|
|
|
Trauma & Orthopaedics Revision
Classifications of PAEDIATRIC AND ADULT TRAUMA - Go to Main Contents
Classifications: In 1963 Salter Harris described 5 types of physeal injuries, 5th one being a compression injury of the physis. In 1969 Salter Harris Type 6 was added by Mercer Rang. In 1981 Ogden proposed a classification which consisted of 9 types and 11 subtypes making all together 20 types
Most commonly and widely accepted classification is still that of 1963 Salter Harris classification for physeal injuries.
Shoulder region:
Head of humerus 1 month
Greater tuberosity 1 y
Lesser tuberosity 3 y
Clavicle (Membranous )1st bone to ossify
Elbow region:
Capitellum 3 m
Medial epicondyle 6 y
Trochlear 9 y
Lateral epicondyle 12 y
Radial head 5 y
Olecranon 10 y
Wrist region
Distal radius 6 m
Distal ulnar 6 y
CLASSIFICATION OF UPPER LIMB FRACTURES IN CHILDREN
Classification of MONTEGGIA Fracture Dislocations (BADO)
Type 1
(a) Anterior radial head dislocation
(b) # ulnar shaft at any level with anterior angulation
Type 2
(a) Posterior or posterolateral radial head dislocation
(b) # ulnar shaft with posterior angulation
Type 3
(a) Lateral or anterolateral radial head dislocation
(b) # of the ulnar metaphysis with lateral angulation
Type 4
(a) Anterior radial head dislocation
(b) # of proximal radius & ulna at the same level
Monteggia "equivalent" fractures:
(1) Isolated radial head dislocation
(2) Fracture of proximal ulna with # radial neck
(3) Both bone proximal 1/3 # - Radial # more proximal than ulnar #
GALEAZZI FRACTURE DISLOCATION is:
Fracture of the distal shaft radius + Dislocation of distal radioulnar joint
SUPRACONDYLAR FRACTURES OF THE HUMERUS (Gartland)
Flexion or Extension fractures
Type I Undisplaced
Type II Angulated fractures with one intact cortex
Type III : Completely displaced fractures
Baumann's Angle (AP view): Angle between longitudinal axis of humeral shaft & physis of the lateral condyle is approximately 700
Humerotrochlear angle (Lateral) Angle between the longitudinal axis of the humerus & the axis of the condyles is approximately 400
Classification of Lateral & Medial HUMERAL CONDYLAR FRACTURE (Milch)
Type I : Usually stable - # line through the trochlear grove - # of the smaller, outer margin of the humeral condyle - SH type IV
Type II: usually unstable injury - # through the trochlear sulcus which involves the trochlear ridge, a bony prominence just lateral to the trochlear sulcus, which provides osseous stability to the elbow joint - SH type II epiphyseal #
Classification for Fractures of THE HUMERAL HEAD (Neer & Horowitz)
mainly SH I or II
Grade I: < 5mm displacement
Grade II: Displacement up to 1/3 width of the shaft
Grade III: Up to 2/3 width
Grade IV: > 2/3
CLASSIFICATION OF LOWER LIMB FRACTURES IN CHILDREN
Pelvis
Primary ossification centres
(1) Ilium 2nd fetal month
(2) Ischium 3rd fetal month
(3) Pubis 4th fetal month
- Ischium & Pubis Fuse inferiorly at 6 to 7 years
- All 3 centres Fuse at 16 - 18 years at the triradiate cartilage
Secondary ossification centres
Iliac crest appear 13 - fuse 15
A.Inf.Iliac Spine appear 14 - fuse 16
Ischial tuberosity appear15 - fuse 19
Femur
Secondary ossification centres
(1) Head 6 months
(2) Greater trochanter 4 years
(3) Lesser trochanter 8 years
After puberty fusion with the shaft of femur in the order of 3 2 1
(4) Shaft of femur 8th week in utero
2nd bone to ossify after clavicle
(5) Distal femur 7th month in utero
fuses with shaft at 20 years
Tibia
(1) Proximal tibia 1 month after birth
(2) Tibial shaft (POC) 8th fetal week
(3) Distal tibia 1 year old
(4) Tubercle Puberty
Fibula
(1) Proximal fibula 4 years
(2) Fibula shaft (POC) 8th fetal week
(3) Distal fibula 1 year old
CLASSIFICATION OF CHILDREN HIP FRACTURES (Dilbet)
Type I: Transepiphyseal
Type II: Transcervical
Type III: Cervicotrochanteric (basal)
Type IV: Intertrochanteric (pertrochanteric)
Classification of Tibial Intercondylar eminence or TIBIAL SPINE fractures:
(Meyers & McKeever)
Based on lateral X-ray of the knee:
Type I: Minimally displaced
Type II: 1/3 or ½ of the tibial eminence is elevated, hinged on its posterior insertion
Type III: completely displaced
Type III+: displaced + Rotated
TRIPLANE ANKLE FRACTURES IN CHILDREN
Caused by external rotational force
(1) 3 fragments triplane # = combination of SH II & III #
(2) 2 fragments triplane # = SH IV #
Epiphyseal fusion of distal tibia:
Girls 15, boys 17 years of age. It begins from center, progress to medial then posterior. Antero-lateral portion of the plate fuses last
Avulsion of anterolateral segment of distal tibial epiphyseal plate.
