Classifications of Fractures, Dislocations, and Sports-Related Injuries

Open Versus Closed

( Fig. 1-1 )

• closed f.: does not produce an open wound of the skin but does result in loss of continuity of bone subcutaneously; formerly called simple f.

• open f.: one of the fragments has broken through the skin, and there is loss of continuity of bone internally; formerly called compound f.

Portion of Bone Involved

The portion of bone involved or the point of reference of a fracture may be referred to as the distal third ( D/3 ), the middle third ( M/3 ), and the proximal third ( P/3 ). Middle third fractures are commonly called midshaft fractures. For specific anatomic locations, the following terms are commonly used.

• apophyseal f.: avulsion of or fracture through an apophysis (bony prominence) where there is strong tendinous attachment.

• articular f.: involves a joint surface; also called joint f. and intraarticular f.

• cleavage f.: fracture through cartilage and bone that may be a large fragment such as a tibial plateau or avulsion of a small fragment of bone such as the capitellum.

• condylar f.: involves any round end of a hinge joint (see sections on femoral and distal humeral fractures).

• cortical f.: involves cortex of bone.

• direct f.: results at specific point of injury and is due to the injury itself.

• extracapsular f.: occurs near but outside the capsule of a joint, especially the hip; also called extraarticular.

• intracapsular f.: occurs within the capsule of a joint; also called intraarticular.

• nonphyseal f.: any childhood fracture that does not involve a growth plate.

• periarticular f.: occurs near but not involving a joint.

• transchondral f.: fracture through cartilage, which may not be apparent unless there is a bone fracture line into the joint; not to be confused with transcondylar f.

• transcondylar f.: occurs transversely between the condyles of the elbow. This term is also used in fractures of the femur and bones with condyles; also called diacondylar f.

• tuft f.: involves the distal phalanx (tuft) of any digit.

General Appearance

( Fig. 1-2 )

• avulsion f.: tearing away of a part; a fragmentation of bone where the pull of a strong ligamentous or tendinous attachment tends to forcibly pull the fragment away from the rest of the bone. The fragment is usually at the articular surface.

• burst f.: multiple fragments, usually at the end of a bone; f. of the first cervical vertebra or the body of the any vertebra where there is typically displacement of bone into the spinal canal.

• butterfly f.: a bone fragment shaped like a butterfly in which the fragment is completely detached from the proximal and distal segments of the bone; usually involves high-energy force delivered to the bone.

• chip f.: a small fragment, usually at the articular margin of a joint.

• comminuted f.: more than two fragments; described by degree and quantity of pieces; any third fragment of bone will constitute some element of comminution. A butterfly segment is a type of comminution. Typically, comminution is used to describe multiple fracture fragments (highly comminuted) versus only an additional fragment or two (minimally comminuted); also called splintered fracture or multifragmentary fracture.

• complete f.: the bone is completely broken through both cortices.

• compression f.: crumbling or smashing of cancellous bone by forces acting parallel to the long axis of bone; applied particularly to vertebral body fractures.

• depressed f.: typically an intraarticular depression of fragments, but may also be applied to depressed skull fractures.

• double f.: segmental f. of a bone in two places.

• epiphyseal f.: involves the portion of the bone that on the joint surface side of of the physis, which is the growth plate.

• fissure f.: crack in one cortex (surface) only of a long bone.

• fragility fracture: fracture that occurs with minimal trauma; caused by osteoporosis.

• greenstick f.: in children, incomplete, angulated fracture with a partial break; also called incomplete f., interperiosteal f., hickory-stick f., and willow f.

• hairline f.: nondisplaced fracture line (crack) in the cortex of bone.

• impacted f.: fragments are compressed by force of original injury, driving one fragment of bone into adjacent bone.

• incomplete f.: cortices of bone are buckled or cracked, but continuity is not destroyed; the cortex is broken on one side and only bent on the other. Microscopically, the fracture is present on bent side, and resorption and callus will occur on this side as well; types are greenstick f., torus f.

• infraction f.: small radiolucent line seen in pathologic fractures, most commonly resulting from metabolic problems.

• insufficiency f.: a fracture that occurs because bone is made insufficient as a result of osteoporosis or a metabolic process.

• inverted Y f: typically used for a tibial medial and lateral condyle fracture with central fracture line entering joint. Term has also be applied to other Y shaped fracture.

• linear f.: lengthwise fracture of bone straight line fracture; implies that there is no displacement.

• multiple f.: two or more separate lines of fracture in the same bone.

• oblique f.: slanted fracture of the shaft on long axis of bone.

• occult f.: hidden fracture (undetectable on a radiograph), generally occurring in areas of the ribs, tibia, metatarsals, and navicular. Alternatively, difficult to detect fractures occurring in severe osteoporosis such as hip, pelvis, or vertebrae.

