Trauma

 Shock

Class % Blood Loss  HR BP Urine pH MS Treatment

< 15% 
I normal normal > 30 mL/hr  normal anxious Fluid
(<750ml)
15% to 30%  confused
(750-1500ml)  > 100 bpm  20-30
II normal normal irritable Fluid
mL/hr 
  combative
30% to 40%
(1500-2000ml) > 120 bpm lethargic Fluid &
III decreased 5-15 mL/hr  decreased
irritable Blood 
 
> 40% (life
lethargic Fluid &
IV threatening)  > 140 bpm decreased negligible decreased
coma Blood 
(>2000ml)

Hypovolemic
  Septic Shock 
Shock 
Systemic Vascular
increased decreased
Resistance 
Cardiac Output  decreased increased
Pulmonary Capillary
decreased decreased
Wedge Pressure 
Central Venous
decreased decreased
Pressure 
Mixed Venous Oxygen  decreased increased
 Gustilo Type I II IIIA IIIB IIIC
Images
Energy Low  Moderate High High High
Wound Size ≤ 1 cm 1-10 cm  usually >10 cm usually >10 cm usually > 10 cm
Soft Tissue Minimal Moderate  Extensive  Extensive  Extensive 
Damage
Contamination Clean Moderate  Extensive  Extensive  Extensive 
contamination
Fracture Pattern Simple fx pattern Moderate Severe Severe Severe
with minimal comminution  comminution or comminution or comminution or
comminution segmental segmental segmental
fractures fractures  fractures 
Periosteal No No Yes Yes Yes
Stripping
Skin Coverage Local coverage Local coverage Local coverage Requires free Typically requires
tissue flap or flap coverage
rotational flap
coverage
Neurovascular Normal  Normal Normal  Normal Exposed fracture
Injury with arterial
damage that
requires repair
Antibiotics 1st generation 1st generation cephalosporin for gram positive
cephalosporin (e.g. cefazolin) coverage.
for 24 hours after closure  Aminoglycoside (such as gentamicin) for gram
negative coverage in type III injuries 
the cephalosporin/aminoglycoside should be
continued for 24-72 hours after the last debridement
procedure
Penicillin should be added if concern for anaerobic

Antibiotics (other
considerations)
Doxycycline and 3rd or 4th-generation cephalosporin (e.g. ceftazidime)
organism (farm injury)
aminoglycoside (such as gentamicin) for gram
negative coverage 
1st cephalosporin (ancef) for gram positive coverage. 
the cephalosporin/aminoglycoside should be
continued for 72 hours after the last debridment
procedure
penicillin should be added if concern for anaerobic
organism (farm injury
Flouroquinolones (e.g. ciprofloxacin) 
should be used for fresh water wounds or salt water wounds
can be used if allergic to cephalosporins or clindamycin
can be used for salt water wounds

Osteomyelitis Organism Table

Age group Most common organisms
Newborns 
(younger than 4 S. aureus, Enterobacter species, and group A and B Streptococcus species
mo)
Children  S. aureus, group A Streptococcus species, Kingella kingae,
(aged 4 mo to 4 y) and Enterobacter species
Children,
S. aureus (80%), group A Streptococcus species, H. influenzae,
adolescents 
and Enterobacter species
(aged 4 y to adult)
Adult S. aureus and occasionally Enterobacter or Streptococcus species
 Unusual Osteomyelitis Organism Table
Organism Patient characteristic
Salmonella Sickle cell anemia patients (S. aureus is still most common)
IV drug use with AC or SC joint infection or puncture wound through rubber
Pseudomonas
soled shoes
Bartonella HIV/AIDS patient following cat scratch or bite
Fungal
Immunosuppressed, long-term IV medications, or parentarel nutrition
osteomyelitis
Manifestations include Potts disease
Copy
Tuberculosis
Note
Highlight (default)

Cierny-Mader Classification of Osteomyelitis 

(describes anatomic involvement, host, treatment, prognosis)
 Anatomic Location
Stage I Medullary
Stage 2 Superficial
Stage 3 Localized
Stage 4 Diffuse
Host Type
Type A Normal   
Type BL Locally compromised  
Type BS Systemically compromised  
Type C Treatment is worse to the patient than infection
  Necrotizing Fasciitis Classification
Type Organism Characteristics
Type 1  Polymicrobial   • Most common (80-90%)
Typical 4-5 aerobic and anaerobic species  • Seen in immunosuppressed (diabetics and
cultured:  cancer patients)
• non-Group A Strep  • Postop abdominal and perineal infections
• anaerobes including Clostridia
• facultative anaerobes
• enterobacteria
• Synergistic virulence between organisms
Type 2  Monomicrobial   • 5% of cases
• Group A β-hemolytic Streptococci is most  • Seen in healthy patients
common organism isolated  • Extremities  
Type 3 Marine Vibrio vulnificus  • Marine exposure
(gram negative rods)
Type 4 MRSA  
  Neer Classification   
Type I  • fracture is LATERAL to coracoclavicular ligaments  Nonoperative
 • conoid and/or trapezoid ligament remain INTACT
 • minimal displacement
 • STABLE
Type IIA  • fracture occurs MEDIAL to coracoclavicular ligaments  Operative
 • conoid and trapezoid ligment remain INTACT  
 • significant medial clavicle displacement
 • UNSTABLE 
          • up to 56% nonunion rate with nonoperative
management
Type IIB  • two fracture patterns   Operative
          • (1) fracture occurs
either BETWEEN the coracoclavicular ligaments 
                    • conoid ligament TORN
                    • trapezoid ligament INTACT
          • (2) fracture occurs LATERAL to coracoclavicular
ligaments  
                    • conoid ligament TORN
                    • trapezoid ligament TORN
 • signficant medial clavicle dispalcement
 • UNSTABLE
          • up to 30-45% nonunion rate with nonoperative
management
Type III  • INTRA-ARTICULAR fracture extending into AC joint  Nonoperative
 • conoid and trapezoid ligaments remain INTACT 
 • minimal displacement
 • STABLE
          • patients may develop posttraumatic AC arthritis
Type IV  • PHYSEAL fracture that occurs in the skeletally immature  Nonoperative
 • conoid and trapezoid ligaments remain INTACT 
  • displacement of lateral clavicle occurs superiorly through a
tear in the thick periosteum (clavicle pulls out of periosteal
sleeve)
 • STABLE
Type V  • COMMINUTED fracture pattern  Operative
 • conoid and trapezoid ligaments remain INTACT
 • significant medial clavicle displacement
 • usually UNSTABLE

Capitulum fracture
 Bryan and Morrey Classification (with McKee modification)  
Type I Large osseous piece of the capitellum involved    
Can involve trochlea 
Type II Kocher-Lorenz fracture   
Shear fracture of articular cartilage
Articular cartilage separation with very little subchondral bone attached 
Type III Broberg-Morrey fracture   
Severely comminuted
Multifragmentary
Type IV McKee modification
Coronal shear fracture that includes the capitellum and trochlea 
 O'Driscoll Classification
Subdivides coronoid injuries based on location and number of coronoid fragments
Recognizes anteromedial facet fractures caused by varus posteromedial rotatory
force   

Regan and Morrey Classification

Type I coronoid process tip fracture
Type II fracture of 50% or less of height
Type III fracture of more than 50% of height

Radial head fracture

Mason Classification (Modified by Hotchkiss and Broberg-Morrey)
Nondisplaced or minimally displaced (<2mm), no
Type I 
mechanical block to rotation
Displaced >2mm or angulated, possible mechanical
Type II 
block to forearm rotation
Type III  Comminuted and displaced, mechanical block to motion
Type IV Radial head fracture with associated elbow dislocation
 Montage
Bado Classification
Type I  Fracture of the proximal or middle third of the ulna with anterior dislocation of
60%
the radial head (most common in children and young adults)
Type II Fracture of the proximal or middle third of the ulna with posterior dislocation of
15%
the radial head (70 to 80% of adult Monteggia fractures)
Type III Fracture of the ulnar metaphysis (distal to coronoid process) with lateral
20%
dislocation of the radial head
Type IV Fracture of the proximal or middle third of the ulna and radius with dislocation of  
5%
the radial head in any direction

Jupiter Classification of Type II Monteggia Fracture-Dislocations

Type IIA Coronoid level  
Type IIB Metaphyseal-diaphyseal junction  
Type IIC Distal to coronoid  
Type IID Fracture extending to distal half of ulna  

View Measurement Normal Acceptable criteria 

AP Radial height 13mm < 5mm shortening 
Radial
  23° change < 5° 
inclination
  Articular stepoff congruous < 2 mm stepoff 
dorsal angulation < 5° or within 20° of
Lateral Volar tilt 11°
contralateral distal radius 

  Descriptions Xray CT
 Anterior Posterior Compression (APC)
APC I Symphysis widening < 2.5 cm  

APC II Symphysis widening > 2.5 cm. Anterior SI joint diastasis    . Posterior SI
ligaments intact. Disruption of sacrospinous and sacrotuberous ligaments. 
APC III Disruption of anterior and posterior SI ligaments (SI dislocation). Disruption of
sacrospinous and sacrotuberous ligaments.
APCIII associated with vascular injury   
Lateral Compression (LC)
LC I Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression
fracture. 

LC II Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent  

fracture). 
LC III Ipsilateral lateral compression and contralateral APC (windswept pelvis).   
Common mechanism is rollover vehicle accident or pedestrian vs auto. 
Vertical Shear (VS)
Vertical Posterior and superior directed force.     
shear Associated with the highest risk of hypovolemic shock (63%); mortality rate up to
25%

Obt.O C
AP Iliac.Obl. Comments 
Illus. bl. T
Elementary 
Posterior wall  • Most common
• "gull sign" on obturator oblique view
Posterior column  • check for injury to superior gluteal NV bundle
Anterior wall • Very rare
Anterior column  • More common in elderly patients with fall from standing (most common in
elderly is "anterior column + medial wall")
Transverse         • Axial CT shows anterior to posterior fx line 
• Only elementary fx to involve both columns
Associated 
Associated Both • Characterized by dissociation of the articular surface from the inonimate
Column  bone     
• "spur sign" on obturator oblique   
Transverse + Post. • Most common associated fx
Wall 
T Shaped • May need combined approach
Anterior column or wall + • Common in elderly patients
Post. hemitransverse
Post. column + Post. wall • Only associated fracture that does not involve both columns

Pipkin Classification 
Type I Fx below fovea/ligamentum (small)    
Does not involve the weightbearing portion of the femoral head
 Type II Fx above fovea/ ligamentum (larger)      
Involves the weightbearing portion of the femoral head 
Type III Type I or II with associated femoral neck fx  
High incidence of AVN
Type IV Type I or II with associated acetabular fx (usually posterior wall fracture)  

Garden Classification
(based on AP radiographs and does not consider lateral or sagittal plane alignment)
Type I Incomplete, ie. valgus impacted  
Type II Complete fx. nondisplaced  
Type III Complete, partially displaced  
Type IV Complete, fully displaced  
Posterior roll-off and/or angulation of femoral head leads to increased reoperation rates
 
Simplified Garden Classification
Nondisplaced Includes Garden I and II
Displaced Includes Garden IIII and IV

Pauwels Classification
 (based on vertical orientation of fracture line)
Type I < 30 deg from horizontal
ASBMR Task Force Case Definition of Atypical Femur Fractures (AFFs), Revised criteria
Type
FourII of five major
30features
to 50 deg from be
should horizontal
present to designate a fracture as atypical; minor features may or
> 50 deg from horizontal
may not (most
be unstable
present with highest
in individual risk
cases
Type III
Major of nonunion and AVN)
Associated with no trauma or minimal trauma, as in a fall from a standing height or less
Criteria Fracture originates at the lateral cortex and is substantially transverse in its orientation,
although it may become oblique as it crosses the medial femur
Noncomminuted 
 Complete fractures extend through both cortices and may be associated with a medial
spike; incomplete fractures involve only the lateral cortex
 Localized periosteal or endosteal thickening of the lateral cortex is present at the fracture
site
Minor Generalized increase in cortical thickness of the femoral diaphyses
Criteria Prodromal symptoms such as dull or aching pain in the groin or thigh
Bilateral incomplete or complete femoral diaphysis fractures  
Delayed fracture healing
Specifically excluded are fractures of the femoral neck, intertrochanteric fractures with
spiral subtrochanteric extension, pathological fractures associated with primary or metastatic
bone tumors, and periprosthetic fractures

Schenck Classification (based on the number of ruptured ligaments)

KD I Multiligamentous injury with the involvement of the ACL or PCL
KD II Injury to ACL and PCL only (2 ligaments)
Injury to ACL, PCL, and PMC or PLC (3 ligaments). KDIIIM (ACL, PCL, MCL) and
KD III
KDIIIL (ACL, PCL, PLC, LCL). 
Injury to ACL, PCL, PMC, and PLC (4 ligaments) KDIV has the highest rate of vascular
KD IV
injury (5-15%%) based on Schenck classification
KD V Multiligamentous injury with periarticular fracture