Occurs after medial epiphyseal plate had closed but before lateral part closes
SH III injury
CLASSIFICATION OF FRACTURES IN ADULTS
Group 1 - Middle third fracture
Group 2 - Lateral third
Group 3 - Medial third
NEER (LATERAL CLAVICLE)
Type 1 - Coraco Clavicular ligament intact
Type 2 - Coraco Clavicular ligament torn & displacement of medial fragment
Type 3 - Fractures involving the A-C joint
Type 1 -Sprained
Type 2 -Subluxed
Type 3 -Superior Dislocation
Type 4 -Superior/ Posterior dislocation
Type 5 - Severe superior dislocation
Type 6 - Severe Inferior dislocation
Anatomical classification Body Glenoid Rim or Fossa Anatomical Neck Surgical Neck
Acromion Coracoid Process Soine
NEER classification
TWO part / THREE part / FOUR part / Head splitting / Impression
Following parts are displaced >5mms, or angulated >450 and can be associated with anterior or posterior dislocations
(1) Anatomical neck
(2) Surgical neck
(3) Greater tuberosity segment
(4) Lesser tuberosity segment
COFIELD & IRVING CLASSIFICATION OF SHOULDER DISLOCATIONS
(1) Anterior
(2) Posterior
(3) Multidirectional
Each can be subdivided according to the following parameters:
(1) Degree: Subluxation Dislocation
(2) Cause : Microtrauma Macrotrauma Atraumatic
(3) Type : Acute Recurrent Voluntary Involuntary
(4) Primary direction: (multidirectional instability only): Anterior inferior Posterior inferior All directions
Condylar: MILCH - Medial or lateral
Type 1: Smaller outer margin of articular surface - < 30% (stable)
Type 2: Larger fragment - > 30% (unstable)
Capitellum Fracture:
Type 1: Hahn-Steinthal - articular surface with large amount of subchondral & cancellous bone
Type 2: Kocher-Lorenz - articular slice # of capitellum with little underlying bone
Type 3: Crushed capitellum
(A) Dislocation of radius & ulna
(1) Posterior
(a) Posteromedial
(b) Posterolateral
(2) Anterior
(3) Medial
(4) Lateral
(5) Divergent dislocation with superior R/U joint disruption
(a) Anteroposterior
(b) Mediolateral
(B) Isolated dislocation of radius
(1) Anterior
(2) Posterolateral
(C) Isolated dislocation of ulna
(1) Anterior
(2) Posterior
Bado classification
Type 1:
(a) Anterior Dislocation of Radius
(b) Anterior Angulation of proximal or mid third of Ulna
Type 2:
(a) Posterior dislocation of Radius
(b) Posterior Angulation of proximal / mid third of Ulna
Type 3:
(a) Lateral or Ant-Lat dislocation Radius
(b) Ulna # just distal to coracoid process
Type 4:
(a) # of radial head or neck with dislocation
(b) # of proximal or middle third of Ulna
Mason's classification:
Grade 1:Undisplaced segmental #
Grade 2:Displaced segmental #
Grade 3:Comminuted #
Grade 4:Grade 3 with associated elbow dislocation
Type A (Acute stable fractures)
A1 tubercle fractures
A2 undisplaced waist #
Type B (Acute unstable fractures)
B1 oblique distal third #
B2 displaced waist fractures
B3 proximal pole fractures
B4 # dislocation of carpus
B5 comminuted fractures
Type C (Delayed union)
Type D (Established non-union)
D1 fibrous non-union
D2 sclerotic non-union (pseudoarthrosis)
Also known as
Chauffeur's #
Hutchinson's #
Scaphoid impression #
Ulnar styloid fractures
Associated with TFCC
CLASSIFICATION OF THORACOLUMBAR SPINE INJURIES
(1) Compression
(a) both endplate #
(b) upper endplate #
(c) lower endplate #
(d) no end plate # (osteoporosis)
(2) Burst
(a) both endplate #
