Classification of fractures

Presented by: Dr. Momin Mohammad Farhan

Moderator: Dr. Aseemuddin
What is fracture(#)?
A break in the continuity of a bone .
CAUSES OF FRACTURES :
 Automobile accidents major cause
 Motor cycle injury common in young adults

 Fall from height

 Sports injury
 Trivial injury fall at home
 Machine injuries
 Repetitive stress (stress fracture)
 Gun shot injuries
 Pathological problems of bone
 Metabolic bone diseases
 Defective collagen
Described and classified on the basis of :
Type
Aetiology
Displacements
Pattern
Anatomic location
Quantum of force causing fractures
Complexity of treatment
Relationship with external environment
Region involved
AO classification
Types of fracture

Type is the overall

fracture pattern
Examples are:
Simple
Spiral
segmental
On the basis of Aetiology:
Traumatic - fracture sustained due to trauma ( eg. Closed, open,)
Pathological - fracture through a bone which has been made weak by
underlying disease. (e.g. secondary malignant deposit, osteoporosis)
Stress - fracture sustained due to chronic repetitive injury

On the basis of Displacements:

Undisplaced fracture - these fractures are easy to identify by
absence of significant displacement
Displaced fractures - factors responsible for displacement
1)fracturing force
2)muscle pull on the fracture fragments
3)gravity
On the basis of Displacements:
Undisplaced fracture - these fractures are easy to identify by
absence of significant displacement
Displaced fractures - factors responsible for displacement
-fracturing force
-muscle pull on the fracture fragments
-gravity

1) Translation is sideways motion

of the fracture - usually
described as a percentage of
movement when compared to
the diameter of the bone.
2) Angulation is the amount 3) Shortening is the
of bend at a fracture amount a fracture is
described in degrees. collapsed expressed in
Described with respect to centimeters.
the apex of the angle or Sometimes called
with respect to direction bayonette apposition.
of distal fragment.
On the basis of Pattern

Transverse Fracture Oblique Fracture

A fracture in which the # line is A fracture in which the # line is at
perpendicular to the long axis of oblique angle to the long axis of the
the bone . bone.
On the basis of Pattern

Spiral Fracture Longitudinal Fracture

A severe form of oblique fracture in A fracture in which the # line runs
which the # plane rotates along the nearly parallel to the long axis of the
long axis of the bone. These #s occur bone. A longitudinal fracture can be
secondary to rotational force. considered a long oblique fracture.
On the basis of Pattern

Comminuted # : Segmental # :
The bone is broken into than two There are two fractures in one bone ,
fragments. but at different levels.
 On the basis of Anatomic location
Anatomic location of the fracture usually described by giving the bone
involved and location on the bone
Examples are: distal radial shaft, proximal 1/3 humeral shaft, intra-articular
distal tibial
Depressed fracture:
Stellate fracture:
This # occurs in the skull where a
This # occurs in the flat bones of the skull
segment of bone gets depressed into
and in the patella, where the fracture lines
the cranium.
run in various directions from one point.
 On the basis of Anatomic location
Impacted fracture:
This # where a vertical force drives
the distal fragment of the fracture
into the proximal fragment.
Avulsion fracture:
This is one, where a chip of bone is avulsed by the
sudden and unexpected contraction of a powerful
muscle from its point of insertion,
Examples
1. The supra spinatus muscle avulsing the
greater tuberosity of the humerus.
2. Avulsion fracture of the tibial tuberosity
Anatomic description
Simple, transverse,
non-communited
midshaft radial and
ulnar fracture with 30
degrees apex radial
angulation.
 Anatomic description
Simple, transverse,
non-communited
distal radial and ulnar
fracture with 100%
radial translation, 45
degrees apex ulnar
angulation and 2 cm
of shortening.
On the basis of Quantum of force causing fractures:
High velocity injury :
- fractures sustained as a result of severe trauma force, as in
traffic accidents
- there is severe soft tissue injuries, extensive
devascularisation of fracture ends.
- these fractures are often unstable and slow to heal.

Low velocity injury :

- fractures sustained as a result of mild trauma force, as in a
fall.
- there is little soft tissue injury, and hence they heal
predictably
On the basis of Complexity of treatment

1) simple fractures :

A fracture in two pieces
Usually easy to treat
Eg. Transverse fracture of tibia
2) complex fracture
A fracture in multiple pieces
Difficult to treat
Eg. Communited fracture of tibia
On the basis of Relationship with external
environment
Closed
Open

Closed fracture
- A fracture not communicating with the external
environment, i.e, the overlying skin and soft tissues are
intact, is called a closed fracture.
- Commonly classified according to the Tscherne
classification
 Tscherne Classification of closed fracture
- Classifies soft tissue injury in closed #and takes into account
direct versus indirect injury mechanism

Grade 0
Injury from indirect
force
Minimal soft tissue
damage
Grade 1
Low to moderate energy
mechanism
Superficial contusions or
abrasions of soft tissue
 Tscherne Classification of closed fracture
Grade 2
Direct injury
Moderate to severe energy
mechanism
More extensive soft tissue
injury with muscle
contusion, contaminated
skin abrasions
More severe bone injury
(usually)
High risk of compartment
syndrome
 Tscherne Classification of closed fracture
Grade 3
Severe injury to soft tisues
Degloving with destruction of
subcutaneous tissue and muscle
Can include a compartment
syndrome, vascular injury