• physeal f: one that involves the cartilaginous growth plate of a bone; also called epiphyseal slip f., Salter f., and Salter-Harris f. ( Fig. 1-3 ).

  

• plastic bowing f.: curved deformity of a tubular bone without gross fracture; also called bowing f., greenstick f.

• pathologic f.: fracture of bone weakened by disease such as tumors, metabolic disease, or severe osteoporosis; Also called secondary f.

• segmental f.: several large fractures in the same bone shaft where the two principal fragments are not adjacent.

• spiral f.: fracture line is spiral shaped and multiplanar, usually on shaft of long bones where the mechanism of injury is usually torsion.

• stellate f.: numerous fissures radiate from central point of injury, usually a vertebral body.

• subperiosteal f.: bone but not its periosteal tube is broken; uncommon; usually the result of a direct blow.

• torus f.: usually noticed in children; a stable, often incomplete f. in which one distal cortical surface appears to be wrinkled by compression forces, and the opposite cortex may or may not be infracted by tension forces.

• transverse f.: line of fracture across the shaft at right angles to the long axis of a bone.

• unstable f.: fracture where it is difficult to maintain reduction and most often requires operative intervention because of the likelihood of recurrent deformity despite manipulation.

Position and Alignment of Fragments

( Fig. 1-4 )

The position of a fragment refers to any displacement of one bone fragment in reference to the next. Displacement, should it exist, can be in any plane. Alignment refers to rotatory or angular deviation of the distal fragment in relation to the proximal fragment. For example:

• angulation: typically described by the apex of the deformity. An apex anterior angulation means that the “point” or apex of the fracture is pointed anteriorly. This could also be described as antecurvatum or procurvatum. An apex posterior angulation is therefore recurvatum.

• bayonet position: the fragments touch and overlap, but there is good alignment. Internal and external rotation can also be stated in degrees.

• bow: the two fragments form an angle where the apex is sometimes described as an anterior or posterior bow.

The descriptive radiographic interpretations of fractures are defined as follows. The angulation of the fracture is designated by the direction of the apex of the fracture points. Fragments themselves are designated as proximal and distal displacement, which is the amount of offset of the proximal to distal fragment as seen in an anterior to posterior or medial to lateral direction.

When broken ends of the principal fragments are touching on end, they are said to be in apposition. Accuracy or degree of apposition is defined in percentages, such as 50%, indicating at least one radiographic view shows 50% contact and other views may appear to be more.

The site may be diaphyseal, metaphyseal, or epiphyseal portions of a specific bone or may be intraarticular. Extent may be described as complete, incomplete, cracked, hairline, buckled, or greenstick. The configuration may be transverse, oblique, or spiral, and is referred to as comminuted when more than two fragments are present. The fracture fragments may be undisplaced or displaced.

Thus a fracture is described radiographically by its site, bone name, extent, configuration, relationship of fragments to each other and to the external environment (open or closed), and the presence or absence of complications.

Shoulder Fractures (Proximal Humerus and Scapula)

• anatomic neck f.: occurs in the area of tendinous attachments, the true neck of humeral metaphysis.

• Bankart f.: detachment of a small piece of bone from the anteroinferior rim of the glenoid; seen with anterior shoulder dislocation, usually called a Bankart fragment. The cartilage rim may detach without a fracture, and this is called a Bankart lesion.

• coracoid f.: fracture of coracoid process of scapula.

• greater tuberosity f.: fracture of bone prominence and attachment of supraspinatus.

• lesser tuberosity f.: fracture of bone prominence for attachment of subscapularis.

• Hill-Sachs f.: moderate compression f. or indentation f. of the humeral head usually seen after an anterior dislocation of the shoulder. In a classic Hill-Sachs lesion the anterior glenoid causes a dent or defect of the region near the greater tuberosity. A reverse Hill-Sachs is seen with posterior dislocations, and where the defect is in the region of the lesser tuberosity; also called Hermodsson f.

• surgical neck f.: occurs in area below the anatomic neck of the humerus.

Arm and Elbow Fractures (Distal Humerus)

• boxer’s elbow: chip f. at the tip of the olecranon caused by a fast extension of the elbow in a missed jab (punch).

• condylar f.: occurs at the medial or lateral articular process of the humerus at the elbow.

• epicondylar f.: occurs through one of the two epicondyles, medial or lateral.

• Hahn-Steinthal f.: complete capitellar fracture with little or no extension into the lateral trochlea typically associated with anterior displacement.

• Holstein-Lewis f.: involves the humerus at the junction of the middle and distal thirds; associated with radial nerve paralysis because of nerve proximity to posterior septum and bone.

• Kocher f.: semilunar chip f. of capitellum with displacement into joint.

