FRACTURE CLASSIFICATION
CALCANEAL FRACTURES
DIGITAL FRACTURES
Distal Phalangeal – crush injury w/ subungual hematoma (tx
as an open fx)
Middle and Proximal Phalangeal – Usually spiral oblique
SESAMOID FRACTURES
Tibial sesamoid most commonly fx, result from direct trauma.
May be a simple fx or “stellate” (sesamoidal comminuted –
high potential for AVN.) Differentiate from bipartite:
Bipartite Sesamoid – combined size is larger than a single
sesamoid, division is clear, regular, and following a cardinal
body plane.
Fractured Sesamoid – Combined size equal to single
sesamoid, division is irregular, indistinct, and oblique.
1ST MPJ DISLOCATIONS – JAHSS CLASSIFICATION
Type I – Hallux/sesamoid dislocation, no disruption of
sesamoid apparatus, irreducible to closed reduction.
Type IIa – closed reduction possible, disrupted
intersesamoidal ligament
Type IIb – closed reduction possible, transverse fx of
sesamoids
5TH METATARSAL BASE FRACTURES – STEWART CLASSIFICATION
Type I – “Jones Fracture,” transverse fx of diaphyseal /
metaphyseal junction. Healing potential is poor.
Type II – Intraarticular avulsion fx
Type III – Extraarticular avulsion fx
Type IV – Intraarticular comminuted fx
Type V – (peds) Extraarticular fx through epiphysis
Type I Type II Type III Type IV Type V
NAVICULAR FRACTURES – WATSON/JONES
CLASSIFICATION
Type I – Avulsion fx off tuberosity by PT tendon
Type II – Dorsal lip fx, may look like os supranaviculare
Type III – fx through main body of the navicular
CUBOID FRACTURES
Difficult to see – occur due to a “nutcracker” motion
LISFRANC’S FRACTURES – HARDCASTLE CLASSIFICATION
Type A – either homolateral (metatarsals displaced laterally)
or homomedial (metatarsals displaced medially.)
Type B – Partial incongruity; not all metatarsals are displaced
in the same direction.
Type C – Divergent; 1st metatarsal is medially dislocated, 2-5
are either partially or completely laterally dislocated.
Signs & Symptoms: Acute pain, edema about heel, pain w/
compression/palpation, pain w/ STJ motion, fx blisters on
skin, plantar medial&lateral ecchymosis (mondur’s sign)
Bohler’s Angle: Measures sagittal plane relationship of talus
and calcaneus – compare to contralateral side.
Normal = 25 -40 degrees; fx lowers or reduces this angle
Critial Angle of Gissane: Measure of calcaneal strut that
supports the lateral talar process.
Normal = 130 degrees; intraarticular fx will decrease
Broden View: Lateral oblique projection to visualize the
posterior facet and a medial oblique to view the sinus tarsi.
Isherwood View: Lateral oblique axial to visualize posterior
facet, medial oblique axial to visualize middle articular facet,
and lateral oblique to visualize anterior process.
ROWE CLASSIFICATION
Type Ia – plantar calcaneal tuberosity fx,
secondary to eversion force (medial
tuberosity) or inversion (lateral tuberosity.)
View w/ axial calcaneal, lateral foot.
Type Ib – shearing fx of
the sustentaculum tali,
secondary to inverted
landing of heel. View w/
axial calcaneal.
Type Ic – anterior process fx, may appear
similar to os
calcaneum
secundum.
Occurs as a bifurcate ligament
avulsion, secondary to adduction
and plantarflexion. View w/
lateral, lat oblique isherwood.
Type IIa – “beak fracture,” meaning a lift-off of the posterior
superior surface of the calcaneus; some cortex still intact.
Occurs when heel strikes ground
w/ knee extended and foot
dorsiflexed. View w/ lateral foot
radiograph.
Type IIb – avulsion fx of the tendo Achilles, same as a IIa but Type IIc – comminuted STJ fx.
with complete dislocation.
Type IIIa – simple fx, oblique through calcaneal body not
involving the STJ. Occurs secondary to a fall, landing on both
heels w/ the feet inverted or everted. View w/ lateral foot,
axial calcaneal.
Type IIIb – same as IIIa, but comminuted.