Schatzker Classification
Type I Lateral split fracture  
Type II Lateral Split-depressed fracture    
Type III Lateral Pure depression fracture  
Type IV Medial plateau fracture         
Type V Bicondylar fracture  
Type VI Metaphyseal-diaphyseal disassociation   
 

Hohl and Moore Classification of proximal tibia fracture-dislocations 

Type I Coronal split fracture
Type II Entire condylar fracture
Type III Rim avulsion fracture of lateral plateau
Type IV Rim compression fracture
Type V Four-part fracture
Classification useful for
1) true fracture-dislocations 
2) fracture patterns that do not fit into the Schatzker classification (10% of all tibial plateau fractures)
3) fractures associated with knee instability

Lauge-Hansen Class Sequence

Supination - Adduction (SA)  Talofibular sprain or distal fibular avulsion
Vertical medial malleolus and impaction of anteromedial
 distal tibia
Supination - External Rotation (SER) Anterior tibiofibular ligament sprain
Lateral short oblique fibula fracture (anteroinferior to
posterosuperior)
Posterior tibiofibular ligament rupture or avulsion of posterior
malleolus
Medial malleolus transverse fracture or disruption of deltoid
ligament 
Pronation - Abduction (PA)  Medial malleolus transverse fracture or disruption of deltoid
  ligament 
Anterior tibiofibular ligament sprain
Transverse comminuted fracture of the fibula above the level
of the syndesmosis 
Pronation - External Rotation (PER) Medial malleolus transverse fracture or disruption of deltoid
       ligament 
Anterior tibiofibular ligament disruption
Lateral short oblique or spiral fracture of fibula
(anterosuperior to posteroinferior) above the level of the joint
Posterior tibiofibular ligament rupture or avulsion of posterior
malleolus 

Hawkins Classification
 Type Description AVN Images
Hawkins I Nondisplaced 0-13% AVN
Hawkins II Subtalar dislocation 20-50%
Hawkins III Subtalar and tibiotalar dislocation 20-100%
Subtalar, tibiotalar,
Hawkins IV 70-100%
and talonavicular dislocation

Sanders Classification
Type I  • Nondisplaced posterior facet (regardless of number of fracture lines)  
Type II  • One fracture line in the posterior facet (two fragments)
Type III  • Two fracture lines in the posterior facet (three fragments)
Type IV  • Comminuted with more than three fracture lines in the posterior facet (four or more
fragments)

 Beavis Classification
Type 1 Sleeve fracture - small shell of cortical bone avulses from the tuberosity  
Beak fracture - oblique fracture line runs posteriorly from most superior portion of the
Type 2  
posterior facet
Type 3 Infrabursal fracture from the middle of the tuberosity

Spine
 Waddell identified 5 exam findings that correlated with non-organic low back pain. The tests include
Finding Description
1. Tenderness a. superficial - pain with light touch to skin
b. deep - nonanatomic widespread deep pain
2. Simulation a. pain with light axial compression on skull 
b. pain with light twisting of pelvis
3. Distraction No pain with distracted SLR
4. Regional a.nonanatomic or inconsistent motor findings during entire exam 
b. nonanatomic or inconsistent sensory findings during entire exam
5. Overreaction Overreaction noted at any time during exam

Vertebral artery injury

  Biffl VAI Injury Grading
Grade I  • arteriographic appearance of vessel dissection/intraumural hematoma; <25%  
luminal stenosis
Grade II  • intraluminal thrombosis or raised intimal flap; dissection/intramural hematoma with
>25% luminal stenosis
Grade III  • pseudoaneurysm
Grade IV  • vessel occlusion
Grade V  • vessel transections  

ASIA Impairment Scale

Motor Sensory
A Complete No motor function. Complete deficit
B Incomplete  Incomplete
No motor function.
deficit
C Incomplete Motor function is preserved - more than half of key muscles below the neurological level have a Incomplete
muscle grade less than 3. deficit
D Incomplete Motor function is preserved - at least half of key muscles below the neurological level have a Incomplete
muscle grade of 3 or more. deficit
E Normal Normal Motor Normal Sensory

Spinal Shock Neurogenic Shock Hypovolemic Shock

BP Hypotension  Hypotension Hypotension
Pulse Bradycardia Bradycardia Tachycardia
Reflexes /
Bulbocavernosus Absent Variable/independent Variable/independent
Reflex
Motor Flaccid Paralysis Variable/independent Variable/independent
Time ~48-72 hours immediately ~48-72 hours immediately after spinal cord
Following excessive blood loss
after spinal cord injury injury
Mechanism Peripheral neurons become Disruption of autonomic pathway leads to loss Decreased preload leads to
temporarily unresponsive to of sympathetic tone and decreased systemic decreased cardiac output.
brain stimuli. vascular resistance.

Level Patient Function
C1-C3 - Ventilator dependent with limited talking. 
- Electric wheelchair with head or chin control
 C3-C4 - Initially ventilator dependent, but can become independent
- Electric wheelchair with head or chin control
C5 - Ventilator independent
- Has biceps, deltoid, and can flex elbow, but lacks wrist extension and
supination needed to feed oneself
- Independent ADL’s; electric wheelchair with hand control, minimal manual
wheelchair function 
C6 - C6 has much better function than C5 due to ability to bring hand to mouth
and feed oneself (wrist extension and supination intact)
- Independent living; manual wheelchair with sliding board transfers, can
drive a car with manual controls
C7 - Improved triceps strength
- Daily use of a manual wheelchair with independent transfers
C8-T1 - Improved hand and finger strength and dexterity
- Fully independent transfers
T2-T6 - Normal UE function
- Improved trunk control
- Wheelchair-dependent
T7- - Increased abdominal muscle control
T12 - Able to perform unsupported seated activities; with extensive bracing
walking may be possible
L1-L5 - Variable LE and B/B function
- Assist devices and bracing may be needed
S1-S5 - Various return of B/B and sexual function
- Walking with minimal or no assistance

 Anderson and Montesano classification of occipital condyle fractures

Type I  • Impaction-type fracture with comminution of the occipital condyle     
3%  • Due to compression between the atlanto-occipital joint
 • Stable injury due to minimal fragment displacement into the foremen magnum 
Type II  • Basilar skull fracture that extends into one- or both occipital condyles    
22%  • Due to a direct blow to skull
 • Stable injury as the alar ligament and tectorial membrane are usually preserved
Type III  • Avulsion fracture of condyle in region of the alar ligament attachment (suspect underlying    
occipitocervical dissociation)
75%
 • Due to forced rotation with combined lateral bending. 
 • Has the potential to be unstable due to craniocervical disruption

Harborview Classification of Craniocervical Injuries

Type I  • MRI shows craniocervical ligament injury  
 • Craniocervical alignment is within 2mm of normal
 • <2mm of cervical distraction with traction
Type II  • MRI shows craniocervical ligament injury.   
 • Craniocervical alignment is within 2mm of normal. 
 • >2mm of cervical distraction with traction
Type III  • Craniocervical malalignment is greater than 2mm  
 •  >2mm of cervical distraction with traction

Traynelis Classification (direction of displacement)

Type I Anterior occiput dislocation                                      
Type II Longitudinal dislocation
Type III Posterior occiput dislocation
Harbourview Classification System (degree ofLandells instability)
Atlas Fractures Classification
Stage I        Type
    Isolated
Minimalanterior
or non-displaced, unilateral injuryAto"plough
or posterior arch fracture. craniocervical
fractureligaments
is an isolated anterior arch fractureStable
Stage II        I        caused by adisplaced,
  Minimally force driving
but the
MRIodontoid throughsignificant
demonstrates the anterior arch. Stable.
soft-tissue Treat
injuries. with hard
Stability maycollar. 
be Stable or
based onburst
Type Jefferson traction test with bilateral fractures of anterior and posterior arch resulting from axial Unstable 
fracture
Stage III  II Gross
load. craniocervical
Stability determinedmisaligment (BAI
by integrity or BDI > 2mm
of transverse beyond
ligament. normalhard
If intact, limits)
collar. If disrupted, Unstable
halo vest (for bony avulsion) or C1-2 fusion (for intrasubstance tear)(see Dickman classification
below).
Type Unilateral lateral mass fx. Stability determined by integrity of transverse ligament. If stable, treat
  III with hard collar. If unstable, halo vest.  

Dickman Transverse Ligament Injuries Classification

Type I Intrasubstance tear. Treat with C1-2 fusion.
Type II Bony avulsion at tubercle on C1 lateral mass. Treat with halo vest (successful in
75%)

Anderson and D'Alonzo Classification

Type I  Oblique avulsion fx of tip of odontoid. Due to avulsion of alar ligament.    
Although rare, atlantooccipital instability should be ruled out with flexion
and extension films.
Type II  Fx through waist (high nonunion rate due to interruption of blood    
supply).  
Type III  Fx extends into cancellous body of C2 and involves a variable
portion of the C1-C2 joint.    
 
Grauer Classification of Type II Odontoid fractures
Type IIA Nondisplaced/minimally displaced with no comminution. Treatment is  
external immobilization
Type IIB Displaced fracture with fracture line from anterosuperior to  
posteroinferior. Treatment is with anterior odontoid screw (if
adequate bone density).
Type IIC  Fracture from anteroinferior to posterosuperior, or with  
significant comminution. Treatment is with posterior
stabilization.

Levine and Edwards Classification (based on mechanism of injury)   

Type I    Axial < 3mm horizontal displacement C2/3  Rigid collar x 4-6 weeks
compression No angulation
and C2/3 disc remains intact
hyperextension stable fx pattern 
Type II    > 3mm of horizontal displacement If < 5mm displacement, reduction
Significant angulation with tractionthen halo immobilization x 6-
Hyperextension Vertical fracture line 12 weeks
and axial load C2/3 disc and PLL are disrupted If > 5mm
followed by unstable fracture pattern displacement, surgery or prolonged
rebound flexion traction
Usually heal despite displacement
(autofuse C2 on C3)
Type IIA    Flexion- No horizontal displacement Avoid Traction in Type IIA.
distraction Horizontal fracture line Reduction with gentle axial load +
 Significant angulation hyperextension, then compression
haloimmobilization for 6-12 weeks.
Flexion-
Type I fracture with associated bilateral C2-
distraction Surgical reduction of facet dislocation
Type III    3 facet dislocation
followed by Rare injury pattern
followed by stabilization required.
hyperextension

Allen and Ferguson Classification (of subaxial spine injuries)

1. Flexion-compression    
2. Vertical compression    

3. Flexion-distraction      Stage 1: Facet subluxation  

Stage 2: Unilateral facet dislocation
Stage 3: Bilateral facet dislocation with 50% displacement
Stage 4: Complete dislocation (100% displacement)  
4. Extension-compression      
5. Extension-distraction      
6. Lateral flexion      

 )
 Kotani Classification 
Fracture Type Fracture Description  Rates of Anterior Rates of Anterior  
Translation (same Translation (adjacent
level)   level)  
Type A - Separation
2 fracture lines of unilateral lamina and pedicle 91% 20%
fracture
Type B - Multiple fracture lines with lateral wedging in coronal  
Comminution type plane - 50%

Type C - Split typeVertical fracture line in the coronal plane, with

invagination of the superior articular process of the 80% 0%
caudal vertebra
Type D - Traumatic  Bilateral horizontal fracture lines of the pars )
spondylolysis interarticularis, leading to separation of the anterior- 100% 50%
posterior spinal elements
 Nurick Classification
Grade 0 Root symptoms only or normal
Grade 1 Signs of cord compression; normal gait
Grade 2 Gait difficulties but fully employed
Grade 3 Gait difficulties prevent employment, walks unassisted
Grade 4 Unable to walk without assistance
Grade 5 Wheelchair or bedbound
Based on gait and ambulatory function 
 

Ranawat Classification
Class I Pain, no neurologic deficit
Class II Subjective weakness, hyperreflexia, dyssthesias
Class IIIA Objective weakness, long tract signs, ambulatory
Class IIIB Objective weakness, long tract signs, non-ambulatory
 
Japanese Orthopaedic Association Classification
A point scoring system (17 total) based on function in the following categories 
upper extremity motor function
lower extremity motor function
sensory function
bladder function
Usually a significant improvement at 1-year postop, even in cases of severe
myelopathy 

 Park and Associates Classification of Adjacent Level Ossification

Grade 0  • No adjacent level ossifcation
Grade 1  • Ossification extending less than 50% of the disc space
Grade 2  • Ossification exending greater than 50% of the disc space
Grade 3  • Complete bridging of the adjacent disc space