• Kocher-Lorenz f.: minimal osteochondral capitellar fracture typically associated with posterior displacement.

• Laugier f.: involves the trochlea of the humerus.

• Malgaigne f.: extension mechanism supracondylar f. of humerus; name also applied to a vertically dissociated fracture dislocation of the pelvis and a proximal fibular fracture.

• Posada f.: anteriorly angulated fracture of distal humerus associated with posterior dislocation of radius and ulna.

• sideswipe f.: comminuted fracture of distal humerus and sometimes radius and ulna caused by direct blow against elbow.

• supracondylar f.: occurs through the distal metaphysis of the humerus or femur.

• T f.: intercondylar fracture shaped like a T.

• Y f.: intercondylar fracture shaped like a Y.

Forearm and Wrist Fractures

• Barton f.: an intraarticular fracture of the dorsal articular rim of the distal radius resulting in volar displacement radial carpal fragment.

• chauffeur’s f.: oblique fracture of the radial styloid caused by a twisting- or snapping-type injury; also called backfire f., Hutchinson f., and lorry driver’s f.

• chisel f.: incomplete, usually involving medial head of radius, with fracture line extending distally.

• Colles f.: named prior to x-ray technology; implies a fracture of the distal radius, either articular or nonarticular, with dorsal angulation of the distal fragment producing a silver fork deformity; generally associated with a fracture of the ulnar styloid.

• corner f.: a small bucket-handle-appearing fracture in the distal metaphyseal corner in a young child, often associated with child abuse.

• de Quervain f.: combination of a wrist scaphoid fracture with volar dislocation of scaphoid fragment and lunate.

• dye-punch f.: an intraarticular fracture of the ulnar (volar) portion of the distal radius, usually caused by direct impaction of the lunate onto the lunate fossa of the distal radius.

• Essex-Lopresti f.: a comminuted radial head fracture with an injury to the distal radioulnar joint caused by disruption of the interosseous membrane, which can cause a proximal migration of the radius if the radial head is excised secondarily.

• Galeazzi f.: typically a displaced fracture of the distal third or quarter of the radius with disruption of the distal radioulnar joint; called fracture of necessity because surgical fixation is required for reduction; also called a reverse Monteggia f., Dupuytren f., or Piedmont f.

• Kocher f.: fracture of capitellum of distal humerus with possible displacement of fragment into joint.

• Laugier f.: isolated fracture of the trochlea of the humerus at the elbow.

• lead pipe f: typically in the forearm, a combination of greenstick fracture and torus fracture in the immature skeleton. Such fractures do not penetrate the entire shaft of the bone and have the appearance of a slightly bent lead pipe.

• Lenteneur’s f.: a distal radial fracture of the palmar rim, similar to Smith’s type II fracture.

• Monteggia f.: isolated fracture of proximal third of ulna, with posterior or anterior dislocation of radial head allowing angulation and overriding of ulnar fragments.

• Moore f.: like a Colles f.; specifically, fracture of distal radius with dorsal displacement of ulnar styloid and impingement under annular ligament.

• Mouchet f.: involves humeral capitellum.

• nightstick f.: undisplaced fracture of the ulnar shaft caused by a direct blow.

• Piedmont f.: oblique f. usually at the proximal portion of distal third of the radius; obliquity runs from proximal ulnar to distal radial aspect, allowing distal fragments to be pulled into the ulna by the pronator quadratus muscle; fracture of necessity requiring operative management.

• radial head f.: involves the most proximal part of the radius, a dish-shaped portion of bone.

• radial styloid f.: involves distal radial tip of radius.

• reverse Barton f.: dorsal displacement of carpus on radius, with associated fracture of dorsal articular surface of radius. The mechanism and appearance of this fracture are similar to those of a Colles f.

• Skillern f.: open f. of the volar or dorsal rim of the distal radius, usually resulting in subluxation or dislocation of the radial carpal joint line associated with greenstick f. of distal ulna.

• Smith f.: fracture of the distal radius in which the distal fragment is displaced volarly; also called reverse Colles f. This fracture was defined before the advent of radiography, and, classically, there are three types:

  • Nonarticular

  • Intraarticular; also called volar Barton f.

  • Oblique nonarticular fracture near the joint line

Hand Fractures

• Bennett f.: fracture of the base of the thumb metacarpal, usually leaving a volar ulnar fragment attached to a retaining ligament with radial subluxation of the metacarpal.

• crush f.: term used for comminuted impaction of any bone, but for the finger is a distal phalanx fracture resulting from a crush injury.

• mallet f.: avulsion f. of the extensor tendon from the dorsal base of the distal phalanx of any digit that includes insertion of extensor apparatus, thus allowing distal segment to drop into flexion; also called baseball finger, drop finger, and mallet finger deformity.