Type IVa&b – same as type III, but w/ STJ involvement.
WATSON-JONES CLASSIFICATION
Not involving the STJ
Type A – vertical fracture of tuberosity
Type B – horizontal fracture of tuberosity
Type C – fracture of sustentaculum tali
Type D – fracture of the anterior process
Involving the STJ
Type A – undisplaced fracture through body
Type B – displaced fracture through body
Type C – fracture w/ comminution and displacement of STJ
(Note: This classification is crappy. Don’t actually use it.)

SANDER’S CLASSIFICATION
(Note: this classification system is based on posterior facet
Type Va – intraarticular STJ fx w/ comminution and
depression of the articular segment.
Type Vb – intraarticular fx of the calcaneo-cuboid joint.

fractures and is designed for a particular type of ORIF kit.

Classification has to be visualized w/ coronal CT scan.)
Type I (A, B, and C) – nondisplaced articular fx.

ESSEX-LOPRESTI CLASSIFICATION
Type Ia – tuberosity fx; beak/medial avulsion fx,
vertical/horizontal body fx. (Rowe types I and II)
Type Ib – calcaneo-cuboid joint involvement
Type IIa – undisplaced STJ fx, secondary fx line exits
posteriorly through calcaneus.
Type IIb – displaced STJ fx, secondary fx line exits dorsally
through calcaneus and a fragment dislocates.
Type II (A, B, and C) – two part fx of posterior facet.
Type III (AB, AC, and BC) – three part fx w/ central
depressed segment.

Type IV – comminuted fx of posterior facet.
The standard of care for calcaneal classification currently is
the Rowe system. For Rowe class IV and V (intraarticular –
75% chance) then a coronal CT scan is indicated, and the
Sanders system is typically used to classify.
TALAR NECK FRACTURES – HAWKIN’S CLASSIFICATION
These fxs are usually seen in MVAs or short-height falls
Type I – minimal displacement, 7-15% chance of AVN
Type II – STJ subluxation, 35-50% chance of AVN
Type III – ankle dislocation, 85% chance of AVN
Type IV – STJ/ankle/TNJ dislocation, 100% chance of AVN
Hawkin’s Sign – subchondral lucency of the body of the talus
following fx; appears 6-8 weeks post fx and indicates
revascularization of the talar body. (Good thing)
TALAR DOME LESIONS – BERNDT-HARDY CLASSIFICATION
These fxs occur due to torsional injuries.
Stage I – small area of compression in subchondral bone.
Prognosis good.
Stage II – partially detached osteochondral fragment.
Prognosis good.
Stage III – completely detached osteochondral fragment, in
crater. Prognosis good.
Stage IV – complete osteochondral fx, out of crater.
Prognosis bad.
DIAL a PIMP denotes the location of talar dome lesions –
dorsiflexion internal rotation = anterior lateral lesion,
plantarflexion inversion = medial posterior lesion.
Medial Lesions: (PIMP, 56% chance) Deep, cup shaped, less
likely to displace.
Lateral Lesions: (DIAL, 44% chance) Thin, wafer shaped,
easily displaces.
FRACTURES OF THE TALAR BODY - SNEPPEN
Type I – Transchondral Dome Fracture (use Berndt-Hardy)
Type II – Shear Fracture – 50% AVN, requires ORIF
Type III – Posterior Tubercle Fracture – Shepherd’s Fx
Type IV – Lateral Process Fracture (Use Fjeldborg)
Type V – Crush injury – highly comminuted
FRACTURES OF THE LATERAL PROCESS OF THE TALUS -
FJELDBORG
Type I – Incomplete fx (no ORIF necessary)
Type II – Fx w/ displacement (ORIF)
Type III – Fracture w/ STJ dislocation (ORIF)
EPIPHYSEAL FRACTURES – SALTER-HARRIS CLASSIFICATION
Type I – shearing force, separation of epiphysis from
metaphysic w/o fx, seen at birth and in young children.
Type II – fx line extends through physis and exits metaphysis.
Shearing or avulsion force, + Thurston Holland sign.
Thurston Holland Sign – triangle shaped metaphyseal fx.
Type III – fx line extends through physis and exits epiphysis
(intraarticular). Due to shearing force.
Type IV – intraarticular fx through epiphysis, physis, and
metaphysis. Prognosis is poor.
Type V – compression fx, compacted germinal cells of physis
die and cause premature closure. Poor prognosis.
Type VI (Rang) - contusion of perichondral ring of physis,
acts like type V if a bony bridge develops – prognosis good.
Type VII (Ogden) – epiphyseal fx not affecting physis
Type VIII (Ogden) – partial fx of metaphysis, growth lines
Type IX (Ogden) – degloving loss of periosteum on diaphysis
EPIPHYSEAL FRACTURES – POLAND CLASSIFICATION
Types I to III – same as salter-harris I to III
Type IV – fx through entire physis w/ epiphyseal fx as well
EPONYMOUS FRACTURES
Pott’s Fracture – bimalleolar fx through tibia & fibula
Cotton’s Fracture – trimalleolar fx; medial/lateral malleoli +
posterior or anterior distal tibia.
Maisonneuve Fracture – proximal fibular fx (near head) as a
result of torsional stress.
Bosworth Fracture – mid-fibular fracture that is displaced
posteriorly.
Shepherd’s Fracture – fx of lateral tubercle of posterior talar
process. Dx w/ hallux push-up test. Bohler’s triangle will be
obliterated on lateral x-ray.
ANKLE ARTHROGRAPHY
Single contrast used for acute deltoid or anterior talofibular
ligament tears. Only visible 24-48h post injury.
Double contrast used for chronic ligamentous tears and talar
dome lesions.