Myerding Classification
Grade I < 25%    
Grade II 25 to 50%    
Grade III 50 to 75% (Grade III and greater are rare in degenerative spondylolithesis)    
Grade IV 75 to 100%    
Grade V Spondyloptosis (all the way off)  
 
 Difference between Idiopathic (residual) and Degenerative (de novo) ASD
  Idiopathic (residual) Degenerative (de novo)
Curve pattern Follows classic curve Lack classic curve patterns
patterns 
Vertebral segments Involves more vertebral Involves fewer vertebral
segments segments
Curve location Thoracic spine  Confined to lumbar spine
Curve magnitude Larger curves Smaller curve magnitude

Wiltse-Newman Classification
Type I • Dysplastic
• Secondary to congenital abnormalities of lumbosacral articulation including
maloriented or hypoplastic facets, sacral deficiency, poorly developed pars
• Posterior elements are intact (no spondylolysis)
• More significant neurologic symptoms
 Type II-A  • Isthmic - Pars Fatigue Fx
 Type II-B  • Isthmic - Pars Elongation due to healed stress fx
 Type II-C  • Isthmic - Pars Acute Fx
 Type III  • Degenerative
 Type IV  • Traumatic
 Type V  • Neoplastic
 Fielding Classification of AARD   
Type I  • Unilateral facet subluxation with intact transverse ligament
 • Odontoid acts as a pivot point with 1 facet subluxating anteriorly, 1 facet subluxating posterioly.
   • Most common and benign type
Type II  • Unilateral facet subluxation with 3 to 5 mm of anterior displacement.
Marchetti-Bartolozzi classification
 • Injured Transverse ligament
 Developmental  • 1 facet acts as pivot point and 1 lateral
 • Includes Wiltsemass
I andisIIdisplaced anteriorly
Type III
 Acquired  • Bilateral anterior facet displacement of > 5 mm. pathologic, degenerative
 • Traumatic, postsurgical,
 • Rare with higher risk of neurologic involvement or instantaneous death.
   • Both lateral masses are displaced
Type IV  • Posterior displacement of atlas Myerding Classification
(C1) (with odontoid fracture, or hypoplastic dens)
 Grade I  • < 25%
 • Rare with higher risk of neurologic involvement or instantaneous death
 Grade II  • 25-50%
 Grade III  • 50-75%
 Grade IV  • 75-100%
 Grade V  • Spondyloptosis

 Classification of Congenital Scoliosis

Failure of Formation  Fully segmented hemivertebra
(has normal disc space above and below)
Semisegmented hemivertebra
(hemivertebra fused to adjacent vertebra on one side with disk on the  
other)
Unsegmented hemivertebra
(hemivertebra fused to vertebra on each side) 
Incarcerated hemivertebra
 (found within lateral margins of vertebra above and below)
Unincarcerated hemivertebra  
(laterally positioned)
Wedge vertebra
Failure of Block vertebra  
Segmentation (bilateral bony bars)
Bar body
(unilateral unsegmented bar is common and likely to progress)
Mixed  Unilateral unsegmented bar with contralateral hemivertebra  
(most rapid progression)

Classification and Treatment

(for more detail go to disease content)
Category Disease Nonoperative Treatment Operative Treatment
Upper motor Cerebral palsy  Boston-type underarm bracing until Group I treat with PSF with
neuron puberty (age 10-12) and wheelchair instumentation
modification Group II treat with PSF +/- ASF with
instrumentation and fusion to pelvis (Luque-
Galveston)
Indications for surgery
curve > 50°
worsening pelvic obliquity with
sitting imbalance
Rett Syndrome    Bracing for C-shaped curves Bracing
C shaped curves
Posterior Spinal Fusion indications
  thoracic curve that intefers with
sitting and balance
C shaped curves that do not
respond to bracing
Muscle Spinal muscular atrophy  Boston-type underarm bracing until Treat with PSF with fusion to pelvis for
Weakness puberty (age 10-12) improved wheelchair sitting
address hip contractures before
PSF
may lead to temporary loss of
upper extremity function
Muscular dystrophy  bracing is contraindicated PSF with or without fusion to pelvis
(fusion to pelvis is controversial)
indications
absolute curve > 20°
progressive curve
Treat early before pulmonary
function declines (curve from 20 to 30°)
Paralytic Spinal bifida and spinal cord bracing is contraindicated ASF/PSF with instumentation and
Syndromes injuries  pelvic fixation
anterior fusion required because
minimal posterior element to obtain fusion
Polio  Boston-type underarm bracing until PSF
puberty (age 10-12)

Ligamentous Restraints in different Arm Positions

Arm Position Anterior Res. Inferior Res. Posterior Res.
0° (side) and adduction x SGHL/CHL xxx
45° (ER) and 45° abducted MGHL x MGHL
Adduction   SGHL/CHL  
 90° (ER) Anterior band IGHL Anterior band IGHL Posterior band IGHL
90° (forward flexed, abduction, and IR) Anterior band IGHL   Posterior band IGHL
SGHL/CHL

Gartner and Heyer Classification of Calcific Tendinitis   

Type I        • Well circumscribed, dense calcification, formative     
Type II  • Soft contour/dense or sharp/transparent
 • Translucent and cloudy appearance without clear circumscription,
Type III
resorptive     

Mole et al. Classification of Calcific Tendinitis 

Type A   • Dense, homogeneous, sharp contours          
Type B  • Dense, segmented, sharp contours
Type C  • Heterogeneous, soft contours
Type D  • Dystrophic calcifications at the insertion of the rotator cuff tendon

Anatomic Classification
Supraspinatus, Make up majority of tears
infraspinatus, teres Associated with subacromial impingement
minor (SIT) tears Mechanism is often a degenerative tear in older patients or a shoulder dislocation in
patients > 40 yrs.

Subscapularis tears New evidence suggest higher prevalence than previously thought
Associated with subcoracoid impingement
Mechanism is often an acute avulsion in younger patients with a
hyperabduction/external rotation injury or an iatrogenic injury due to failure of repair
Cuff Tear Size
Small 0-1 cm
Medium 1-3 cm
Large 3-5 cm
Massive > 5 cm (involves multiple tendons. In the European classification a massive tear is defined as
involving 2 or more tendons)

Ellman Classification of Partial-Thickness Rotator Cuff Tears

Grade  Description
I <3mm (<25% thickness)
II 3-6mm (25-50%)
III > 6 mm (>50%)
Location  
A Articular sided
B Bursal Sided
 C Intratendinous
Cuff Atrophy (Goutallier)
0 Normal
1 Some fatty streaks
2 More muscle than fat
3 Equal amounts fat and muscle
4 More fat than muscle
Cuff Tear Shape
Crescent Usually do not retract medially, are quite mobile in the medial to lateral direction, and can be
.................... repaired directly to bone with minimal tension.
U-shape Similar shape to crescent but extend further medially with apex adjacent or medial to the rim
of the glenoid. Must be repaired side-to-side using margin convergence first to avoid
overwhelming tensile stress in the middle of the rotator cuff repair margin.
L-shape Similar to U shape except one of the leaves is more mobile than the other. Use margin
convergence in repair.
Massive & May be u-shaped or longitudinal. Difficult to repair and often requires and interval slide.
immobile

Seebauer Classification of Rotator Cuff Arthropathy   

Type IA  • Intact anterior restraints
(centered, stable)  • Minimal superior migration
 • Dynamic joint stabilization  
 • Femoralization of the humeral head and acetabularization of
coracoacromial arch
Type IB  • Intact or compensated anterior restraints  
(centered, medialized)  • Minimal superior migration
  • Compromised joint stabilization
 • Medial erosion of the glenoid 
Type IIA  • Compromised anterior restraints
(decentered, limited  • Superior translation  
stability)  • Minimum stabilization by coracoacromial arch
Type IIB  • Incompetent anterior restraints
(decentered, unstable)  • Anterosuperior escape
 
 • Nonexistent dynamic stabilization
 • No coracoacromial arch stabilization
 Hamada Classification of Rotator Cuff Arthropathy
Grade 1  • Acromiohumeral interval ≥ 6mm    
Grade 2  • Acromiohumeral interval ≤ 5mm  
Grade 3  • Acromiohumeral interval ≤ 5mm, with acetabularization of acromion  
Grade 4  • 4A: Glenohumeral arthritis without acetabularization, AHI < 7mm
 • 4B: Glenohumeral arthritis with acetabularization, AHI ≤ 5mm
Grade 5  • Humeral head collapse

Rockwood Classification 
AC CC
Type Exam Radiographs Reducibility  Treatment Illus. Xray
ligament ligament
Type I sprain normal AC tenderness; no normal  
  sling
AC instability 
Type torn sprain AC horizontal AC joint disrupted; increased CC  
reducible sling
II instability distance < 25% of contralateral
Type torn torn increased CC distance 25- reducible controversial
 III  100% of contralateral
AC vertical
IIIA     instability, no        
horizontal  stability
AC vertical +
IIIB     horizontal        
instability
Type torn torn skin lateral clavicle displaced  
not
IV tenting, posterior posterior through trapezius on surgery
reducible
fullness the axillary lateral XR
Type torn torn severe shoulder increased CC distance >  
V droop, does not 100% of contralateral not
surgery
improve with reducible
shrug
Type torn torn inferior dislocation of lateral  
rare; associated
VI clavicle, lying either in not
injuries; surgery
subacromial or subcoracoid reducible
paresthesias
position

Anteroposterior Translation Grading Scheme

Grade 0  • Normal glenohumeral translation
Grade 1+  • Humeral head translation up to glenoid rim
Grade 2+  • Humeral head translation over glenoid rim with spontaneous reduction once force withdrawn
Grade 3+  • Humeral head translation over glenoid rim with locking
 
Sulcus Test Grading Scheme
Grade 1  • Acromiohumeral interval <1cm
 Grade 2  • Acromiohumeral interval 1-2cm
Grade 3  • Acromiohumeral interval >2cm
 

Instability Severity Score 

Variable Parameter SCORE
< 20 years 2
AGE
> 20 years 0
Competitive 2
DEGREE OF SPORTS PARTICIPATION 
Recreational/none 0
TYPE OF SPORT PARTICIPATION  Contact/forced overhead 1
 Other 0
Hyperlaxity (anterior/inferior) 1
SHOULDER HYPERLAXITY 
Normal 0
Visible on external rotation 2
HILL SACHS ON AP XRAY 
Not visible on external rotation 0
Loss of contour 2
GLENOID  CONTOUR LOSS ON AP XRAY 
No lesion 0
Clinical Implications Total Possible = 10
An acceptable recurrence risk of 10% with arthroscopic stabilization. < 6 points
A score of > 6 points has an unacceptable recurrence risk of 70% and should be
> 6 points
advised to undergo open surgery (i.e. Laterjet procedure).
 

Posterior Load & Shift Grading

1+ apparent translation but not to rim
2+ translation to glenolabral rim
3+ translation over glenolabral rim
4+ translation with complete dislocation

SLAP Classification
Type Description % Images
I Labral and biceps fraying, anchor intact 11%
II Labral fraying with detached biceps tendon anchor 41%
III Bucket handle tear, intact biceps tendon anchor (biceps separates from bucket handle 33%
tear)
 IV 15%
Bucket handle tear with detached biceps tendon anchor (remains attached to bucket
handle tear)

V Type II + anteroinferior labral extension (Bankart lesion) m m

VI Type II + unstable flap m m
VII Type II + MGHL injury m m
             VIII Type II + posterior extension    
IX Circumferential    
       X Type II + posteroinferior extension (reverse Bankart)    

Idiopathic Neuralgic Amyotrophy Hereditary Neuralgic

Factor
(INA) Amyotrophy (HNA)
Incidence 1-30/100,000/yr Rare
Gene - Septin 9 (c'some 17)
Age at Onset Middle-age (20-60 y/o) Young (20s)
Recurrence Uncommon (~1.5 episodes) More frequent (~3.5 episodes)
Appearance Normal features Dysmorphic
Involvement of Nerves outside Brachial
Uncommon (17%) Common (56%)
Plexus
 

Walch Classification of Glenoid Wear

Type A  Concentric wear, no subluxation of HH, well centered  
 • A1 no or minor central erosion
 • A2 deeper central erosion, line connects anterior/posterior glenoid rims and transects humeral
 head (HH)
Type B  Biconcave glenoid, asymmetric glenoid wear and head subluxated posteriorly
 • B0 pre-osteoarthritic posterior subluxation of HH
 • B1 posterior joint narrowing (no posterior bone loss), osteophytes, subchondral sclerosis
 • B2 posterior rim erosion, retroverted glenoid
 • B3 monoconcave, posterior wear, at least HH subluxation >70%  OR retroversion >15%
Type C  • C1 Glenoid retroversion >25 degrees, regardless of erosion
 • C2 Biconcave, posterior bone loss, posterior translation of HH
Type D  • Glenoid anteversion or anterior HH subluxation (HH subluxation <40%)

Cruess Classification (stages)

Stage I Normal x-ray. Changes on MRI. Core decompression.
Stage II Sclerosis (wedged, mottled), osteopenia. Core decompression.
Stage III Crescent sign indicating a subchondral fracture. Resurfacing or hemiarthroplasty.
Stage IV Flattening and collapse. Resurfacing or hemiarthroplasty.
Stage V Degenerative changes extend to glenoid. TSA.  

