Fracture Classification

Classification of Fractures

        Fractures in any discontinuity in the bone which can occur due to trauma or any pathological causes. To understand the anatomy, pathophysiology, mechanics of fractures and to aid in the treatment fractures have been classified in many different ways. Following are various classifications of fractures
        Fractures can be classified depending upon the presence or absence of wound as

1. Closed Fractures

   : No wound associated with fracture.

2. Open Fractures

   : Wound present communication with the fracture.

        Open fractures are further classified :

Tscherne Classification for Open Tibial Fractures:

Grade 1	Bone Fragment causes skin laceration, skin contusion may or may not be present.
Grade 2	Skin laceration with surrounding skin or soft-tissue contusion and moderate contamination.
Grade 3	Fracture with severe bone comminution, Severe soft-tissue damage, with or without major vessel or nerve injury or both, or compartment syndrome
Grade 4	Subtotal and total amputation, defined as separation of all important anatomical structures, especially major vessels with total ischemia; remaining soft tissue may not exceed one fourth of circumference of extremity (any revascularization is grade 3)

Gustilo Anderson Classification

      This classification system now most commonly used by Orthopedic surgeons to describe and treat open fractures. This classification system takes into account the

• Skin wound
• Extent of local soft tissue injury and contamination.
• Severity of the fracture pattern.

      The Gustilo classification system originally included type I, type II, and type III fractures. This system was modified later to expand the type III open fractures into subtypes A, B, and C.

Classification of Open Fractures

Type	Wound	Level of Contamination	Soft Tissue Injury	Bone Injury
I	<1 cm long	Clean	Minimal	Simple, minimal comminution
II	>1 cm long	Moderate	Moderate, some muscle damage	Moderate comminution
III
A	>10 cm long	High	Severe with crushing	Usually comminuted; soft tissue coverage of bone possible
B	>10 cm long	High	Very severe loss of coverage; usually requires soft tissue reconstructive surgery	Bone coverage poor; variable, may be moderate to severe comminution
C	>10 cm long	High	Very severe loss of coverage plus vascular injury requiring repair; may require soft tissue reconstructive surgery	Bone coverage poor; variable, may be moderate to severe comminution

There are other general ways of classifying fractures

1. Based on the anatomy of the fracture-
   1. Transverse
   2. Oblique
   3. Spiral
   4. Comminuted
2. Based on cause of fracture
   1. Traumatic : caused due to traumatic injury.
   2. Pathological : caused due to inherent bone pathology weakening the bone.
3. AO/OTA classification System:

This system uses the coding method to classify fractures and can be applied to almost all bones. This is a complicated system but communication and data analysis easier.
Apart from the above general methods fractures do have their individual classification separately to describe and decide treatment depending upon their individual characteristics.

Limitations of Classification Systems
All classification systems are not perfect and they have some limitations:

1. Inter-observer reliability and reproducibility : same fracture classified differently by different surgeons.
2. Quality of Radiographs : Quality of radiographs are variable in clinical practise which affects the ability to accurately classify fractures.
3. Fracture line identification: in some complex fracture anatomy and overlapping fragments fracture line identification may become difficult.
4. Inherent variability in human observation.