26 Fracture Classification Review 2024.pdf

Fracture Classification Review DPM 2026 Kevin Smith, DPM, PhD CPMS Mission Statement To educate a diverse group of highly competent and compassionate podiatric health professionals to improve lives in a global community. Ankle Fractures  LAUGE-HANSEN — Fir...

Fracture Classification Review DPM 2026 Kevin Smith, DPM, PhD CPMS Mission Statement To educate a diverse group of highly competent and compassionate podiatric health professionals to improve lives in a global community. Ankle Fractures  LAUGE-HANSEN — First word = Position of foot at time of injury — Second word = Motion of talus through the injury — Four Main Patterns of Injury — Supination-adduction — Pronation-abduction — Supination-external rotation — Pronation-external rotation — Most fractures fit into system 4  SUPINATION-ADDUCTION — Stage 1 — Rupture of lateral collateral ligaments OR — Transverse fracture of fibula below ankle joint — Stage 2 — Vertical fracture of medial malleolus 5 6 7  PRONATION-ABDUCTION — Stage 1 — Rupture of deltoid ligament OR — Transverse fracture of medial malleolus — Stage 2 — Disruption of AITFL and PITFL OR — Tillaux Chaput, Wagstaffe or Volkmann fracture — Stage 3 — Short oblique fracture of the fibula at ankle joint 8 9 10  SUPINATION-EXTERNAL ROTATION — Stage 1 — Disruption of AITFL OR — Tillaux Chaput/Wagstaffe fracture — Stage 2 — Spiral fracture of fibula at ankle joint — Stage 3 — Disruption of PITFL OR — Volkmann fracture — Stage 4 — Rupture of deltoid ligament — Transverse fracture of medial malleolus 11 12 13 14  PRONATION-EXTERNAL ROTATION — Stage 1 — Rupture of deltoid ligament OR — Transverse fracture of medial malleolus — Stage 2 — Disruption of AITFL OR — Tillaux Chaput/Wagstaffe fracture — Rupture of interosseous membrane — Stage 3 — Fibular fracture proximal to syndesmosis — Stage 4 — Disruption of PITFL OR 15 — Volkmann fracture 16 17 18  DANIS-WEBER — Three main patterns of injury — Based on fibular fracture and its relationship to the ankle joint 19  DANIS-WEBER — A: Fibular fracture below level of the ankle B: Fibular fracture at level of the ankle C: Fibular fracture above level of the ankle 20  DANIS-WEBER — A=Supination-Adduction B=Supination-External Rotation =Pronation-Abduction C=Pronation-External Rotation 21 22 Pilon Fractures — Ruedi/Allgower — Stage I: No comminution or displacement of joint fragments — Stage II: Some displacement but not comminution or impaction — Stage III: Comminution and/or impaction of the joint surface Growth Plate Injuries initial SH I — Through hypertrophic zone — No x-ray evidence, need high degree of suspicion with pain with palpation directly over the physis — Closed reduction with excellent prognosis — NWB cast for 3 weeks, followed by WB cast for 3 weeks SH II — Partially splits through physis and then out through metaphysis with a metphyseal triangular shaped piece of bone (Thurston- Holland sign) — Periosteum on side of fragment remains intact, facilitating closed reduction — Prognosis excellent — 75% of all physeal fractures SH III — Partially extends through physis and then through epiphysis into the joint, disrupting joint surface — ORIF SH IV — Runs obliquely through the metaphysis, through the physis and epiphysis, and enters joint — Thurston Holland sign also seen — ORIF SH V — Compression or crush injuries that are difficult to diagnose — No fracture lines evident — If growth disturbance occurs, treatment still possible if child younger with remaining growth potential — Rang (1969) added SH VI-result of damage to periosteum or perichondral ring with resultant bony bridge formation external to growth plate — SH VII (Ogden): damage to epiphysis and not to physis — SH VIII: damage to metaphysis and not to physis — SH IX: injury to diaphyseal periosteum that may result in disruption of normal diaphyseal growth and remodelling Calcaneal Fractures CLASSIFICATIONS — Extra-articular and Intra-articular — Rowe: Extra-articular (does describe some intra-articular fractures) — Essex-Lopresti: Intra-articular — Sanders: Intra-articular CT classification  ROWE CLASSIFICATION — I a - Fracture of the calcaneal tubercle — I b - Fracture of the sustentaculum tali — I c - Fracture of the anterior process — II a - Beak fracture of the tuberosity — II b - Avulsion fracture of the tuberosity — III - Oblique body fracture not involving the STJ — IV - Body fracture involving the STJ — V - Joint depression with comminution ROWE I a — Fall with the heel everted or inverted — Fracture of the medial or lateral tubercle — Lateral — Treatment depends on displacement and size of the fragment ROWE I b — Fall with twisting on a supinated foot — Fracture of the sustentaculum tali — First stage in a joint depression fracture — ROM of FHL — Calcaneal axial — Treatment depends on displacement ROWE I c — Supination and plantarflexion — Most common type I — Fracture of anterior process — MO and lateral — Treatment depends on displacement ROWE II a — Direct trauma — Fracture of the superior portion of the tuberosity — Lateral — Spares achilles tendon insertion — Treatment depends on displacement ROWE II b — Strong pull of achilles tendon — Avulsion fracture of tuberosity — Involves achilles tendon insertion — Lateral — Treatment depends on displacement, but favors surgical ROWE III — Fall from height with heel in varus or valgus — Fracture of body without STJ involvement — Most common extra- articular — Treatment depends on displacement ROWE IV — Fall from height with foot plantarflexed — Fracture of the body that is intra-articular — CT scan — Treatment? — Same as Essex-lopresti tongue type fracture ROWE V — Fall from height with foot dorsiflexed — Intra-articular fracture with joint depression and comminution — Same as Essex-Lopresti joint depression fracture — Treatment? ESSEX-LOPRESTI TONGUE TYPE FRACTURE — Primary fracture line (shear fracture) which is intra-articular separates the sustentaculum tali from the lateral body — Secondary fracture line through the tuberosity — Resembles avulsion fracture  ESSEX-LOPRESTI JOINT DEPRESSION TYPE FRACTURE — Shear fracture divides the calcaneus into two parts - sustentaculum fragment and tuberosity fragment — Lateral portion of posterior facet is isolated and impacted into the body — Lateral wall blow-out — Position of the foot may determine the type of blow-out fracture — Decrease in the height and width of calcaneus  ESSEX-LOPRESTI JOINT DEPRESSION TYPE FRACTURE — Shear fracture divides the calcaneus into two parts - sustentaculum fragment and tuberosity fragment — Lateral portion of posterior facet is isolated and impacted into the body — Lateral wall blow-out — Position of the foot may determine the type of blow-out fracture — Decrease in the height and width of calcaneus  ESSEX-LOPRESTI JOINT DEPRESSION TYPE FRACTURE — Shear fracture divides the calcaneus into two parts - sustentaculum fragment and tuberosity fragment — Lateral portion of posterior facet is isolated and impacted into the body — Lateral wall blow-out — Position of the foot may determine the type of blow-out fracture — Decrease in the height and width of calcaneus SANDERS CLASSIFICATION — CT classification - coronal and axial — Section with widest part of posterior facet used — The calcaneus can be divided into four parts by three fracture lines — Lines named A,B and C from lateral to medial — Four types with subclassifications SANDERS CLASSIFICATION SANDERS TYPE I — All nondisplaced intra-articular fractures are Type I, irrespective of the number of fracture lines SANDERS TYPE II — Two part fractures of the posterior facet — Type IIA, IIB and IIC based on primary fracture line SANDERS IIA — Two part fracture — Primary fracture line is lateral separating the lateral column from the central SANDERS IIB — Two part fracture — Primary fracture line is central separating the central column from the medial SANDERS IIC — Two part fracture — Primary fracture line is medial separating the medial column from the sustentaculum column SANDERS III — Three part fracture of posterior facet — Features a centrally depressed fragment — Type IIIAB, IIIAC and IIIBC based on two fracture lines SANDERS IIIAB — Three part fracture — Two fracture lines separate the posterior facet into lateral, central and medial columns SANDERS IIIAC — Three part fracture — Two fracture lines separate the posterior facet into lateral column, central/medial column and sustentaculum column SANDERS IIIBC — Three part fracture — Two fracture lines separate the posterior facet into lateral/central column, medial column and sustentaculum column SANDERS IV — Four part fracture — Highly comminuted — Usually more than four fragments — Joint depression present SANDERS IV — Four part fracture — Three fracture lines which separate all of the columns of the posterior facet and sustentaculum Talar Fractures Sneppen Classification — Based on anatomical location — I – Transchondral dome — II – Shear — III – Posterior tubercle — IV – Lateral process — V – Crush Hawkins Classification 1970 Talar Neck Fractures — Of the many fracture classifications this one has value — Excellent correlation with prognosis — Predictive of AVN rate — Widely accepted  Hawkins 1 — Non displaced neck fracture — AVN 0 – 13 %  Hawkins 2 — Displaced neck fracture — Subtalar subluxation — AVN 20 – 50 %  Hawkins 3 — Subtalar and ankle joint dislocated — Talar body is tethered around deltoid ligament — AVN 83 – 100 % Hawkins 4 — Includes talonavicular subluxation — Rare variant — Complex talar neck fractures which do not fit classification can be included  Berndt & Harty Classification — I – Small area of compression — II – Partially detached OCD — III – Fully detached OCD but remains in crater — IV – Displaced Berndt & Harty Generalizations — Medial – Posterior – Deeper — Lateral – Anterior - Shallower Navicular Fractures Watson-Jones Classification — I – Avulsion fracture of tuberosity — II – Dorsal chip fracture — III – Body fracture — IV – Stress fracture Tarsal-Metatarsal Fractures Quenu and Kuss Hardcastle — Type A - Total incongruity of the TMT joint — Type B1 - Partial incongruity affecting the first ray in relative isolation (ie, partial medial incongruity) — Type B2 - Partial incongruity in which the displacement affects one or more of the lateral four metatarsals (ie, partial lateral incongruity) — Type C1 and C2 - A divergent pattern, with partial or total displacement Fifth Metatarsal Fractures Stewart Classification — Type 1 - fracture at the metaphyseal-diaphyseal junction. This is the classic Jones fracture. — Type 2 - intra-articular tuberosity fracture without comminution. — Type 3 - extra-articular tuberosity fracture. — Type 4 - intra-articular, comminuted tuberosity fracture. — Type 5 - fracture of the epiphysis.  Jones / Stress Fractures When to Operate — Jones fractures in athletes* — Stress fractures — Torg type I – same as Jones — Torg type II — Inlay bone graft Based on pt’s — Intramedullary screw activity level — Torg type III — Inlay bone graft — Intramedullary screw