Clinical Stages
Freezing/Painful   Gradual onset of diffuse pain (6 wks to 9 mos)
Frozen/Stiff Decreased ROM affecting activities of daily living (4 to 9 mos or more)
 Thawing Gradual return of motion (5 to 26 mos)
Arthroscopic Stages
Stage 1 Patchy, fibrinous synovitis
Stage 2 Capsular contraction and fibrinous adhesions
Stage 3 Increasing contraction, synovitis resolving
Stage 4 Severe contraction

Portal Location Use Nerve at Risk

Proximal 1-2cm proximal, 1cm anterior to lateral Radial (risk decreases as
 
anterolateral    epicondyle portal moved more proximally)
1 cm anterior and 1-3cm distal to lateral 1st portal for supine position Radial/PIN and
  epicondyle See radial head, medial side of elbow, lateral antebrachial cutaneous
coronoid, trochlea, brachialis insertion,
Distal anterolateral    coronoid fossa
 Initial site for joint distension before scope is
Direct lateral (or "soft spot" portal (in triangle formed by inserted, viewing posterior compartment relatively safe, lateral
midlateral)      olecranon, radial head, epicondyle) (capitellum, radial head, radioulnar antebrachial cutaneous nerve 
articulation)
Anteromedial    2 cm anterior and 2cm distal to medial Used most often to augment the proximal medial antebrachial
epicondyle.  anteromedial portal to access medial recess. cutaneous and
Place under direct visualization. median 
Proximal anteromedial Medial antebrachial
2cm proximal to medial epicondyle, viewing entire anterior compartment, radial
(superomedial)      cutaneous, ulnar (3-4mm
anterior to intermuscular septum head, capitellum, coronoid, trochlea
away) and median 
Straight posterior Elbow partially extended, good for removing posterior antebrachial
3cm proximal to olecranon, triceps
impinging olecranon osteophytes and loose cutaneous 
(transtriceps)    midline (musculotend. junction)
bodies from posteromedial compartment ulnar nerve
Elbow 20-30deg flexion (to relax triceps)
posterior antebrachial
2-3 cm proximal to olecranon and just Best access to posterior compartment,
cutaneous  
Posterolateral    lateral to triceps radiocapitellar joint (debridement of OCD
medial brachial cutaneous  
center of anconeus triangle capitellum), olecranon fossa and posterior
ulnar 
structures

Walch Classification of Glenoid Wear

Type A well-centered 
A1 minor erosion
A2 deeper central erosion
Type B head subluxated posteriorly 
B1 posterior wear
B2 severe biconcave wear
Type C glenoid retroversion of more than 25 degrees (dysplastic in origin)

Wright & Cofield Classification of Periprosthetic fracture   

Type  Characteristics Treatment of Intraoperative Fracture Treatment of Postop Fracture
Usually min displaced/angulated
Centered near Span fracture with standard length (treat nonop). If significant
the tip of the stem prosthesis (2-3 cortical diameters) or long- overlap between prox-distal
Type A
and extends stem prosthesis. Transosseous sutures for fragments, treat as if stem loose
proximally tuberosity fractures and revise to long stem
prosthesis.
Type B Centered at the Span fracture with standard length
tip of the stem prosthesis (2-3 cortical diameters) or long-
Revise to long-stem prosthesis.
and extends stem prosthesis. Cement in distal canal to
Cement in distal canal to
distally.  engage prosthesis (do NOT let cement
engage prosthesis 
escape from fracture site). Cortical strut
allograft + cerclage. 
Type C Located distal to Long-stem prosthesis, or if close to ORIF (plate overlap prosthesis
the tip of the olecranon fossa, plate+screws ± cerclage by 2 cortical diameters to avoid
stem. wire, strut allograft stress riser)

Sirveaux Classification of Scapular Notching

Grade 1 limited to scapular pillar
Grade 2 in contact with inferior screw of baseplate
Grade 3 beyond the inferior screw
 extends under baseplate approaching central
Grade 4
peg

Radiographic and Arthroscopic Classification

Type I Intact cartilage 
Bony stability may or may not be present 
Type II Cartilage fracture with bony collapse or displacement 
Type III Loose bodies present in joint  
 

Mayo (O'Driscoll & Morrey) Classification of Periprosthetic fracture   

Type  Characteristics Treatment 
Periarticular fracture involving the humeral Undisplaced - Immobilization /soft tissue repair is sufficient to achieve fibrous
condyle or olecranon. Caused by osteolysis union (Rigid fixation not required).
Type I
around hinge components and distracting forces Displaced - ORIF with heavy nonabsorbable sutures or tension band wiring (if
from muscle attachments  limited periprosthetic bone)
Type II Fracture along length of humeral or ulnar stem. II1: ORIF with component retention +/- strut allograft 
 Subtypes: II2: Revision arthroplasty using long-stem prosthesis ± strut allograft and
     II1: well-fixed implant impaction bone grafting. Locking plates/ cerclage wires may be added for
    II2: loose implants, good bone stock added stability.  
    II3: loose implants, severe bone loss II3: Require revision arthroplasty with extensive allograft supplementation.
Often times require resection arthroplasty
Type III Distal to prosthesis. Treated like routine fractures.
If implants are well-fixed, immobilization for humerus and ORIF for ulna. 
Radiographs/CTs to ensure implants are not
If implants are loose, treat as Type II2 fractures.
loose, cement mantle not cracked.

Overview of Knee Ligament Function

Ligament Primary function Secondary function
Anterior Cruciate Resists anterolateral displacement of the Resists varus displacement at 0 degrees of
Ligament (ACL) tibia on the femur flexion
Posterior Cruciate Resists posterior tibial displacement, Resists varus displacement at 0 degrees of
Ligament (PCL) especially at 90 degrees of flexion flexion
Lateral Collateral Resists varus displacement at 30 degrees Resists posterolateral rotatory displacement
Ligament (LCL) of flexion with flexion that is less than approximately 50
 degrees
Popliteofibular Ligament / Resists posterolateral rotation of the tibia on Resists varus angulation
Posterior Lateral the femur and posterior displacement of the tibia on the
Corner (PLC) femur
Medial Collateral Resists valgus angulation Works in concert with ACL to provide restraint
Ligament (MCL) to axial rotation
 
Lateral Structures of Knee
Layer I Iliotibial tract, biceps femoris
  Common peroneal nerve lies between layer I and II
Layer 2 Patellar retinaculum
Layer 3 Superficial: LCL, fabellofibular ligament, ALL
Lateral geniculate artery runs between deep and superficial layer
Deep: Arcuate ligament, coronary ligament, popliteus tendon, popliteofibular ligament, capsule

Medial Structures of Knee

Layer I Sartorius and fascia (patellar retinaculum)
gracilis, semitendinosis, and saphenous nerve run between layer 1 and 2
Layer 2 Semimembranosus, superficial MCL, MPFL, posterior oblique ligament 
Layer 3 Deep MCL, capsule, coronary ligament

Classification based on posterior subluxation of tibia relative to femoral condyles (with knee in 90° of flexion)
o Grade I (partial)
 1-5 mm posterior tibial translation
 tibia remains anterior to the femoral condyles
o Grade II (complete isolated)
 6-10 mm posterior tibial translation
 complete injury in which the anterior tibia is flush with the femoral condyles
o Grade III (combined PCL and capsuloligamentous)
 >10 mm posterior tibial translation
 tibia is posterior to the femoral condyles and often indicates an associated ACL and/or PLC injury

Hughston Modification of the AMA Classification

o based on joint laxity and injury severity
 severity graded by extent of tenderness and quality of the endpoint with valgus stress at 30 degrees of
knee flexion
 often referred to as "degree" of injury
o revised in 1994
o Grade I -- First-degree injury
 mild
 localized tenderness
 firm endpoint
 no joint laxity
 stretch injury or few MCL fibers torn
 no significant loss of ligamentous integrity 
o Grade II -- Second-degree injury
 moderate
 more generalized tenderness
 firm endpoint
 +/- mild increase in joint laxity
 incomplete / partial MCL tear
 some MCL fibers remain intact, generating the firm end point 
o Grade III -- Third-degree injury
 severe
 generalized tendernesss
 no endpoint with valgus stress 
 increased joint laxity
 third-degree injuries are further subdivided by joint laxity, described by the original AMA system
 Grade 1+: 3-5 mm
 Grade 2+: 6-10 mm
 Grade 3+: > 10 mm
 complete MCL tear

LCL tear classification 

(based on lateral joint opening compared to contralateral side)
Grade 1  0-5 mm lateral joint opening
Grade 2  6-10 mm lateral joint opening
Grade 3  > 10 mm lateral joint opening without a firm endpoint
LCL tear MRI classification 
Grade 1 Subcutaneous fluid surrounding the midsubstance of the ligament at one or both insertions
Grade 2 Partial tearing of ligament fibers at either the midsubstance or one of the insertions 
Grade 3 Complete tearing of ligament fibers at either the midsubstance or one of the insertions
 

Lateral Structures of Knee by Layer

Layer I   Iliotibial tract, biceps
common peroneal nerve lies between layer I and II
Layer 2 patellar retinaculum, patellofemoral ligament
Layer 3 superficial: LCL, fabellofibular ligament
 lateral geniculate artery runs between deep and superficial layer
deep: arcuate ligament, coronary ligament, popliteus tendon, popliteofibular ligament, capsule

Modified Hughston classification

o grade I
 0-5 mm of lateral opening on varus stress
 0°-5° rotational instability on dial test
 sprain, no tensile failure of capsuloligamentous structures 
o grade II 
 6-10 mm of lateral opening on varus stress
 6°-10° rotational instability on dial test
 partial injuries with moderate ligament disruption
o grade III 
 > 10 mm of lateral opening on varus stress, no end point
 > 10° rotational instability on dial test, no end point
 complete ligament disruption

Outerbridge Classification of Chondromalacia

Type I Softening
Type II Fissures
Type III Crabmeat changes  
Type IV Exposed subchondral bone
 Outerbridge Arthroscopic Grading System
 Grade 0 Normal cartilage
Grade I Softening and swelling
Grade II Superficial fissures
Grade III Deep fissures, without exposed bone               
Grade IV Exposed subchondral bone
 
ICRS (International Cartilage Repair Society) Grading System
Grade 0 Normal cartilage
Grade 1 Nearly normal (superficial lesions)
Grade 2 Abnormal (lesions extend < 50% of cartilage depth)
Grade 3 Severely abnormal (>50% of cartilage depth)
Grade 4 Severely abnormal (through the subchondral bone)
 

Clanton Classification of Osteochondritis (Clanton and DeLee)

Type I Depressed osteochondral fracture
Type II Fragment attached by osseous bridge
Type III Detached non-displaced fragment
Type IV Displaced fragment

Blazina Classification
Stage 1Pain occurs after activity
Stage 2Pain present while performing activity and persists after activity
Stage 3Pain affecting/limiting function during activity
  Hamstring tear MRI classification
Grade  •T2 hyperintense signal about a tendon or muscle without fiber disruption
1
 Grade  •T2 hyperintense signal around and within a tendon/muscle with fiber disruption less than half the
2 tendon/muscle width
Grade  •Tendon/muscle fiber disruption greater than half its tendon/muscle width
3

Jackson and Feagin Classification

Mild  >90 degrees ROM
Moderate  45-90 degrees ROM
Severe  <45 degrees

Modified Whelan Classification

Type I Medial head of the gastrocnemius is normal but the popliteal artery runs in a aberrant course
Type II Medial head of the gastrocnemius is located laterally, no deviation of popliteal artery
Type III There is an abnormal muscle bundle from the medial head of the gastrocnemius that
surrounds and constricts the popliteal artery
Type IV Popliteal artery is entrapped by the popliteus muscle
Type V occurs when the popliteal vein is entrapped with the popliteal artery in any of the above
Type V  
scenarios