Closed tibia fracture

Note periosteal stripping
Compartment syndrome
 Open fracture
A break in the skin
and underlying soft
tissue leading into or
communicating
directly with the
fracture and its
hematoma
Fracture may be open
from within or
outside, i.e internally
or externally open
fracture respectively
 Open fracture

a) Internally open ( from within)

- sharp fracture end pierces the skin
from within
b) Externally open ( open from outside)
- objet causing the fracture lacerate
the skin and soft tissue
Commonly described byOpen
the Gustilo and Anderson
fracture

system
Routinely applied to all types of open fractures
Gustilo and Anderson emphasis on size of skin injury
Gustilo and Anderson classification used for prognosis
Fracture healing, infection and amputation rate correlate
with the degree of soft tissue injury by Gustilo and Anderson
Fractures should be classified in the operating room at the
time of initial debridement
 Evaluate periosteal stripping
 Consider soft tissue injury
Gustilo and anderson Classification of open fracture

Type I
Clean wound < 1 cm,
usually “ poke hole”
Inside-out injury
Minimal soft tissue damage
Low energy simple spiral or
short oblique
No significant periosteal
stripping
Gustilo and anderson Classification of open fracture
Type II
Laceration > 1 cm long
Outside-in mechanism
Moderate soft tissue
damage
Higher energy injury
simple transverse or
short oblique fractures
Some necrotic muscle,
some periosteal
stripping
Gustilo and anderson Classification of open fracture
Type IIIA
Wound usually >10 cm
long
Outside-in injury
High energy
Extensive soft tissue
damage , minimal
periosteal stripping
Note Zone of Injury
Gustilo and anderson Classification of open fracture

Type IIIB
Wound usually >10 cm
long
Outside in injury
High energy
Extensive soft tissue injury
with Periosteal stripping
Requires a local flap or
free flap for bone coverage
and soft tissue closure
Associated with massive
contamination
Gustilo and anderson Classification of open fracture

Type IIIC
Wound usually >10
cm long
High energy
Increased risk of
amputation and
infection
Major vascular
injury requiring
repair
 Tscherne Classification of open fracture
This takes into account wound size, level of contamination and
fracture mechanism
Grade 1 : small puntured wound, negligible contamination,
low energy mechanism of fracture
Grade 2 : small laceration, skin and soft tissue contusions, moderate
bacterial contamination, variable mechanism of injury
Grade 3 : large laceration with heavy bacterial contamination,
extensive soft tissue damage, with frequent associated
arterial or neural injury
Grade 4 : incopmlete or complete amputation with variable
prognosis based on location and nature of injury
On the basis of Region involved
Metaphyseal fractures
Diaphyseal fractures
Epiphyseal or intra-articular fractures

Salter-Harris Classification
Only used for pediatric fractures that involve the
growth plate (physis)
Five types (I-V)
Salter-Harris type I fracture
Type I fracture is
when there is a
fracture across the
physis with no
metaphysial or
epiphysial injury
Salter-Harris type II fracture
Type II fracture is
when there is a
fracture across the
physis which extends
into the metaphysis
Salter-Harris type III fracture
Type III fracture is
when there is a
fracture across the
physis which extends
into the epiphysis
Salter-Harris type IV fracture
Type IV fracture is
when there is a
fracture through
metaphysis, physis,
and epiphysis
Salter-Harris type V fracture
Type V fracture is
when there is a crush
injury to the physis
Odgen classification
The odgen classification has extended the salter-harris
classification to include periphyseal fracture
Type VI farcture isinjury to perichondral ring at the
periphery of the physis.
Tpye VII is fracture involving epiphysis only.
Type VIII is metaphyseal fracture
Type IX is diaphyseal fracture
AO classification

Arbeitsgemeinschaft fur Osteosynthesfragen

Association for the Study of Internal Fixation

Founded in 1958 by small group of Swiss surgeons

There has been a need for an organized, systematic
fracture classification
Goal: A comprehensive classification adaptable to
the entire skeletal system and to improving the care
of patients with musculoskeletal injuries
AO classification
AO classification

1st number = long bone

2nd number = bone segment
Letter = fracture type (A,B,C)
Then 3rd & 4th numbers classify fracture group &
subgroup
AO classification

To Classify a Fracture
Which bone?
Where in the bone is
the fracture?
Which type?
Which group?
Which subgroup?
AO classification
Using the AO Classification
Which bone? •Where in the bone?
AO classification

Proximal & Distal Segment Fractures

Type A
Extra-articular
Type B
Partial articular
Type C
Complete disruption
of the articular surface
from the diaphysis
AO classification

Diaphyseal Fractures
Type A
 Simple fractures with two
fragments
Type B
 Wedge fractures
 After reduced, length and
alignment restored
Type C
 Complex fractures with no
contact between main
fragments
AO classification

Grouping-Type A
1. Spiral
2. Oblique
3. Transverse
AO classification

Grouping-Type B

1. Spiral wedge
2. Bending wedge
3. Fragmented wedge
AO classification

Grouping-Type C

1. Spiral
multifragmentary
wedge
2. Segmental
3. Irregular
AO classification

Subgrouping
Differs from bone to bone
Depends on key features for any given bone and its
classification
The purpose is to increase the precision of the
classification
Reference
1) Handbook of fractures (5th edition) by kenneth A.Egol, kenneth J.koval,
joseph D.zuckerman
2) Essential orthopaedics by maheshwari & mhaskar
3) www.ota.org
4) www.aofoundation .org
Thank you