• Rolando f.: an intraarticular comminuted fracture of the base of the thumb metacarpal resulting in a Y- or T-shaped fracture at the base of the metacarpal.

• unciform f.: fracture of the hook of the hamate, usually caused by direct trauma that may or may not be associated with ulnar neuropathy.

• Wilson f.: involves the proximal volar portion of the middle phalanx because of strong attachment of volar plate.

Spine Fractures

• burst fracture: Involved a compressive fracture of the vertebra that can disrupt stability and cause retropulsion of bone into the spinal canal resulting in paralysis. Depending on severity and location, they can be treated by bracing or require extensive surgical intervention.

• Chance f.: involves vertebra, with horizontal splitting of spinous process and neural arch with disruption through vertebral body; an unstable fracture.

• clay shoveler’s f.: involves spinous process(es) C-6, C-7, T-1, T-2, or T-3.

• compression fracture: most frequently a “wedge-shaped” compression fracture seen in older adults. They contribute to deformity of a “hunched” back commonly seen in older adults and are mostly painful and do not risk neurologic compromise. They may be just as disabling and commonly caused by low-energy mechanisms (jolt or fall) with bone insufficiency resulting from osteoporosis.

• hangman’s f.: posterior element (pedicles) fracture with anterior subluxation of the cervical neck of C-2 on C-3.

• Jefferson f.: bursting f. of the ring of the first cervical vertebra (atlas).

• posterior element f.: broad term used to describe any fracture of the spinous process, lamina, facets, pars interarticularis, or pedicle.

• seatbelt f.: thoracic or lumbar spine fracture resulting from tensile stress that occurs on spine with forward motion of thorax with abdominal or thoracic restraint resulting in bony or ligament disruption. If only the bone is involved, the injury is called a Chance f.

• sentinel f.: a cervical spine fracture characterized by fractures through the lamina on either side of the spinous process. A sentinel of potential instability.

• slice f.: an unstable lumbar spine fracture caused by a flexion rotation injury that results in a fracture in the upper body of the lower vertebra and a dislocation of the articular process of the upper vertebra.

• spondyloptosis: dislocation of one vertebra from another without any bone fracture.

• teardrop f.: exists in two forms: (1) an isolated anteroinferior fracture of the cervical spine (unstable); or (2) a three-part, two-plane fracture of an anteroinferior corner of the vertebral body (the teardrop), a sagittal vertebral body, and the posterior neural arch.

• vertebra plana f.: wafer-thin compression f. of a vertebral body resulting from an intrinsic pathologic condition of the bone.

• wedge f.: anterior compression f. of any vertebra; most common in the dorsal thoracic spine.

Pelvis, Hip, and Proximal Femur Fractures

• acetabular fracture: Any fracture that involves the acetabulum (socket).

• basal neck f.: involves base of femoral neck at junction of trochanteric region basicervical.

• bucket-handle f.: vertical shear fracture of anterior pubis and opposite ilium.

• central f.: acetabular fracture, centrally displaced through inner wall of pelvis.

• dashboard f.: posterior lip of acetabulum chips when femoral head is driven against it; often caused by a sudden jolt when knee hits dashboard.

• dome f.: acetabular fracture involving weight-bearing surface of the acetabulum. This term can also be applied to a fracture of the superior surface of the talus.

• Duverney f.: involves ilium just below the anterosuperior spine.

• extracapsular f.: occurs outside of joint capsule of humerus or femur.

• femoral neck f.: transcervical fracture through midportion of femoral neck.

• hip f.: implies a fracture of the femoral neck or intertrochanteric area.

• intertrochanteric f.: the principal plane of the fracture disrupts the intertrochanteric line.

• intracapsular f.: commonly used for high femoral neck fractures, but is also used for any fracture within a joint capsule.

• Malgaigne f.: occurs through wing of the ilium or sacrum with associated fractures through the ipsilateral pubic rami, allowing upward displacement of hemipelvis; often associated with internal injuries.

• open book f: pelvis fracture with symphysis separation and disruption of the sacral pelvic ligaments to give appearance of opening a book.

• pertrochanteric f.: involves proximal femur where the fracture line passes through both the lesser and greater trochanters.

• ring f.: involves at least two parts of pelvic circumference.

• shaft f.: occurs between subtrochanteric and supracondylar area.

• sprinter’s f.: involves anterosuperior or anteroinferior spine of ilium, with a fragment of bone being pulled forcibly by sudden muscular pull.

• straddle f.: double f. or dislocation of the pubis usually caused by a straddling mechanism, for example, falling onto a rail with the point of contact between the legs.

• subcapital f.: femoral fracture at head-neck junction.

• subtrochanteric f.: transverse f. of femur just below lesser trochanter.

• Waddell triad: femoral fracture associated with head and thorax injuries.