Physeal Growth Plate 

(letters on right correspond to histology)
 Reserve zone (B) Cells store lipids, glycogen, and proteoglycan aggregates for later growth and matrix Gaucher's
production diastrophic dysplasia
Low oxygen tension Kneist
pseudoachondroplasia
 Proliferative zone Proliferation of chondrocytes with longitudinal growth and stacking of chondrocytes. Achondroplasia
(C) Highest rate of extracellular matrix production Gigantism
Increased oxygen tension in surroundings inhibits calcification MHE
 Hypertrophic zone Zone of chondrocyte maturation, chondrocyte hypertrophy, and chondrocyte SCFE (not renal)
(D)  calcification. Rickets (provisional
Three phases occur in the hypertrophic zone calcification zone)
Maturation zone: preparation of matrix for calcification, chondrocyte growth Enchondromas
Degenerative zone: further preparation of matrix for calcification, further Mucopolysacharide disease
chondrocyte growth in size (5x) Schmids
Provisional calcification zone: chondrocyte death allows calcium release,
Fractures most commonly
allowing calcification of matrix
occur through zone of provisional
Chondrocyte maturation regulated by local growth factors (parathyroid related
calcification     
peptides, expression regulated by Indian hedgehog gene)
Type X collagen produced by hypertrophic chondrocytes important for mineralization
Primary spongiosa Vascular invasion and resorption of transverse septa. Metaphyseal "corner
(E) Osteoblasts align on cartilage bars produced by physeal expansion.  fracture" in child abuse
(metaphysis) Scurvy
Primary spongiosa mineralized to form woven bone and then remodels to become
secondary spongiosa (below)
Secondary Internal remodeling (removal of cartilage bars, replacement of fiber bone with Renal SCFE
spongiosa lamellar bone) 
(metaphysis) External remodeling (funnelization)
Physis Periphery
Groove of Ranvier During the first year of life, the zone spreads over the adjacent metaphysis to form a
fibrous circumferential ring bridging from the epiphysis to the diaphysis.   
This ring increases the mechanical strength of the physis and is responsible for
Osteochondroma
appositional bone growths  
supplies chondrocytes to periphery
  

Perichondrial Dense fibrous tissue that is the primary limiting membrane that anchors and supports  
fibrous ring of La the physis through peripheral stability 
Croix

NON-OP TREATMENT CRITERIA  

MUSCLE
Iliac crest abdominal muscles always
ASIS sartorius + TFL < 3 cm displacement
AIIS rectus femoris always
Ischial hamstrings (ST, SM, long head of biceps 1 tendon + < 2 cm
tuberosity femoris) displacement
Pubic
adductors + gracilis always
symphysis

Prox hum peds

 Neer-Horowitz Classification
Type I  • Minimally displaced (<5mm)  
Type II  • Displaced < 1/3 of shaft width
Type III  • Displaced greater than 1/3 and less than 2/3 of shaft width
Type IV  • Displaced greater than 2/3 of shaft width

Simple Deformities
Deformity Strong Muscle Weak Muscle
equinus gastrocnemius-soleus complex dorsiflexors
cavus plantar fascia, intrinsics dorsiflexors
varus posterior tibialis and anterior tibialis peroneal brevis
supination anterior tibialis  peroneus longus
flatfoot peroneus brevis posterior tibialis
Complex Deformities
equinovarus + gastroc-soleus complex, posterior tibialis, peroneus brevis & longus
supination anterior tibialis   
equinovalgus gastroc-soleus complex, peroneals posterior tibialis, anterior
tibialis
calcaneovalgus foot dorsiflexors/evertors (L4 and L5) plantar flexors /inverters
(S1 and S2)
  Accessory Ossicles and Sesamoids of the Foot and Ankle
Accessory bone Prevalence Clinical significance Differential Diagnosis Image
Os trigonum 10-25% Posterior ankle impingement, Shepherd's fracture
FHL entrapment
Type II accessory 2-12% Posterior tibial tendon Navicular tuberosity avulsion frx, type
navicular dysfunction I accessory navicular
Os subfibulare 2% Painful os subfibulare  Lateral malleolus avulsion frx  
Os peroneum 9-20% Painful os peroneum, fracture, Painful os vesalianum, bipartite os  
diastasis peroneum
Os vesalianum 2% Painful os vesalianum Avulsion frx of the 5th metatarsal base  
Hallux sesamoids ~100% Fracture, stress fracture Bipartite tibial sesamoid

Years at fusion (appear on
Ossification center Years at ossification (appear on xray) (1)
xray) (1)
Capitellum 1 12
Radial Head 4 15
Medial epicondyle 6 17
Trochlea 8 12
Olecranon 10 15
Lateral epicondyle 12  12

Gartland Classificaiton 
(may be extension or flexion type)
 Nondisplaced
beware of subtle medial comminution leading to cubitus varus,
Type I which technically means it is not a Type I Fracture, and it requires reduction and  
pinning
Treated with cast immobilization x 3-4wks, with radiographs at 1 week
Displaced 
Type II posterior cortex and posterior periosteal hinge intact 
 
Deformity is in the sagittal plane only
Typically treated with CRPP
Displaced, often in 2 or 3 planes
Type III
Treated most commonly with CRPP or open reduction if needed
Complete periosteal disruption with instability in flexion and extension
Type IV*,** Diagnosed with examination under anesthesia during surgery    
Treated most commonly with CRPP or open reduction if needed
Collapse of medial column, loss of Baumann angle 
Medial leads to varus malunion/classic gunstock deformity
 
comminution*  may or may not be associated with a sagittal plane deformity
Treated with CRPP, often requires significant valgus force to reduce
Mechanism of injury is usually a fall on the olecranon
Flexion type Treated with CRPP  
More likely to require open reduction 
*not a part of original Gartland classification   
**diagnosed intraoperatively when capitellum is anterior to AHL with elbow flexion and posterior with extension on lateral
XR
 Fracture Displacement Classification-Weiss, et al
Type 1 <2mm, indicating intact cartilaginous hinge Casting
Type 2 >2 mm < 4 displacement, intact articular cartilage on arthrogram Closed
reduction
and
fixation
Type 3 >4 mm,  articular surface disrupted on arthrogram Open
reduction
and
fixation
Bado Classification
Type I  Apex anterior proximal ulna fracture with anterior dislocation of the radial head   
Type II Apex posterior proximal ulna fracture with posterior dislocation of the radial head
Type III Apex lateral proximal ulna fracture with lateral dislocation of the radial head   
Type IV Fractures of both the radius and ulna at the same level with an anterior dislocation of the
radial head (1-11% of cases)
Table of Acceptable Reduction (Tolerances)  *
Malrotation Bayonet
   Angle (°) Apposition
Yes, if
0-10 years <15 <45 <1cm
short
≥10 years <10 <30 No
Approaching skeletal maturity (<2y growth
remaining)
0 0 No
 "Classically" Acceptable Angulation for Closed Reduction in Pediatric Forearm Radius Fractures
 (controversial with ongoing discussion)
  Shaft / Both bone fx Distal radius/ulna
Acceptable
Age Acceptable Angulations Malrotation* Dorsal Angulation
Bayonetting

< 9 yrs < 1 cm 15-20° 45° 30 degrees

> 9 yrs. < 1 cm 10° 30° 20 degrees

Bayonette apposition, or overlapping, of less than 1 cm, does not block rotation and is acceptable in patients
less than 10 years of age.
General guidelines are that deformities in the plane of joint motion are more acceptable, and distal deformity
(closer to distal physis) more acceptable than mid shaft.
The radius and ulna function as a single rotational unit. Therefore a final angulation of 10 degrees in the
diaphysis can block 20-30 degrees of rotation. 
*Rotational deformities do not remodel and are increasingly being considered as not acceptable.

Delbet Classification   
 Type Description Incidence AVN Nonunion  Images
Transphyseal (with <10% 38%-100%  
or without
Type I    
epiphyseal
dislocation)
Type II Transcervical 40-50% 28% 15%    
Type III Cervicotrochanteric 30-35% 18% 15-20%
   
(or basicervical)
Type IV Intertrochanteric 10-20% 5% 5%  

Treatment Table by Age

< 6 months  • any fracture pattern  • Pavlik harness       
 • early spica casting
6 months - 5 years  • stable fracture pattern  • early spica casting       
 • unstable fracture pattern  • traction with delayed spica casting  
 • polytrauma, multiple/open fx  • external fixator
5-11 years  • length stable and <49kg • flexible titanium nails 
 • length unstable fx (comminuted or spiral)  • ORIF with submuscular bridge plating 
 • very proximal or distal fx  • stainless steel Enders nails
  • any weight  • external fixation 
> 11 years  • patient weighs > 49kg (100 lbs)    • antegrade rigid intramedullary nail fixation 
 • proximal or distal fx  • ORIF with submuscular bridge plating 
 • severe comminution
 
Modified Meyers and McKeever Classification
Type Nondisplaced (<3mm)
I
Type Minimally displaced with intact posterior hinge
II
Type Completely displaced
III
Type
Type III fracture with rotation     
III+
Type Completely displaced, rotated, comminuted
IV
 Ogden Classification (modification of Watson-Jones)
Type I fracture of the secondary ossification center near the insertion of the
patellar tendon 
Type fracture propagates proximal between primary and secondary
II ossification centers     
Type coronal fracture extending posteriorly to cross the primary ossification
III center    
Type
IV fracture through the entire proximal tibial physis   
Type periosteal sleeve avulsion of the extensor mechanism from the
V secondary ossification center 
Modifier: A (nondisplaced), B (displaced)
 Dias & Tachdjian Classification (patterned off adult Lauge-Hansen classification) 
Supination-inversion  Grade 1
 • adduction or inversion force avulses the distal fibular epiphysis (SH I or II)
 • occasionally can be transepiphyseal
 • rarely occurs with failure of lateral ligaments
 Grade 2 
 • further inversion leads to distal tibial fracture (usually SH III or IV, but can be SH I or II) 
 • occasionally can cause fracture through medial malleolus below the physis
Supination-  • plantarflexion force displaces the tibial epiphysis posteriorly (SH I or II)
plantarflexion  • Thurston-Holland fragment is composed of the posterior tibial metaphysis and displaces
posteriorly
 • occurs without fibular fracture
 • can be difficult to see on AP radiograph
Supination-external  Grade 1
rotation  • external rotation force leads to distal tibial fracture (SH II)
  • distal fragment displaces posteriorly
 • Thurston-Holland fragment displaces posteromedially
 • easily visible on AP radiograph (fracture line extends proximally and medially)
 Grade 2
 • further external rotation leads to low spiral fracture of fibula (anteroinferior to posterosuperior)
 • external rotation force leads to distal tibial fracture (SH I or II) and transverse fibula fracture
 • occasionally can be transepiphyseal medial malleolus fracture (SH II)
Pronation/eversion-
 • distal tibial fragment displaces laterally
external rotation
 • Thurston-Holland fragment is lateral or posterolateral distal tibal metaphysis
 • can be associated with diastasis of ankle joint
 • leads to SH V injury of distal tibial physis
Axial compression  • can be difficult to identify on initial presentation (diagnosis typically made when growth arrest is
seen on follow-up radiographs)
 Classification by Pattern
Lateral triplane  • most common
fracture  • epiphyseal fracture occurs in the sagittal plane
 • physeal fracture occurs in the axial plane
 • metaphyseal fracture occurs in the coronal plane
 • similar to tillaux fractures on AP radiographs (distinguish from tillaux fractures
by SH II or I fracture on lateral radiograph)
Medial triplane  • epiphyseal fracture occurs in the coronal plane
fracture  • physeal fracture occurs in the axial plane
 • metaphyseal fracture occurs in the sagittal plane
Intramalleolar  • type I - intraarticular intramalleolar fracture involving the weight-bearing
triplane surface
fracture  • type II - intraarticular intramalleolar fracture outside of the weight-bearing
surface
 • type III - extraarticular intramalleolar fracture
  Microbiology by Organism
Group B streptococcus   • most common in neonates with community-acquired infection 
 • exposed during transvaginal delivery
 • most common in children over 2 years of age  
Staph aureus          • gram positive cocci in clusters
 • most common in nosocomial infections of neonates
Neisseria gonorrhoeae   • still the most common organism in adolescents 
 • gram negative diplococci, negative Gram stain a majority of the
time 
 • patients usually have a preceding migratory polyarthralgia,
multiple joint involvement, and small red papules  
 • may treat with large doses of penicillin alone and usually does
not require surgical debridement.
Group A beta-hemolytic
• most common organism following varicella infection  
streptococcus
HACEK organisms   • Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and
Kingella
 • fastidious
 • incidence of septic arthritis caused by H influenzae has markedly
decreased since the advent of its vaccine
 • Kingella is best isolated on blood culture media 
 Septic Arthritis Antibiotic Treatment
Age Organism Antibiotics
staphylococcus sp., group B streptococci, and gram-negative 1st generation
<12 mos
bacilli  cephalosporin
2nd or 3rd generation
6 mos to 5 yrs S. aureus, S. pneumoniae, group A streptococci, H. influenzae
cephalosporin
1st generation
5-12 yrs S. aureus
cephalosporin
12-18 yrs N. gonorrhoeae, S. aureus oxacillin/cephalospori

Peds to cont

Classification of Low Ankle Sprains

  Ligament disruption Ecchymosis and swelling Pain with weight bearing
Grade I none minimal normal
Grade II stretch without tear moderate mild
Grade III complete tear severe severe
Classification
Class Description Images
Zone 1 Proximal tubercle avulsion
(pseudo Jones fx) Due to long plantar ligament, lateral band of the plantar fascia, or contraction of the peroneus brevis
May extend into cubometatarsal joint 
Nonunion uncommon
Zone 2 Metaphyseal-diaphyseal junction 
(Jones fx) Involves the 4th-5th metatarsal articulation
Vascular watershed area 
Acute injury
Increased risk of nonunion (15-30%)
Zone 3 Proximal diaphyseal fracture
Distal to the 4th-5th metatarsal articulation
Stress fracture in athletes
Associated with cavovarus foot deformities or sensory neuropathies 
Increased risk of nonunion

Sangeorzan Classification of Navicular Body Fractures

(based on plane of fracture and degree of comminution)
Transverse fracture of dorsal fragment that involves < 50% of bone.
Type I    
No associated deformity
Oblique fracture, usually from dorsal-lateral to plantar-medial.
Type II  
May have forefoot aDDuction deformity.

