Classification of Bone Defects: An Extension of the Orthopaedic Trauma Association Open Fracture Classification

Kevin D. Tetsworth, Henry G. Burnand, Erik Hohmann, Vaida Glatt

Research output: Contribution to journalArticlepeer-review


OBJECTIVES: To develop a post-traumatic bone defect classification scheme and complete a preliminary assessment of its reliability. DESIGN: Retrospective classification. SETTING: Tertiary referral trauma center. PATIENTS/PARTICIPANTS: Twenty open fractures with bone loss. INTERVENTION: Assignment of a bone defect classification grade. MAIN OUTCOME MEASUREMENTS: Open fractures were classified based on orthogonal radiographs, assessing the extent and local geometry of bone loss, including D1-incomplete defects, D2-minor/subcritical (complete) defects (<2 cm), and D3-segmental/critical-sized defects (≥2 cm). Incomplete defects (D1) include D1A-<25% cortical loss, D1B-25%-75% cortical loss, and D1C->75% cortical loss. Minor/subcritical (complete) defects (<2 cm) (D2) include D2A-2 oblique ends allowing for possible overlap, D2B-one end oblique/one end transverse, and D2C-2 transverse ends. Segmental/critical-sized Defects (≥2 cm) include D3A-moderate defects, 2 to <4 cm; D3B-major defects, 4 to <8 cm; and D3C-massive defects, ≥8 cm. Reliability was assessed among 3 independent observers using Fleiss' kappa tests. RESULTS: Interobserver reliability demonstrated the classification scheme has very good agreement, κ = 0.8371, P < 0.0005. Intraobserver reliability was excellent, κ = 1.000 (standard error 0.1478-0.1634), P < 0.00001. Interobserver reliability for the distinction between categories alone (D1, D2, or D3) was also excellent, κ = 1.000 (standard error 0.1421-0.1679), P < 0.00001. CONCLUSIONS: This classification scheme provides a robust guide to bone defect assessment that can potentially facilitate selection of the most appropriate treatment strategy to optimize clinical outcomes.

Original languageEnglish (US)
Pages (from-to)71-76
Number of pages6
JournalJournal of orthopaedic trauma
Issue number2
StatePublished - Feb 1 2021

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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