• Walther f.: transverse ischioacetabular f. where the fracture line passes from ischial spine to acetabular cavity to ischiopubic junction.

Distal Femur, Knee, Tibia, and Fibula Fractures

• bumper f.: involves the tibia or femur and is caused by a direct blow in area of the tibial tuberosity; commonly caused by a car bumper accident; may be bilateral.

• cartwheel f.: fracture of the distal femoral epiphysis in a child, so named by mechanism of a leg caught in the spokes of a cartwheel; also called wagon wheel f .

• clipping injury f.: fracture through growth plate of distal femur or proximal tibia caused by a strike from the lateral side of the knee when the foot is planted.

• Hoffa f.: coronal fracture of medial femoral condyle.

• patellar f.: involves kneecap.

• pillion f.: T-shaped fracture of distal femur with displacement of the condyles posteriorly to femoral shaft, caused by severe blow to knee; so named for pillion back seat position of a motorcycle rider who sustains this injury. Not to be confused with pilon fracture, which is due to a vertical impaction of the distal tibia into the talus.

• Segond f.: small avulsion f. of superolateral tibia caused by tension on the lateral capsule or ligament; usually associated with other severe ligamentous injuries leading to anterolateral knee instability; also called lateral capsule sign.

• sleeve f.: involves a small chip of bone from the superior or inferior portion of the patella associated with loss of integrity of quadriceps extensor mechanism.

• Stieda f.: avulsion f. of origin of medial collateral ligament on medial femoral condyle.

• supracondylar f.: involves the distal shaft of bone above condyles of femur or humerus.

• tibial plateau f.: involves proximal tibial articular surface.

• toddler f.: nondisplaced fracture of the tibia seen in toddlers beginning to walk.

• Trélat fracture: type III fracture crossing the physis of the medial femoral condyle.

• Y and T f.: combined supracondylar and intercondylar f. of the distal femur.

Ankle and Foot Fractures

• ankle mortise diastasis: separation of tibia and fibula at ankle; often associated with a fracture or dislocation.

• aviator’s astragalus: denotes a talar neck fracture caused by sudden impaction of foot into ankle; may be associated with other fractures about the foot and ankle.

• bimalleolar ankle f.: in which both the medial malleolus and distal fibula are fractured; also called Pott f.

• bimalleolar equivalent: a fracture of the medial or lateral malleolus with ligamentous damage on the opposite side of an ankle.

• boot-top f.: involves transverse, distal third of tibia, occurring at boot top of old-style ski boot; also called skier’s injury.

• Bosworth f.: fracture-dislocation of the ankle, with oblique fracture of the distal fibula and displacement of the proximal fibular fragment out of fibular groove to a place posterior and medial to the posterolateral ridge of the tibia.

• bunkbed f.: intraarticular f. of the base of the first metatarsal in children.

• Cedell f.: fracture of the posterior medial process of the talus; may be associated with tarsal tunnel syndrome.

• Chaput f.: involves the anterior tubercle of distal tibia because of strong attachment of anterior tibiofibular ligament.

• Conrad-Bugg trapping: incarceration of soft tissue, usually the posterior tibial tendon, between fragments of an ankle fracture. This produces an injury that usually is reduced by open methods.

• Cotton f.: partial forward dislocation of the tibia to produce a fracture of the posterior inferior margin of the tibia, sometimes called the posterior malleolus. This is most commonly associated with a fibular fracture.

• Descot f.: involves the posterior lip of tibia.

• dome f.: involves the superior articular surface of talus or the weight-bearing portion of the acetabulum.

• Dupuytren f.: spiral f. of the distal end of fibula; associated with ankle diastasis.

• Gosselin f.: V-shaped fracture of the distal tibia into the tibiotalar joint.

• Henderson f.: trimalleolar fracture of the ankle.

• Jones f.: fracture of the base of the fifth metatarsal such that the fracture line extends from lateral to medial cortex in the shaft portion of the apophyseal tip. This term has been misapplied to fractures in the proximal apophyseal portion.

• Kohler f.: involves the navicular and is associated with avascular necrosis; seen in children.

• Lisfranc f.: usually a fracture-dislocation, with displacement of the proximal metatarsals most commonly the first and second.

• Maisonneuve f.: spiral f. of proximal end of fibula, near the neck, associated with a tear of the anterior tibiofibular ligament and the potential for ankle diastasis associated with a tear of the anterior tibiofibular ligament and a medial malleolus fracture or deltoid ligament disruption.

• march f.: stress f. of metatarsal caused by excessive marching; also called fatigue f.

• midnight f.: open, oblique fracture of proximal phalanx of little toe caused by stubbing the toe on a solid object.

• Montercaux f.: fracture of fibular neck with associated diastasis of ankle mortise.

• paratrooper f.: involves posterior articular margin of tibia or lateral malleolus.