Central or lateral comminution.  

Type IIII
ABDuction deformity.

Ogden Classification of Superior Peroneal Retinaculum (SPR) Tears   

Gr The SPR is partially elevated off of the fibula allowing for subluxation
ade 1 of both tendons
 Gr The SPR is separated from the cartilofibrous ridge of the lateral
ade 2 malleolus, allowing the tendons to sublux between the SPR and the
cartilofibrous ridge
Gr There is a cortical avulsion of the SPR off of the fibula, allowing the
ade 3 subluxed tendons to move underneath the cortical frag
m
ent
Gr The SPR is torn from the calcaneous, not the fibula
ade 4

Deformity Physical exam Radiographs

 Stage I • Tenosynovitis  • (+) single-heel raise  • Normal 
• No deformity
Stage IIA • Flatfoot deformity • (-) single-leg heel raise • Arch collapse deformity 
• Flexible hindfoot • Mild sinus tarsi pain
• Normal forefoot
Stage IIB • Flatfoot deformity
• Flexible hindfoot
• Forefoot abduction ("too many
toes", >40% talonavicular
uncoverage)
Stage III • Flatfoot deformity • (-) single-leg heel raise • Arch collapse deformity
• Rigid forefoot abduction • Severe sinus tarsi pain • Subtalar arthritis 
• Rigid hindfoot valgus
Stage IV • Flatfoot deformity • (-) single-leg heel raise • Arch collapse deformity
• Rigid forefoot abduction • Severe sinus tarsi pain  • Subtalar arthritis
• Rigid hindfoot valgus • Ankle pain • Talar tilt in ankle mortise 
• Deltoid ligament compromise


Radiographic Measurements in Hallux Valgus

Hallux valgus (HVA) Long axis of 1st MT and prox. phal. Identifies MTP deformity Normal
< 15°
Intermetatarsal angle (IMA) Between long axis of 1st and 2nd MT   < 9°
Distal metatarsal articular (DMAA) Between 1st MT long. axis and line through base  of distal articular Identifies MTP joint incongruity < 10°
cap
Hallux valgus interphalangeus (HVI) Between long. axis of distal phalanx and proximal phalanx   < 10 °  

 Procedure Technique Indications Complications
Modified McBride 30-50 y/o female withHVA 15-25 -Recurrence
Includes release of adductor from lateral IMA <13 -Hallux varus
sesamoid/proximal phalanx, lateral capsulotomy, IPA < 15
medial capsular imbrication

Original McBride included lateral sesamoidectomy and has been -never indicated -Hallux Varus
abandoned
Chevron reserved for mild to moderate deformities -AVN of MT head
Distal 1st MT osteotomy (intra-articular). Can in adults and children, biplanar chevron-- -recurrence
perform in two planes (Biplanar distal Chevron) >correct increased DMAA -dorsal malunion with
transfer metatarsalgia
 

Mitchell Distal 1st MT osteotomy (extra-articular). More same as Chevron. reserved for mild to -recurrence
proximal than Chevron) moderate deformities, rarely utilized -malunion
-transfer metatarsalgia
Akin  proximal phalanx medial closing wedge osteotomy  
-combined with Chevron in moderate to
severe deformities
-hallux valgus interphalangeus

Scarf / Ludloff / Metatarsal shaft osteotomies. -IMA 14-18°  -dorsal malunion with
Mau -DMAA is normal or increased transfer metatarsalgia
-recurrence
Proximal Proximal metatarsal osteotomies. (plus modified Severe deformity  -hallux varus
crescentric or McBride) IMA > 20  -dorsal malunion with
Broomstick HVA > 50  transfer metatarsalgia 
-recurrence
 Keller resection largely abandoned due to complications. -cock-up toe deformity
arthroplasty Include medial eminence removal and resection of indicated only in older patients with -poor potential for correction
base of proximal phalanx reduced functional demands of deformity

MTP arthrodesis    
-indicated in moderate to severe hallux
valgus
- DJD of 1st MTP
- painful callosities beneath lesser MT
heads

Lapidus -moderate or severe deformity Nonunion (may or may not

procedure   
first TMT joint arthrodesis with distal soft tissue -hypermobility of first ray be symptomatic)
procedures (medial eminence removal, first web dorsiflexion of the first
space release of AdH, lateral capsule release) metatarsal with transfer
metatarsalgia
First Cuneiform -children with ligamentous laxity, flatfoot, Nonunion (may or may not
Osteotomy Opening wedge osteotomy (often requires autograft) and hypermobile first ray be symptomatic)
- adolescent with an open physis

Coughlin and Shurnas Classification

  Exam Findings Radiographic Findings  
Grade 0 Stiffness Normal  
Grade 1 mild pain at extremes of motion mild dorsal osteophyte, normal joint space  
Grade 2 moderate pain with range of motion increasingly more moderate dorsal osteophyte, <50% joint space narrowing  
constant
Grade 3 significant stiffness, pain at extreme ROM, no pain at severe dorsal osteophyte, >50% joint space narrowing    
 mid-range
Grade 4 significant stiffness, pain at extreme ROM, pain at mid-  same as grade III
range of motion

Surgical Indications for Various Techniques to treat Hallux Valgus

  HVA IMA Modifier Procedure
Mild < 25° <13° Distal osteotomy Chevron osteotomy. Biplanar if DMAA > 10° usually with mod McBride
 
Moderate 26-40° 13-15° Proximal osteotomy +/- distal osteotomy Chevron/mod McBride + Akin osteotomy
Proximal MT osteotomy and mod McBride
Severe 41-50° 16-20° Double osteotomy DMAA > 15°  - Proximal MT osteotomy plus biplanar chevron, mod McBride
Lapidus procedure plus Akin
Elderly/very low demand patient Keller
Juvenile/Adolescent with DMAA > 20 Double osteotomy of first ray
   
Surgical Indications for Specific Conditions
Juvenile/Adolescent with open physis First cuneiform osteotomy
Hypermobile 1st MT Lapidus procedure
DJD MTP Arthrodesis
Skin breakdown simple bunionectomy with medial eminance removal
Gout MTP Arthrodesis
Recurrence with pain in 1st TMT joint Lapidus procedure
Rheumatoid arthritis MTP Arthrodesis
Down's syndrome, CP, Ehler-Danlos MTP Arthrodesis
 Description  
Type I Enlarged 5th MT head or lateral exostosis  
Type II Congenital bow of 5th MT, normal 4-5 IMA  
Type III Increased 4-5 IMA (most common)
 

Smillie Classification
Stage 1 Subchondral fracture visible only on MRI  
Stage 2 Dorsal collapse of articular surface on plain radiographs  
Stage 3 Collapse of dorsal MT head, with plantar articular portion intact  
Stage 4 Collapse of entire MT head, joint space narrowing    
Stage 5 Severe arthritic changes and joint space obliteration  


Berndt and Harty Radiographic Classification   

Stage 1  • Small area of subchondral compression
Stage 2  • Partial fragment detachment. 
Stage 3  • Complete fragment detachment but not
displaced. 
Stage 4  • Displaced fragment. 
 
 Ferkel and Sgaglione CT Staging System 
Stage 1  • Cystic lesion within dome of talus with an
intact roof on all view
Stage  • Cystic lesion communication to talar dome
2a surface
Stage  • Open articular surface lesion with the
2b overlying nondisplaced fragment.
Stage 3  •  Nondisplaced lesion with lucency
Stage 4  • Displaced fragment
 
Hepple  MRI Staging System 
Stage 1  • Articular cartilage edema
Stage  • Cartilage injury with underlying fracture and
2a surrounding bony edema
Stage  • Stage 2a without surrounding bone edema
2b
Stage 3  • Detached but nondisplaced fragment
Stage 4  • Displaced fragment
Stage 5  • Subchondral cyst formation


  Takakura Classification
Stage I Early sclerosis and osteophyte formation, no joint space narrowing
Stage II Narrowing of medial joint space (no subchondral bone contact)
Stage Obliteration of joint space at the medial malleolus, with
IIIA subchondral bone contact
Stage Obliteration of joint space over roof of talar dome, with subchondral
IIIB bone contact
Stage IV Obliteration of joint space with complete bone contact


Wagner Classification and Treatment

  Description Treatment
Grade 0 Skin intact but bony deformities lead to Shoe modifications with serial exams
"foot at risk"
Grade 1 Superficial ulcer Office debridement and contact casting
Grade 2 Deeper, full thickness extension Operative formal debridement and contact
casting
Grade 3 Deep abscess formation or Operative formal debridement and contact
osteomyelitis casting
Grade 4 Partial Gangrene of  forefoot Local vs. larger amputation
Grade 5 Extensive Gangrene Amputation
 Brodsky Depth-Ischemia Classification and Treatment
Depth
Classification Definition Treatment
Patient education, accommodative footwear, regular clinical
0  At risk foot, no ulceration
examination
1 Superficial ulceration, not Off-loading with total contact cast, walking brace or special
infected footwear
2 Deep ulceration, exposing Surgical debridement, wound care, off-loading, culture-
tendons or joints specific antibiotics
3 Extensive ulceration or abscess Debridement or partial amputation, off-loading, culture-
specific antibiotics
Ischemia
A Not ischemic  
B Ischemia without gangrene Non-invasive vascular testing and vascular reconstruction
with angioplasty/bypass
C Partial forefoot gangrene Vascular reconstruction and partial foot amputation
Complete vascular evaluation and major extremity
D Complete gangrene 
amputation 
 Paprosky Classification of Acetabular Bone Loss
Type I Minimal deformity, intact rim noncemented, porous-coated, hemispheric
cups with adjunctive screw fixation
Type IIA Superior bone lysis with intact superior rim
Type IIB  Absent superior rim, superolateral migration
Type IIC Localized destruction of medial wall highly porous, noncemented, hemispheric
cups with screw fixation and bone grafting
of the medial wall defect.