ANKLE FRACTURES – LAUGE-HANSEN CLASSIFICATION ADVANCED IMAGING FOR ANKLE INJURY

Lauge-Hansen is the first classification system to make sense
– the class is named after the etiology. The first word in the
classification denotes the position of the foot at time of injury,
and the second word denotes the position of the leg. Closed
reduction is then possible by mimicking and then minimizing
the force that caused the fracture originally.
The numerical classification w/in each class occur each in
chronological order (if at all) and determine the severity of the
fracture given that type of trauma.
Nuclear scanning is sensitive for ankle injuries but not
specific.
CT scanning is used primarily for pre-surgical assessment,
particularly in the case of comminuted fractures.
MRI is used to evaluate surrounding soft tissues, but does not
accurately visualize bone fragments.

Supination – Adduction (Danis Weber A)

I – transverse fx of the lateral malleolus
II – vertical fx of the medial malleolus

Pronation – Abduction (Danis Weber C)

I – Rupture of deltoid ligament/medial malleolar fx
II – Rupture of ant inferior tibio-fibular ligament
III – Bending fx of fibula 1cm proximal to plafond

Pronation – Dorsiflexion
I – Fx of medial malleolus
II – Large anterior lip fx of tibia
III – Fracture of superior lateral malleolus
IV – Fracture of third malleolus (posterior tibia)

Supination – External Rotation (SER) – (Danis Weber B)

I – Rupture of ant inferior tibio-fibular ligament
II – Spiral oblique fx of lateral malleolus (extending
anterior inferior to posterior superior.)
III – Rupture of post inferior tibio-fibular ligament
IV – Deltoid rupture/fx of medial malleolus
Note: this is the most common ankle fx. It can look a lot like
pronation-abduction, except SER has a spiral fibular fx.

Pronation – External Rotation (PER) (Danis Weber C)

I – Rupture of deltoid ligament/medial malleolar fx
II – Rupture of ant inferior tibio-fibular ligament,
Intra-osseous ligament, intra-osseous membrane
III – Spiral fx above syndesmosis (high fibular fx)
IV – Rupture of post inferior tibio-fibular ligament
This injury typically causes diastasis – separation of the tibio-
fibular syndesmosis. The high fibular fx (III) may be missed
on plain ankle films.

ANKLE STRESS VIEWS

Eversion Stress View – abduct foot while imaging. Use to
assess medial ankle ligament instability (positive if 10° greater
than contralateral side.)
Inversion Stress View – adduct foot while imaging. Use to
assess lateral ankle ligament injuries (positive if 10° greater
than contralateral side.)
Anterior Drawer Sign – pull talus forward on the tibia while
imaging. Use to assess isolated anterior talofibular tears
(positive if 3-8mm anterior displacement from normal.)