• Pott f.: spiral oblique f. of distal fibula with associated rupture of the deltoid ligament; avulsion of the medial malleolus and lateral displacement of foot on tibia.

• plafond f.: any fracture that involves the surface of the tibia that comes in contact with the dome of the talus.

• Shepherd f.: involves posterior talus with sheared off piece of bone and, in some instances, a separate piece of bone (os trigonum).

• Tillaux Kleiger f.: involves distal lateral tibia, vertically extending into the joint; sometimes associated with diastasis and other fractures about the ankle.

• tongue f.: involves the posterosuperior portion of calcaneus.

• trimalleolar f.: fracture of medial, lateral, and posterior malleolus.

• triplane f.: involves the ankle in three planes: coronally through the posterior tibial metaphysis, transversely through the growth plate, and sagittally through the distal tibial epiphysis.

• Volkmann f.: involves a triangular portion of the posterior lateral tibia into the joint, leaving a triangular bone fragment sometimes called Volkmann’s triangle.

• Wagstaffe f.: separation of a distal anterior fragment of the fibula, that is, the portion of attachment of the anterior tibiofibular ligament; also called Le Fort f.

AO/ASIF (AO/OTA) Long Bone Fractures

This is a scheme of fracture classification for research purposes and a more uniform description in the literature. The scheme has not been validated or used by all investigators. It tends to be cumbersome in some instances, but in certain locations, the first letter and number modifier is very useful in describing the extent and pattern of fracture. For example, a C3 distal femur fracture is notated as 33.C3. This system is most commonly used in the distal femur, distal tibia, and distal humerus.

• The system defines bones by number ( 1, humerus; 2, radius and ulna; 3, femur; 4, tibia and fibula; 5, spine, jaw, clavicle, and scapula; 6, pelvis and sacrum; 7, hand; 8, foot).

• Nature of fracture is identified by letter ( A, simple involving at least 90% of the cortex or extraarticular; B, wedge with some contact between fragments or partial articular; C, complete with no contact between fragments or complete articular).

• Degree of comminution is identified by number (A: 1, spiral; 2, oblique; 3, transverse less than 30 degrees. B: 1, spiral wedge; 2, bending wedge; 3, fragmented wedge. C: 1, spiral; 2, segmental; 3, irregular).

• The subgroups .1, .2, and .3 further define the complexity of each of the above groupings.

• Limitation: agreement among raters.

AO/ASIF Soft Tissue Classification

For uniform description in the literature.

Allen and Ferguson Classification for Cervical Spine Fracture C3 to C7

Based on mechanism and injury patterns.

• Extension loading force: fracture spinal process and possible lamina, with compression severe displacement with retrolisthesis superior on inferior vertebra.

• Flexion loading force: unilateral or bilateral facet dislocation that, if with posterior ligament disruption, produces facet locking. May also have vertebral compression fracture or teardrop fracture.

• Neutral load: burst fracture, very unstable if complete ligamentous disruption.

Allman Classification for Clavicle Fractures

To define location of most common sites of occurrence and of nonunion.

• Group I: fractures of middle third

• Group II: fractures distal to coracoclavicular ligament, nonunion frequent

• Group III: fractures of proximal end; nonunion and displacement rare

Limitations: does not incorporate other factors such as degree of trauma.

Anderson and d’Alonzo Classification for Odontoid Fractures of the Second Cervical Vertebra

Based on location of fracture; to define fracture pattern likely to require surgery for healing.

• Type I: avulsion fracture of tip of odontoid

• Type II: fracture at junction of odontoid to body of vertebra

• Type III: fracture line extends downward into cancellous bone of body of vertebra

AO Magerl Modification for Thoracic and Lumbar Spine Fractures

Based on location of failure of integrity.

• Type A injuries: failure under axial compression of the anterior elements with intact posterior constraining elements

• Type B injuries: failure of the posterior constraining elements (tension band or PLC injuries in case of TL spine)

• Type C injuries: failure of anterior and posterior elements leading to displacement

Ashurst Classification for Ankle Sprains and Fractures

Based on direction or mechanism of force.

Badelon Classification for Lateral Condylar Fractures of the Humerus in Children

Roentgenographic basis for stability versus displacement, which requires surgical reduction.

• Type I: nondisplaced fracture that can be seen only on one view

• Type II: visible fracture line with minimal displacement

• Type III: displacement of more than 2 mm on all views

• Type IV: severe displacement with complete separation of fracture edges

Bado Classification for Fractured Ulna with Dislocation of the Radial Head [Monteggia]

Based on mechanism of injury; to help define management.