Type IIIA  Bone loss from 10am-2pm around rim, metal augments or structural allograft
superolateral cup migration combined with porous hemispheric cups
and augmentation with screw fixation and
cement.

noncemented acetabular devices combined

with structural allograft, structural augments,
Bone loss from 9am-5pm around rim,
Type IIIB and a reconstruction cage or custom
superomedial cup migration triflange
 Paprosky Classification of Femoral Bone Loss
Type I Minimal metaphyseal bone loss primary total hip arthroplasty components

Type II Extensive metaphyseal bone loss with intact uncemented extensively porous-coated long-
diaphysis stem prosthesis (or porous-coated/grit blasted
Type IIIa Extensive metadiaphyseal bone loss, combination) or modular tapered stems
minimum of 4 cm of intact cortical bone in
the diaphysis
Type IIIb Extensive metadiaphyseal bone loss, less  modular fluted tapered stem
than 4 cm of intact cortical bone in the  femoral impaction bone grafting 
diaphysis  allograft prosthetic composite (APC) 
Type IV Extensive metadiaphyseal bone loss and a  endoprosthetic replacement (EPR) 
nonsupportive diaphysis
 Vancouver Classification & Treatment - Intraoperative Periprosthetic Fracture   
Type Description Treatment
A1 Proximal metaphysis, cortical perforation bone graft alone (e.g. from acetabular reaming)
A2 Proximal metaphysis, nondisplaced crack cerclage wire before inserting stem(to prevent crack
propagation)
ignore the fracture if fully porous coated stem is used
(provided there is no distal propagation) 
A3 Proximal metaphysis, displaced unstable fracture fully porous coated stem, or tapered fluted stem provided 
wires/cables/claw plate for isolated GT fractures 
B1 Diaphyseal, cortical perforation (usually during cement removal) fully porous coated stem (bypass by 2 cortical diameters) ±
strut allograft
B2 Diaphyseal, nondisplaced crack (from increased hoop stress cerclage wire (if implant stable) 
during broaching or implant placement) fully porous coated stem to bypass defect (if implant
unstable) ± strut allograft
PWB and observation (if detected postop)
Diaphyseal, displaced unstable fracture (usually during hip
B3 fully porous coated stem to bypass defect  ± strut allograft
dislocation, cement removal, stem insertion)
morcellized bone graft, fully porous coated stem to bypass
C1 Distal to stem tip, cortical perforation (during cement removal)
defect, strut allograft
 C2 Distal to stem tip, nondisplaced fracture
C3 Distal to stem tip, displaced unstable fracture
Type Description
A Fracture in trochanteric
region. Commonly associated with
osteolysis. AG (greater trochanter)
fractures caused by retraction,
broaching, actual implant insertion,
previous hip screws.
B1 Fracture around stem or just below it,
with a well fixed stem
B2 Fracture around stem or just below it,
with a loose stem but good proximal
bone stock
B3 Fracture around stem or just below it,
with proximal bone that is poor quality or femoral replacement
severely comminuted
C Fracture occurs well below the
prosthesis
cerclage wire, strut allograft
ORIF
Treatment
Often requires treatment that addresses the osteolysis. 
AG fractures with <2cm displacement, treat nonoperatively with
partial WB and allow fibrous union. 
AG fractures >2cm needs ORIF (loss of abductor function leads to
instability) with trochanteric claw/cables.
ORIF using cerclage cables and locking plates  
Revision of the femoral component to a long porous-coated cementless
stems and fixation of the fracture fragment. Revision of the acetabular
component if indicated                 
Femoral component revision with proximal femoral allograft or proximal
     
ORIF with plate
- leave the hip and acetabular prosthesis alone
 Tonnis Classification 
Grade 0  • normal radiographs
Grade 1  • sclerosis of femoral head and acetabulum
 • slight joint space narrowing
 • slight lipping at joint margins
Grade 2  • small cysts in femoral head/acetabulum
 • moderate joint space narrowing
 • moderate loss of head sphericity
Grade 3  • large cysts in femoral head/acetabulum

 • joint space obliteration/severe narrowing
 • severe femoral head deformity vs. AVN

Steinberg Classification (modification of Ficat classification)

Stage Radiographs MRI
0 normal normalNecrotic
Modified Kerboul Combined MRI andAngle
bone scan
I Risk
normal
Group Combined Angle abnormal MRI and/or bone scan
II Low-risk
cystic or sclerosis changes 
<190° abnormal MRI and/or bone scan
III crescent sign (subchondral collapse) abnormal MRI and/or bone scan
IV flattening of femoral head abnormal MRI and/or bone scan
V narrowing of joint abnormal MRI and/or bone scan
VI advanced degenerative changes abnormal MRI and/or bone scan
 Medium-risk between 190° and 240°
High-risk >240°

Crowe Classfication 
Proximal
Grade  Femoral head subluxation
displacement
I <10% vertical height proximal migration of head neck junction from inter-teardrop line <50% of femoral head vertical diameter
of pelvis
II 10-15%  50-75%
III 15-20%  75-100%
IV  > 20%  >100%
 

Hartofilakidis Classification
Dysplasia (Type A) Femoral head within acetabulum despite some subluxation. Segmental deficiency of the
superior wall. Inadequate true acetabulum depth.
Low dislocation (Type B) Femoral head creates a false acetabulum superior to the true acetabulum. There is
complete absence of the superior wall. Inadequate depth of the true acetabulum.
High dislocation (Type C) Femoral head is completely uncovered by the true acetabulum and has migrated superiorly
and posteriorly. There is a complete deficiency of the acetabulum and excessive
anteversion of the true acetabulum.
 Ratio (inner canal  diameter 10 cm Suggested
distal to midportion of lesser trochanter Femoral
Dorr Classification Characteristics Component
divided by inner  canal diameter at
midportion of lesser trochanter) Fixation
  Cortices seen on
Type A <0.5 both AP                Uncemented
and lateral XR
Thinning of
Type B 0.5 to 0.75 posterior cortex on Uncemented
lateral XR
Thinning of
Type C >0.75 cortices on both Cemented
views
 Overview of Knee Ligament Function
Ligament Primary function Secondary function
Anterior Cruciate Resists anterolateral displacement of the Resists varus displacement at 0 degrees of
Ligament (ACL) tibia on the femur flexion
Posterior Cruciate Resists posterior tibial displacement, Resists varus displacement at 0 degrees of
Ligament (PCL) especially at 90 degrees of flexion flexion
Lateral Collateral Resists varus displacement at 30 degrees Resists posterolateral rotatory displacement
Ligament (LCL) of flexion with flexion that is less than approximately 50
degrees

Popliteofibular Ligament / Resists posterolateral rotation of the tibia on Resists varus angulation

Posterior Lateral the femur and posterior displacement of the tibia on the
Corner (PLC) femur
Medial Collateral Resists valgus angulation Works in concert with ACL to provide restraint
Ligament (MCL) to axial rotation
 
Lateral Structures of Knee
Layer I Iliotibial tract, biceps femoris
  Common peroneal nerve lies between layer I and II
Layer 2 Patellar retinaculum
Layer 3 Superficial: LCL, fabellofibular ligament, ALL
Lateral geniculate artery runs between deep and superficial layer
Deep: Arcuate ligament, coronary ligament, popliteus tendon, popliteofibular ligament, capsule

 
 Medial Structures of Knee
Layer I Sartorius and fascia (patellar retinaculum)
gracilis, semitendinosis, and saphenous nerve run between layer 1 and 2
Layer 2 Semimembranosus, superficial MCL, MPFL, posterior oblique ligament 
Layer 3 Deep MCL, capsule, coronary ligament
 Tight in Flexion Balanced in  Loose in Flexion
(can not fully flex)    Flexion  (large drawer test) 
Tight in Extension, Tight in Flexion Tight in Extension, Balanced in Flexion Tight in Extension, Loose in Flexion
 Problem: 
Problem:  Did not cut enough distal femur or did not  Problem: 
Did not cut enough tibia  release enough posterior capsule  Distal femur too long. 
Tight in
Solution:  Solution:  Solution: 
Extension)
Cut more proximal tibia  1) Release posterior capsule  1) Resect more distal femur or use thinner
2) Cut more distal femur distal femoral augmentation wedge
(revision scenario)
2) Upsize femoral component 
Balanced Balanced in Extension, Tight in Flexion Balanced in extension, Balanced in Flexion Balanced in Extension, Loose in Flexion 
in Problem:  (Perfect)     
Extension Did not cut enough posterior femur, PCL scarred  Problem: 
  and too tight. Cut too much posterior femur. 
Solution:  Solution:
1) Decrease femoral component size which 1) Increase size of femoral component(AP
required an increase in resection of the posterior only) 
femoral condyle Recess vs. release of PCL 2) Posteriorize femoral
Release posterior capsule Decrease femoral component(augment posterior femur). 
component size which required an increase in
resection of the posterior femoral condyle
2) Recess vs. release of PCL
3) Release posterior capsule
Solution: 
1) Decrease femoral component size which
required an increase in resection of the posterior
femoral condyle
2) Recess vs release of PCL
 3) Release posterior capsule
4) Recut proximal tibia with increased slope

Loose in Extension, Tight in Flexion  Loose in Extension, Balanced in Flexion Loose in Extension, Loose in Flexion 
Loose in  Problem:  Problem: 
Extension  Solution:   Cut too much distal femur. Cut too much tibia.
 (recurvatu 1) Downsize femur and use thicker tibial insert Solution: Solution: 
m) until balanced.   1) Augment distal femur  1) Use thicker tibia PE 
2) Add medial & lateral metal augments to
 
tibial tray

Su and Associates' Classification of Supracondylar Fractures of the Distal Femur

Type I Fracture is proximal to the femoral component      
Type II Fracture originates at the proximal aspect of the  femoral component and extends      
proximally
Type III Any part of the fracture line is distal to the upper edge  of anterior flange of the    
femoral component

Felix and Associates' Classification of Periprosthetic Fractures of the Tibia Associated with TKA
Type I Fracture of tibial plateau
Type II Fracture adjacent to tibial stem
 Type III Fracture of tibial shaft, distal to component
Type IV Fracture of tibial tubercle

Goldberg Classification 
Type I Fracture not involving implant/cement interface or quadriceps mechanism
Type II Fracture involving implant/cement interface and/or quadriceps mechanism
Type III Type A:  inferior pole fracture with patellar ligament rupture
Type B:  inferior pole fracture without patellar ligament rupture
Type IV All types with fracture dislocations

 Anderson Orthopaedic Research Institute (AORI) Classification   

Type  Description Treatment 
Minor bone defects with intact metaphyseal bone that do
Type 1 Cement fill or impaction allograft
not compromise stability
Type 2A Metaphyseal bone damage that involves 1 femoral Cement fill, augments, small bone graft
condyle or tibial plateau
Type 2B Metaphyseal bone damage that involves both femoral Cement fill, augments, small bone graft
condyles or tibial plateaus
Type 3 Massive bone loss comprising a large portion of Bulk allografts, custom implants, megaprosthesis,
condyle/plateau, and can involve the collateral porous tantalum, metaphyseal sleeves, rotating
ligaments/patellar tendon  hinge
  
Group  
Group I (Duchenne-Erb's Palsy)
Group II (Intermediate Paralysis)  
Group III (Total Brachial Plexus  
Palsy)
Group IV (Total Brachial Plexus Palsy  C5-T1 Flail extremity with Horner's syndrome
with Horner's syndrome)
Narakas Classification
Roots  Characteristics
Paralysis of deltoid and biceps. Intact wrist and digital
C5-C6
flexion/extension.
C5-C7 Paralysis of deltoid, biceps, and wrist and digital
extension. Intact wrist and digital flexion. 
C5-T1 Flail extremity without Horner's syndrome

 Graf Classfication
Class Alpha angle Beta angle Description Treatment
I > 60° < 55° normal none
II 43-60° 55-77° delayed variable
ossification
III < 43° > 77° subluxated Pavlik harness
IV unmeasurable unmeasurable dislocated Pavlik harness/closed vs.
open reduction
 Stages of Legg-Calves-Perthes (Waldenström)
Initial  • Infarction produces a smaller, sclerotic  • Radiographs may remain occult for 3 to 6 m
epiphysis with medial joint space widening
Fragmentation  • Begins with presence of subchondral lucent  • Hip related symptoms are most prevalent
line (cresent sign)                                                  • Lateral pillar classification based on this stage     
• Femoral head appears to fragment or dissolve • Can last from 6m to 2y
• Result of revascularization process with bone
resorption producing collapse with subsequent
patchy density and lucencies
Reossification  • Ossific nucleus undergoes reossification with  • May last up to 18m
new bone appearing as necrotic bone is
resorbed
Healing or  • Femoral head remodels until skeletal maturity   • Begins once ossific nucleus is completely
remodeling reossified;        trabecular patterns return
 
 Lateral Pillar (Herring) Classification
Group A  • lateral pillar maintains full height with no • consistently good outcome  
density changes identified
Group B  • maintains >50% height • poor outcome in patients with bone age > 6  
years
B/C Border • lateral pillar is narrowed (2-3mm) or poorly • recently added to increase consistency &  
ossified with approximately 50% height prognosis of classification
Group C  • less than 50% of lateral pillar height is • poor outcomes in all patient  
maintained
Determined at the beginning of fragmentation stage
usually occurs 6 months after the onset of symptoms   
Based on the height of the lateral pillar of the capital femoral epiphysis on AP imaging of the pelvis
Has best interobserver agreement 
Designed to provide prognostic information
Limitation is that final classification is not possible at initial presentation due to the fact that the patient needs to
have entered into the fragmentation stage radiographically
 
 Catterall Classification
Group I  • involvement of the anterior epiphysis only
Group II • involvement of the anterior epiphysis with a central sequestrum  
Group III  • only a small part of the epiphysis is not involved
Group IV • total head involvement  
Based on degree of head involvement
At risk signs (indicate a more severe disease course) 
Gage sign 
V-shaped radiolucency in the lateral portion of the epiphysis and/or adjacent metaphysis
calcification lateral to the epiphysis
lateral subluxation of the femoral head
horizontal proximal femoral physis
metaphyseal cyst
added later to the original four at risk signs described by Catterall

Loder Classification -- based on ability to bear weight

Stable Able to bear weight with or without crutches
Minimal risk of osteonecrosis (<10%)  
Unstable Unable to ambulate (not even with crutches)
High risk of osteonecrosis (originally ~47%, recent data ~24%) 
Provides prognostic information for complication of femoral head osteonecrosis
 
 Temporal Classification -- based on duration of symptoms; rarely used; no prognostic information
Acute Symptoms that persist for less than 3 weeks
Chronic Symptoms that persist for more than 3 weeks
Acute on Chronic Acute exacerbation of long-standing symptoms
 
