: Garden classification of femoral neck
fractures. Clin Orthop Relat Res. 476:441-445.
• Kim PH and Leopold SS. (2012). Gustilo-Anderson classification. Clin Orthop Relat Res. 470:3270-3274.
• Lopes da Fonseca L, Nunes IG, Nogueira RR, Martins GEV, Mesencio AC, Kobata SI. (2018). Reproducibility of the Lauge-Hanses,
Danis-Weber, and AO classifications for ankle fractures. Rev Bras Ortop. 53(1):101-106.
• Maripuri SN, Rao P, Manoj-Thomas A, and Mohanty K. (2008). The classification systems for tibial plateau fractures: How reliable
are they? Injury, 39(10), 1216–1221.
• Orthopaedic Trauma Association: Open Fracture Study Group. (2010). A new classification scheme for open fractures. J Orthop
Trauma. 24(8): 457-465.

Core Curriculum V5