• Type 1: fracture of any portion of the ulna diaphysis with anterior angulation and anterior dislocation of the radial head

• Type 2: fracture of the ulnar diaphysis with posterior angulation and posterior or posterolateral dislocation of the radial head

• Type 3: fracture of the ulnar metaphysis with lateral or anterolateral dislocation of the radial head

• Type 4: proximal fracture of both bones at the same level with anterior dislocation of the radial head

Limitations: some controversy as to relationship to treatment; types I and II have equivalents that involve dislocation radial head only (type 1) and fractured radial head.

Bohn and Durbin Classification for Epiphyseal Fractures of the Distal Femur and Proximal Tibia Resulting in a “Floating Knee”

Too complicated for inclusion, a complex system based on angulation, dislocation, and associated injury. See Arslan H et al.

Brendt and Harty Modified Classification for Fractures or Development of Osteochondritis Dissecans of the Dome of the Talus

To define stages of osteochondritis of bone.

• Stage I: normal x-ray but positive bone scan or change seen on magnetic resonance imaging (repeated minitrauma)

• Stage II: incomplete separation of subchondral fragment (single injury event)

• Stage IIA: cyst formation (repeated minitrauma)

• Stage III: complete separation of fragment, which is in anatomic position (single injury event)

• Stage IV: separation of fragment (single injury event)

Boyd and Griffin Classification for Extracapsular Fractures of Proximal Femur from Neck to 5 cm Distal to Lesser Trochanter

To define surgical approach and prognosis for fractures near and around the femoral neck.

• Type 1: intertrochanteric f., simple to reduce and maintain

• Type 2: intertrochanteric f. with comminution and additional coronal seen from lateral

• Type 3: subtrochanteric f. with at least one fracture line passing just distal to or through lesser trochanter

• Type 4: fractures of the trochanteric region and proximal shaft and fracture in two planes requiring two-plane fixation

Limitations: crosses over from subtrochanteric fracture type to intertrochanteric and neck fractures.

Bryan and Morrey Classification for Capitellar Fractures

To define shape and direction of elbow capitellar fractures.

• Type 1: shear fracture in plane of capitellum involving none or little of the trochlea

• Type 2: a variable amount of the cartilage of the capitellum with minimal attached subchondral bone

• Type 3: comminuted or compression fracture of the capitellum

Canale-Kelly Classification for Talar Fractures

Based on location of fracture and association with displacement and effect on blood supply; to define prognosis for long-term outcome with particular reference to avascular necrosis.

• Type I: minimal displacement, only one source of blood supply might be disrupted

• Type II: subtalar subluxation or dislocation, two or three sources of blood supply might be affected

• Type III: body of talus dislocated from the ankle and the subtalar joint

• Type IV: fracture of talar neck associated with dislocation of the body from the ankle, or subtalar joint and additional subluxation or dislocation of the head of the talus from the talonavicular joint

Cervical Spine Injury Score System

Four columns: anterior, right pillar, left pillar, and posterior.

For each column, an analogue scale using fracture displacement and ligament disruption is given:

• Fracture nondisplaced with mild ligamentous 1–3 mm (analogue scale 0–1)

• Fracture displaced 1–3 mm, mild ligamentous 1–3 mm (analogue scale 1–2)

• Fracture displaced 1–3 mm, moderate ligamentous 3–5 mm (analogue scale 2–3)

• Fracture displaced 3–5 mm (analogue scale 3–4)

• Fracture displaced > 5 mm, severe ligamentous > 5 mm (analogue scale 4–5)

Chadwick and Bentley Classification for Distal Tibia Fractures Affecting Epiphysis in Children

Based on x-ray analysis; reflects the mechanism of type IV Salter fractures of the distal tibia and fibula and helps predict retardation of growth.

• Group I: epiphysis not fractured

  • Group 1a: abduction injury with fracture of the distal fibular shaft and lateral displacement

  • Group 1b: supination/hyperplantar flexion injury with posterior metaphyseal fragment of the tibia and posterior displacement

  • Group 1c: supination/external rotation injury with large anteromedial metaphyseal component, tibia, and posterior displacement

  • Group 1d: adduction injury (rare), posteromedial metaphyseal fragment of the tibia with fracture of the distal fibular shaft and medial displacement

• Group II: vertical fracture through epiphysis with shift of lateral fragment

• Group III: adduction injury, Salter type I or II fibular slip with type IV medial malleolar fracture

Colonna (Delbet) Classification for Hip Fractures in Children

Attributes classification to Delbet; no purpose given.

• Type I: transepiphyseal separations with or without dislocation of femoral head

• Type II: transcervical fractures, displaced and nondisplaced

• Type III: cervicotrochanteric fractures, displaced and nondisplaced

• Type IV: intertrochanteric fractures

Colton Classification for Olecranon Fractures

To define treatment.

