Fracture Classification

Fracture Classification Overview

  • Presenter: Lisa K. Cannada MD

  • Last Updated: 05/2016

History of Fracture Classification

  • 18th & 19th Century: Based on clinical appearance of limb.

  • Example: Colles Fracture characterized by the "Dinner Fork Deformity".

20th Century Developments

  • Shift to classifications based on radiographs.

  • Many classification systems developed; issues with:

    • Radiographic quality

    • Injury severity

Role of CT Scans in Classification

  • CT scanning provides additional assistance in fracture classification.

  • Example: Sanders classification for calcaneal fractures.

Factors in Fracture Assessment

Soft Tissue Impact

  • Fractures can appear non-complex in radiographs, but soft tissue injuries may complicate treatment.

Patient Variables

  • Considerations include:

    • Age

    • Gender

    • Diabetes

    • Infection

    • Smoking

    • Medications

    • Underlying physiology

Injury Variables

  • Assessment of:

    • Severity

    • Energy of injury

    • Morphology of the fracture

    • Bone loss

    • Blood supply

    • Location

    • Presence of other injuries

Importance of Classifying Fractures

  • Treatment Guide: Standardized approaches for similar bone fractures.

    • Problem: Variations in "fracture personality" based on equipment and surgeon experience.

  • Assist with Prognosis: Helps in managing patient expectations.

    • Problem: Often neglects soft tissue and other complicating factors.

  • Common Language: Facilitates comparison among surgeons.

    • Problem: Poor interobserver reliability in existing classifications.

Interobserver and Intraobserver Reliability

  • Interobserver Reliability: Agreement among different physicians on fracture classification.

  • Intraobserver Reliability: Consistency of classification by a single physician over time.

Descriptive Classification Systems

  • Notable examples include:

    • Garden: Femoral neck fractures

    • Schatzker: Tibial plateau fractures

    • Neer: Proximal humerus fractures

    • Lauge-Hansen: Ankle fractures

Literature Insights

  • Research by Thomsen et al. on ankle fractures:

    • Evaluated accuracy and agreement of classifications.

    • Findings: Acceptable reliability in both Lauge Hansen and Weber classifications, but poor precision in staging, especially for PA injuries.

  • Frandsen study on femoral neck fractures:

    • Only 22 out of 100 fractures classified identically by different observers.

    • Significant disagreement on displacement classification.

OTA Classification System

  • Need: Organized and systematic fracture classification.

  • Goal: A comprehensive system adaptable to the entire skeletal system.

  • Benefits: Creates organized fracture descriptions, constant in research, and adaptable over time.

OTA Classification Framework

  • To classify a fracture, consider:

    • Which bone?

    • Location in the bone?

    • Type?

    • Group?

    • Subgroup?

  • Example: Tibia/Fibula classification into diaphyseal segment.

Fracture Types by Location and Complexity

  • Proximal & Distal Segment Fractures:

    • Type A: Extra-articular

    • Type B: Partial articular

    • Type C: Complete disruption of the articular surface from the diaphysis

  • Diaphyseal Fractures:

    • Type A: Simple fractures (2 fragments)

    • Type B: Wedge fractures (restore alignment)

    • Type C: Complex fractures (no main fragment contact)

Fracture Groupings

Type A Grouping

  • Simple Fractures examples:

    • Spiral (42-A1)

    • Oblique (≥ 30°, 42-A2)

    • Transverse (<30°, 42-A3)

Type B Grouping

  • Wedge Fractures examples:

    • Spiral wedge (42-B1)

    • Bending wedge (42-B2)

    • Fragmented wedge (42-B3)

Type C Grouping

  • Complex Fractures examples:

    • Spiral multifragmentary wedge (42-C1)

    • Segmental (42-C2)

    • Irregular (42-C3)

Subgrouping

  • Varies by bone and is tied to key classification features.

  • Increases precision of classifications.

Importance of Soft Tissue Classification

  • All fractures involve some degree of soft tissue injury.

  • Commonly classified by the Tscherne Classification.

    • Do not overlook soft tissue injury.

Tscherne Classification Grades

  • Grade 0: Minimal soft tissue injury; indirect injury.

  • Grade 1: Superficial contusions or abrasions due to internal injury.

  • Grade 2: Direct injury leading to significant soft tissue damage & possible muscle contusions.

  • Grade 3: Severe soft tissue injury; may involve compartment syndrome and extensive tissue damage.

Literature on Tscherne Classification

  • Study on tibial shaft fractures treated with intramedullary nails

    • Findings showed Tscherne classification had better predictive value for outcomes (union, additional surgery, infection) compared to others.

Open Fractures Overview

  • Defined as a break in the skin and soft tissue leading into the fracture site.

Gustilo-Anderson Classification

  • Commonly used for open fractures, particularly tibia.

  • Correlates size of skin injury with outcomes (healing, infection, amputation).

Open Fracture Types

  • Type I: Clean wounds with minimal soft tissue damage.

  • Type II: Moderate soft tissue damage with some necrotic muscle.

  • Type III: High energy injuries leading to severe muscle devitalization.

    • Type IIIA: Coverage adequate.

    • Type IIIB: Requires flap for coverage and soft tissue closure.

    • Type IIIC: Major vascular injury requiring repair, high infection/amputation risk.

Literature on Open Fracture Classification

  • Study of interobserver agreement varied among surgeons, especially novice vs. trained trauma attendings.

Contact Information

  • For questions or comments, reach out at: ota@ota.org