(b) upper endplate #
(c) lower endplate #
(d) Burst rotation
(e) Lateral flexion burst
(3) Seat Belt
(a) 1 level ligament
(b) 1 level bony (chance #)
(c) 2 level ligament
(d) 2 level bony
(4) Fracture Dislocation
(a) Flexion rotation
(b) Shear - anterior/posterior
(c) Flexion distraction - similar to seat belt but with dislocation/subluxation
DENIS'S DIVISION OF SPINAL COLUMNS
(1) Anterior column - Anterior 2/3 of vertebral body including anterior longitudinal ligament - corresponding annulus fibrosus & nucleus pulposus
(2) Middle column - Posterior 1/3 of vertebral body including posterior longitudinal ligament corresponding annulus fibrosus & nucleus pulposus
(3) Posterior column - Ligaments: Supraspinous & interspinous ligaments / Ligamentum flavum / Capsular ligaments
Bony: Pedicles / Facet joints / Laminae / Spinous processes
Type A: Stable
A1: # of pelvis not involving the ring
A2: Minimally displaced # of the ring
Type B: Rotationally unstable, vertically stable
B1: Open book
B2: Lateral compression (Ipsilateral)
B3: Lateral compression (Contralateral, bucket handle)
Type C: Rotationally and vertically unstable
C1: Unilateral
C2: Bilateral
C3: Associated with acetabular #
(Classification after Letournel)
TYPE A: Partial articular one column
A1-Posterior wall
A2-Posterior column
A3-Anterior wall and/or anterior column
TYPE B: Partial articular transverse oriented with portion of the roof attached to intact ileum
B1-Transverse + posterior wall
B2-'T' types
B3-Anterior with posterior hemitransverse
TYPE C: Complete articular, both column "the floating acetabulum"
C1-Both column- (high variety)
C2-Both column- (low variety)
C3-Both column-anterior fracture enters the sacroiliac joint
FRACTURE & POSTERIOR DISLOCATION OF THE HIP (THOMPSON & EPSTEIN 1973)
Type 1: Dislocation with or without minor acetabular #
Type II: Dislocation with a large posterior fragment. Unstable after reduction
Type III: Dislocation with severe comminuted posterior lip
Type IV: Dislocation with # of the acetabular floor
Type V: Dislocation with # of femoral head
Subclassification by Pipkin of femoral head fracture dislocation (Type V)
Type I: Head # caudal to the fovea capitis femoris
Type II: Head # cephalic to the fovea capitis femoris
Type III: Type I or II associated with # of the femoral neck
Type IV: Type I, II or III associated with an acetabular #
ANTERIOR DISLOCATION OF THE HIP (DELEE)
Type I Superior
(Ia) No associated #
(Ib) Femoral head #
(Ic) Acetabular #
Type II Inferior
(IIa) No associated #
(IIb) Femoral head #
INTERTROCHANTERIC FRACTURES (Boyd & Griffin)
Extracapsular part of the neck to a point 5cm distal to the lesser trochanter
Type I: Along intertrochanteric line
Type II: Comminuted intertrochanteric fracture
Type III: Basically subtrochanteric fracture
Type IV: Fractures of the trochanteric region & proximal shaft # in at least 2 planes
A0 (Muller) classification of SUPRACONDYLAR FRACTURES
Type A: Extra-articular:
A1 - Supracondylar not involving the joint
A2 - 3 part with butterfly fragment
A3 - Comminuted supracondylar #
Type B: Partial articular:
B1 - Condylar # of medial or lat side
B2 - Condylar # extending into intercondylar notch medial or lateral
B3 - Shear # of post part of condyle on lateral view
Type C: Intra-articular
C1 Y shaped #
C2 Y shaped # with extra-articular comminution.