Southwick Slip Angle Classification   -- based on femoral epipyseal-diaphyseal angle difference
Mild < 30°
Moderate 30-50°
Severe > 50°
Epiphyseal-diaphyseal angle can be measured on both AP and frog lateral pelvis radiographs 
Slip angle classification is based on the degree of difference between the affected and unaffected hip
If bilateral hips are involved, use 145° as "unaffected" hip reference for AP and 10° as "unaffected" hip
reference for lateral   
 Infantile Blounts Adolescent Blounts
Age 2-5yrs >10yrs
Bilaterality 50% bilateral Usually unilateral
Risks Early walking, large stature, obesity Obesity
Classification Langenskiold No radiographic classification
Severity More severe physeal/epiphyseal disturbance  Less severe physeal/epiphyseal
disturbance 
Proximal medial tibia physis, producing genu varus, Proximal tibia physis, AND may have
Bone
flexion, internal rotation, AND may have compensatory distal femoral VARUS and distal tibia
Involvement
distal femoral VALGUS valgus
Natural History Self-limited - stage II and IV can exhibit spontaneous Progressive, never resolves
resolution spontaneously (thus bracing unlikely to
work)
Treatment
Bracing and surgery Surgery only
Options
 Achterman and Kalamchi Classification
Type Characteristics   Treatment  Example
A portion of fibula remains present but proximal
Heel lift (if LLD >2cm)
Type fibular epiphysis is distal to level of proximal tibial physis
Contralateral epiphysiodesis  
IA while distal fibula is proximal to the talus. 
Limb lengthening (at/near maturity)
 
Type Partial absence of the fibula (30-50%)  Contralateral epiphysiodesis
IB Distal portion is unable to support the ankle joint Limb lengthening
Supramalleolar osteotomy (to
correct ankle valgus)
Corrective foot procedures to     
achieve stable, plantigrade foot
Proximal tibial osteotomy (for genu
valgus)

Type Complete absence of fibula     

II Multiple Ilizarov surgeries to
equalize limb lengths, achieve stable    
ankle, plantigrade foot
Foot ablation/amputation 

Aitken classification
Class Femoral Head Acetabulum
A present normal
B present mildly dysplastic
C absent severely dysplastic
D absent absent
 Physiologic Classification
Spastic (most Velocity-dependent increased muscle tone and hyperreflexia with slow, restricted
common) movement due to simultaneous contraction of agonist and antagonist muscles. Most
amenable to operative treatments.
Athetoid Characterized by constant succession of slow, writhing, involuntary movements
Ataxic Characterized by inability to coordinate muscle movements. Results in unbalanced, wide
based gait.
Mixed Usually mixed spastic and athetoid features and involves the entire body
Hypotonic Usually precedes spastic or ataxic for 2-3 years
Anatomic Classification
Quadriplegic Total body involvement and nonambulatory
Diplegic Legs more than arms but usually still ambulatory. IQmay be normal (injury in brain is
midline) 
Hemiplegic Arms and legs on one side of the body, usually with spasticity; will eventually be able to
walk, regardless of treatment
Gross Motor Function Classification Scale (GMFCS) 
Level I  Near normal gross motor function, independent ambulator
Level II Walks independently, but difficulty with uneven surfaces, minimal ability to jump
Level III Walks with assistive devices
Level IV Severely limited walking ability, primary mobility is wheelchair
Level V Nonambulator with global involvment, dependent in all aspects of care
 Stages of Hip Deformity in Cerebral Palsy
Hip at risk Hip abduction of <45° with Botox A into spastic muscles (age <3) to delay
partial uncovering of the femoral head surgery
on radiographs Attempt to prevent dislocation with adductor
Reimers index <33% release, psoas release, hamstring lengthening (age 3-4)
Avoid obturator neurectomy 
Hip Reimers index >33% Treat with adductor tenotomy if abduction
subluxation Disrupted Shenton's line is restricted.
If persistent subluxation, proximal femur varus
derotational osteotomy (age 5-6)
Do pelvic osteotomies (Dega, Pemberton, Salter,
PAO or Chiari) if significant acetabular insufficiency is
present
Spastic Frankly dislocated hip  Open reduction with varus derotational
dislocation Reimers index >100% osteotomy, + femoral shortening, and pelvic osteotomies
Windswept Abduction of one hip with Brace adducted hip with or without tenotomy and
hips adduction of the contralateral hip release abduction contracture of abducted hip
 
 Comparison of Spastic Hip Dysplasia and Developmental Dysplasia of the Hip
Factor Spastic Developmental
Findings at birth Hip usually normal Hip usually abnormal
Age at risk Usually normal in 1st year of life; recognized after Most often recognized in 1st year of life
age 2yr
Detection Radiographs needed in most cases Physical exam in most cases
Spastic muscles drive femoral head out of normal Mechanical factors (breech), ligamentous
Etiology
acetabulum, pelvic obliquity laxity, abnormal acetabular growth
Childhood
Progressive subluxation common Progressive subluxation rare
progression
Pain in many subluxated/dislocated hips by 2nd Pain in many subluxated hips by 4th or 5th
Natural history
or 3rd decade decade
Acetabular deficiency Usually posterosuperior Usually anterior
Early measures Muscle lengthening Pavlik harness or closed reduction
Missed or failed early Closed or open reduction, often without
Hip osteotomies, often without open reduction
measures osteotomies (before 18mth of age)
Salvage Castle resection-interposition arthroplasty  Usually total hip arthroplasty
 Descriptive Classification
Equinus Gait Term "equinus" used to refer to the isoloated abnormality in foot position relative to the tibia, i.e. a one-level deviation (e.g. no
knee/hip involvement)
characterized by absence of heal strike during gait
isolated equinus gait is common in hemiplegics
Equinus is either:
true equinus: defined by the foot position in relationship to the tibia being less than plantigrade
apparent equinus: defined by a foot position that is normal in relationship to the tibia, however heel strike does not occur due
to more proximal deviations (flexion of the knee most common)
Jump Gait Deformity includes hip flexion, knee flexion, and equinus ankle deformity ( could result in apparent ankle equinus)
Multi-level gait deviations where treatment of underlying spasticity should be considered
Crouch Gait A combination of hip flexion, knee flexion, and excessive ankle dorsiflexion (the latter may be represented by flatfoot or
calcaneus)   
Common in diplegic CP
Pathophysiology 
often an iatrogenic consequence of isolated lengthening the achilles in a jump gait pattern if the other levels of gait deviations
are not addressed properly
Levels of deviation
Calcaneal contact pattern throughout stance phase
Increased knee flexion throughout stance phase due to disruption of the ankle plantar flexion-knee extension couple
Compensated crouch gait
refers to tertiary deviations that allow the knee extensor mechanism to be off-loaded during stance phase (e.g. pelvic or
truncal forward tilt) - this may be well-tolerated by younger children with CP and low body mass
Uncompensated crouch gait
 occurs secondary to persistent overloading of the extensor mechanism.  This occurs in all crouch eventually, if untreated
Stiff Knee Common in spastic diplegic CP
Gait Characterized by limited knee flexion in swing phase due to rectus femoris firing out of phase (seen on EMG) 
note the above gait decriptions are stance phase deviations
Evaluation  : gait analysis reveals quadriceps activity from terminal stance throughout swing phase
Complications 
Stiff knee gait can be a compensation due to deviations at the hip; surgical management will not help this subset of stiff-knee gait

Similar traits to Duchenne's Distinguishing traits from Duchenne's

Becker's • calf pseudohypertrophy • Becker's has slower progression of weakness
• markedly elevated CPK with diagnosis made later (~8 yrs)
• x-linked transmission  • prone to cardiomyopathy
Spinal muscular • proximal weakness • onset of weakness is earlier in childhood
atrophy • absent deep tendon reflexes and fasciculations 
• CPK levels are normal
• pseudohypertrophy is absent
Emery-Dreifuss • similar clinical picture • no calf pseudohypertrophy
dystrophy • CPK levels near normal 
• elbow and ankle contractures develop early
Limb girdle dystrophy • progressive motor weakness • no calf pseudohypertrophy
• CPK levels are only mildly elevated
Guillain-Barre • acute onset of weakness • absent deep tendon reflexes
syndrome • CPK levels are normal
  Classification of CMT
Type A demyelinating condition that slows nerve
I conduction velocity 
Characteristics:
   1. autosomal dominant
   2. onset in first or second decade of life
   3. most commonly leads to cavus foot
   4. normal life expectancy
   5. motor involvement more profound than sensory
Type Direct axonal death caused by Wallerian
II degeneration (not demyelination) 
Characteristics:
   1. Usually less disabled than Type I
   2. onset in second decade of life or later 
   3. most commonly leads to flaccid foot 
 

Type Name Presentation Prognosis

Type I Acute Werdnig-Hoffman • Present at < 6 months Poor, usually die by 2 yrs.
disease • Absent DTR
• Tongue fasciculations
Type II Chronic Werdnig-Hoffman • Present at 6-12 months  May live to 5th decade
disease • Muscle weakness worse in LE
• Can sit but cant walk
Type III Kugelberg-Welander disease • Present at 2-15 years  Normal life expectancy - may need respiratory
• Proximal weakness support
• Walk as children, wheelchair as
adult

Primary Motion Primary Muscles

Function
L2 • Nonambulatory    
L3 • Marginal Household ambulator Hip flexion Iliopsoas (lumbar plexus,
• High risk of hip dislocation Hip adduction femoral n.) 
Hip adductors (obturator n.)
L4 • Household ambulator plus Knee extension Quadriceps (femoral n.) 
• Key level because quadriceps can Ankle dorsiflexion & inversion Tibialis anterior (deep
function peroneal n.)
L5 • Community ambulator Toe dorsiflexion  EHL (deep peroneal n.) 
Hip extension EDL (deep peroneal n.) 
Hip abduction Gluteus med.& min.
(superior gluteal n.)
S1 • Normal ambulator Foot plantar flexion Gastroc-soleus (tibial n.)
S2 • Normal ambulator Toe plantar flexion FHL (tibial n.)
S3,4 • Normal ambulator Bowel & bladder function  
 Sillence Classification of Osteogenesis Imperfecta (simplified)
Type Inheritence Sclerae Features
Type I Autosomal blue Mildest form.  Presents at preschool age (tarda). Hearing
dominant, quantitativedisorder in deficit in 50%. Divided into type A and B based on tooth
collagen involvement
Type II Autosomal blue Lethal in perinatal period
recessive, qualitativedisorder in
collagen
Type III Autosomal normal Fractures at birth. Progressively short stature. Most severe
recessive, qualitativedisorder in survivable form
collagen
Type IV Autosomal normal Moderate severity. Bowing bones and vertebral fractures are
dominant, qualitativedisorder in common. Hearing normal. Divided into type A and B based
collagen on tooth involvement
                                Type V, VI, VII have been added to the original classification system                                      
(these have no Type I collagen mutation but have abnormal bone on microscopy and a similar phenotype)
Type Hypertrophic callus after fracture. Congenital anterolateral
 Autosomal dominant radial head dislocation. Ossification of IOM between radius
V    and ulna and tibia and fibula
Type VI   Moderate severity. Similar to type IV
Type
 Autosomal recessive Associated with rhizomelia and coxa vara
VII
 
 Genetic Forms
Type Genetic  Clinical Presentation
proton pump or chloride channel dysfunction
Malignant Autosomal recessive    pancytopenia, hepatosplenomegaly and infection
fatal at an early age without bone marrow transplant
carbonic anhydrase II dysfunction       or chloride
Intermediate Autosomal recessive  channel dysfunction
usually live into adulthood
chloride channel dysfunction
Type I does not have increased fracture risk
Type II is known as Albers-Schonberg disease (anemia,
Benign Autosomal dominant pathologic fractures, and premature osteoarthritis)
general health, life span, mental function, and physique are
normal
most common form to be managed by orthopaedic surgeon
 

 Table of Metaphyseal Chondrodysplasias
Type Genetics Characteristic Comments
Jansen's autosomal dominant mental retardation ostebulbous metaphyseal
defect in parathyroid short limbed dwarfism expansion of long bones seen on
hormone related peptide (PTHRP) wide eyes xray
receptor monkey like stance
Schmid's autosomal dominant short limbed dwarfism diagnosed when patient older
defect in Type X collagen excessive lumbar lordosis due to coxa vara and genu varum
severe thigh and leg often confused with Ricketts
bowing, genu varum
wrist swelling, elbow
contractures
trendelenburg gait
McKusicks autosomal reccessive cartilage hair dysplasia seen in Amish population and
(hair had small diameter) in Finland
atlantoaxial instability
ankle deformity due to
fibular overgrowth
immunologic deficiency
and increased risk for malignancy