• Avulsion group: transverse fracture line separating a small fragment of olecranon with or without displacement

• Oblique group: primary failure being an oblique line from the trochlear notch to the distal outer ulnar shaft, degree of comminution staged a to d

  • Stage a: single fracture line, displaced and nondisplaced

  • Stage b: nondisplaced single central large V-shaped fragment

  • Stage c: displaced single central large V-shaped fragment

  • Stage d: highly comminuted central pieces of bone with displacement

• Fracture dislocation (Monteggia group): fracture line at or slightly proximal to coronoid, which may result in anterior fracture or dislocation of the elbow

• Unclassified group: high-energy, highly comminuted fractures not matching previous descriptions

Delbet Classificatiom for Fixation Device Selection for Pediatric Femoral Neck Fracture Based of Age and Fracture Level

Denis Classification for Sacral Fractures

• Denis 1: Lateral to foramen

• Denis 2: Through or involving foramen

• Denis 3: Medial to foramen

Dias-Tachdjian Classification for Ankle Fractures in Children

Uses Lauge-Hansen guidelines, foot position, and direction of force in correlation with the Salter-Harris classification to plan surgical and other treatment approaches.

• Supination-inversion: inversion force applied to supinated foot

  • Grade I: Salter-Harris type I or II of distal fibular epiphysis

  • Grade II: grade I with Salter-Harris type III or IV of tibial epiphysis

• Supination-plantar flexion: plantar flexion force on supinated foot

  • Grade I: Salter-Harris type I or II of distal tibia, usually with posterior displacement

• Supination-external rotation: external rotation ankle force on fully supinated foot

  • Grade I: Salter-Harris type II of distal tibia with long spiral fracture of distal tibia

  • Grade II: grade I with spiral fracture of fibula

• Pronation-eversion-external rotation: a combination of eversion and external rotation force on pronated foot

  • Grade I: posterolateral displacement of Salter-Harris type II tibial fracture with short oblique fibular fracture above physis

Limitations: fractures not covered under this system include Salter-Harris type III distal tibia and triplane fracture (as described by author).

Doyle Classification for mallet Fractures of Finger

Grouped by stable or unstable and open or closed.

• Type I: closed fracture may or may not exist

• Type II: superficial open injury

• Type III: open injury tendon exposed

• Type IVa: physical injury (pediatric)

• Type IVb: involving 20–50%

• Type IVc: involves greater 50% joint surface

Essex-Lopresti Classification for Os Calcis Fractures

Based on direction of injury force (A–C superior to inferior, and D–F anterosuperior to posteroinferior); helps define method of closed and open management.

• Type A: nondisplaced fracture inferior to lateral process of talus and through lateral cortex

• Type B: type A with shearing of sustentaculum tali along with one-third to one-half of the posterior facet

• Type C: type B with depression of joint and superior posterior displacement of distal portion

• Type D: affects lateral half or two-thirds of subtalar joint and fracture of the lateral cortex without displacement

• Type E: type D with superior displacement of anterior portion of calcaneus

• Type F: type E with displacement of posterior facet of calcaneus and further superior migration of anterior portion

Evans-Wales Classification for Intertrochanteric Fractures of Femur

Grouped by stable or unstable and expected response to treatment.

• Type I: fracture line extends upward and outward from lesser trochanter:

  • Undisplaced stable

  • Displaced reduced with stable medial apposition

  • Displaced unreduced with no medial apposition

  • Comminuted unstable with no medial apposition

• Type II: reversed obliquity with line from lesser trochanter to inferior lateral cortex

Limitations: directed at open versus closed management, which is no longer used.

The FEDS System for Classifying Glenohumeral Joint Instability

System Based on Frequency, Etiology, and Direction.

• Frequency

  • Solitary 1 episode

  • Occasional 2–5 episodes

  • Frequent >5 episodes

• Etiology

  • Traumatic

  • Atraumatic

• Direction

  • Anterior

  • Inferior

  • Posterior

The direction is confirmed at the time of the physical examination using provocative tests to determine directions most closely reproduces symptoms.

• Severity

  • Subluxation

  • Dislocation

Ferkel-Cheng Arthroscopic Classification of Osteochondral Lesions of the Talus

To define stages of appearance and attachment of lesion to subchondral bone.

• Stage A: smooth, intact, but soft or ballottable

• Stage B: rough surface

• Stage C: fibrillations or fissures

• Stage D: flap present or bone exposed

• Stage E: loose, nondisplaced fragment

• Stage F: displaced fragment

Ferkel-Sgaglione Classification for CT Classification of Osteochondral Lesions of the Talus)

To define stages of attachment of subchondral bone.

• Stage I: cystic lesion within dome of talus

• Stage IIA: cystic lesion with communication to talar dome surface

• Stage IIB: open articular surface lesion with overlying nondisplaced fragment

• Stage III: nondisplaced lesion with lucency

• Stage IV: displaced fragment