C3 Y shaped # with comminution at the joint line
Schatzker's modification, Originally described by Hohl & Moore
Type I: Pure split # lateral side
Type II: Split with depression - lateral side
Type III: Pure central depression - Lateral condyle
Type IV: Fractures of medial condyle
Type V: Bicondylar fractures Continuity of metaphysis & diaphysis maintained
Type VI: Dissociation of metaphysis & diaphysis in addition to plateau #
Lauge-Hansen:
- 1st word indicate the position of foot at the time of injury
- 2nd word defines the direction of force applied to the foot
- Further subclassified by the stages of severity (1 to 4) according to the structures involved(not given below)
(1) Supination external rotation (SER)
(2) Supination adduction rotation (SAR)
(3) Pronation external rotation (PER)
(4) Pronation abduction (PA)
(5) Pronation dorsiflexion (PD)
Weber A/O classification (44)
Type A: # fibula below the joint line
Type B: # at the syndesmosis
Type C: # proximal to the ankle joint
TALAR NECK FRACTURES (HAWKINS)
Type I: Undisplaced
Type II: Displaced # subluxation or dislocation of subtalar joint ankle joint normal
Type III: # with dislocation of body of talus from both subtalar & ankle joints
Type IV: # with complete dislocation of subtalar joint / ankle joint & Talonavicular joint
FRACTURE OF LATERAL PROCESS OF TALUS (HAWKINS)
Intraarticular # due to forced dorsiflexion on inverted heel. Best visulised: AP & Lateral 150 IR views in plantar flexion / Tomograms / CT
Type I: Minimal displacement involving talocalcaneal joint
Type II: Type I + Talofibula joint
Type III: Comminuted #
Type I: Osteochondral #
Type II: Coronal, sagittal or horizontal # of body
Type III: Posterior process #
Type IV: Lateral process #
Type V: Crush # of body
Type I Hawkins subclassification of TALAR DOME FRACTURE (BERNDT & HARTY)
Stage I: A small area of compression of subchondral bone
Stage II: A small, partly detached osteochondral fragment
Stage III: A completely detached undisplaced osteochondral fragment
Stage IV: A displaced osteochondral fragment in the joint
(1) Extraarticular fractures - 25%
(a) Tuberosity fractures: Posterior superior # Posterior inferior #
(b) Anterior process #: Avulsion # Compression #
(c) Sustentaculum tali # :
(d) Body extraarticular #
(2) Intraarticular fractures - Classification by - Essex Lopresti
- Sanders
- Eastwood / Kenwright
INTRA-ARTICULAR CALCANEAL FRACTURES
(1) Essex-Lopresti - 2 patterns of secondary #
(a) Tongue type
(b) Joint depression type
(2) Eastwood / Kenwright et al JBJS 1993 75B (2):183 of 3 part fractures
Type I: The lateral wall is formed by
the lateral joint fragment
Type II: The lateral wall is formed by the lateral joint fragment & body fragment
Type III: The lateral wall is formed
by the apparently intact lateral wall of the body fragment
MIDFOOT INJURIES
(1) Proximal articulation - Navicular/Cuboid - Chopart joint
(2) Distal articulation - 3 cuneiforms (medial, middle & lateral)/ Cuboid - Lisfranc joint
MIDTARSAL DISLOCATION (CHOPART)
(1) Medial
(2) Lateral
(3) Plantar
CLASSIFICATION OF LISFRANC FRACTURES (Hardcastle)
Type A: Homolateral
Type B: Homolateral incomplete
Type C: Divergent displacement
OPEN # Gustillo & Anderson (1976 revised 1984)
Type I: Clean wound < 1cm
Type II: Wound > 1cm without extensive soft tissue damage
Type III:
IIIA: Extensive soft tissue laceration or flaps; but maintained adequate soft tissue coverage of bones
IIIB: Extensive soft tissue loss, periosteal stripping & bone exposure
IIIC: Open # with arterial injury
Type IV: Replantation
Incidence of wound infection in open fractures:
Type I 0 - 2%
Type II 2 - 7%
Type IIIA 7%
Type IIIB 10 - 50%
Type IIIC 25 - 50%
(50% amputation rate)
Mangled Extremity Severity Score (MESS)
Four Categories
A. Skeletal/soft-tissue injury
Low energy = 1
Medium energy = 2
High energy = 3
Very high energy = 4
B. Limb ischaemia
Pulse reduced, perfusion normal 1
Pulses, parenthesis, diminished capillary refill = 2
Cool, paralysed, insensate, numb = 3
C. Shock
Systolic BP always >90 mm Hg = 0
Hypotensive transiently = 1
Persistent hypotension = 2
D. Age (Years)
<30 = 0
30-50 =1
>50 = 2
Score doubles for ischaemia >6 hours.
Good correlation between MESS score greater than 7 and amputation has been demonstrated
PHYSIOLOGICAL TRAUMA SCORE:
Revised Trauma score:
Respiratory rate
10-29 = 4
>29 = 3
6-9 = 2
1-5 = 1
0 = 0
Systolic BP
>90 = 4
76-89 = 3
50-75 = 2
1-49 = 1
0 = 0
Glasgow coma scale
13-15 = 4
9-2 = 3
6-8 = 2
4-5 = 1
3 = 0
ANATOMICAL SCORING SYSTEM
Injury Severity Score (ISS)
It utilises the Hospital Trauma Index of the American College of Surgeons, which scores injuries to six organ systems, including the cardiovascular, nervous, respiratory systems, abdomen, extremities, and skin.
The severity of these injuries is graded from zero (no injury) to 5 (critical). ISS is calculated by summing the squares of the three highest values on the Hospital Trauma Index. Maximum injury-severity score is 75.
