Clasificacion AO 2007

INTRODUCTION
Fracture and Dislocation Classification Compendium - 2007

Orthopaedic Trauma Association Classification, Database and Outcomes Committee
J.L. Marsh, MD,* Theddy F. Slongo, MD, Julie Agel, NA, ATC, J. Scott Broderick, MD, William Creevey, MD, Thomas A. DeCoster, MD, Laura Prokuski, MD,# Michael S. Sirkin, MD,** Bruce Ziran, MD, Brad Henley, MD, Laurent Audig, DVM, PhD
Summary: The purpose of this new classification compendium is to republish the Orthopaedic Trauma Associations (OTA) classification. The OTA classification was originally published in a compendium of the Journal of Orthopaedic Trauma in 1996. It adopted The Comprehensive Classification of the Long Bones developed by Mller and colleagues and classified the remaining bones. In this compendium, the introductory chapter reviews new scientific information about classifying fractures that has been published in the last 11 years. The classification is presented in a revised format that is easier to follow. The OTA and AO classification will now have a unified alphanumeric code eliminating the differences that have existed between the 2 codes. The code was significantly revised for the clavicle and scapula, foot and hand, and patella. Dislocations have been expanded on an anatomic basis and for most joints will be coded separately. This publication should stimulate new developments and interest in a unified language to code and classify fractures. Further improvements in classification will result in better patient care and clinical research.
J Orthop Trauma 2007;21(Suppl.): S1-S133
THE RATIONALE FOR REPUBLISHING

The Orthopaedic Trauma Association (OTA) fracture classification was published in a compendium of the Journal of Orthopaedic Trauma (JOT) in 1996.1 It adopted The Comprehensive Classification of Fractures of the Long Bones developed by Mller and collaborators,2 classified bones that had not been previously classified and revised the alphaFrom the *Department of Orthopaedics and Rehabilitation, The University of Iowa Hospitals and Clinics, Iowa City, IA; Department of Paediatric Surgery, Paediatric Trauma and Orthopaedics, University Children's Hospital, Bern Switzerland; Department of Orthopaedics, Harborview Medical Center, Seattle, WA; Greenville University Medical Center, Greenville, SC; Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA; Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, NM; #University of Wisconsin, Madison, WI; **Department of Orthopaedics, New Jersey Medical School, Newark, NJ; Orthopaedic Trauma, St. Elizabeth Health Center, Orthopaedic Surgery Northeast Ohio Universities College of Medicine, Youngstown, OH; AO Clinical Investigation and Documentation, Dbendorf, Switzerland Disclosure: Dr. Henley is a consultant for Zimmer. The remaining authors report no conflicts of interest. Material presented in this Compendium is based on the Comprehensive Classification of Fractures of Long Bones, by M.E. Mller, J. Nazarian, P. Koch and J. Schatzker, Springer-Verlag, Berlin, 1990. The Orthopaedic Trauma Association is indebted to Professor Maurice Mller for allowing the Association to use the system. Correspondence: JL Marsh, MD, Department of Orthopaedics and Rehabilitation, The University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01071 JPP, Dept. of Orthopaedics, Iowa City, IA 52242 (e-mail: j-marsh@uiowa.edu). Copyright 2007 by Lippincott Williams & Wilkins
numeric code developed by the Mller group. In their introduction to the 1996 compendium, the Coding and Classification Committee noted that the goal of the comprehensive classification was to classify fractures in a uniform and consistent fashion to allow standardization of research and communication.1 The committee observed that the current state of fracture classification was ineffective for these purposes with multiple diverse systems used in different parts of the skeleton for various purposes, thwarting any possibility of a standardized language and accumulation of uniform data. Their intent was for the new classification to be a flexible, evolving classification system in which changes would be made based on comment, criticism and appropriate clinical research. In this way the classification could continue to optimally serve the needs of orthopedic traumatologists for both clinical practice and research. Since the compendium was published in 1996, the classification has resided on the OTA website and has been regularly used in trauma databases in North American Trauma Centers. It is the official classification of the OTA and of the JOT. In these ways it has developed wide acceptance and has dramatically improved the way information about fractures is communicated, stored, and used to advance knowledge through clinical research. In some anatomic areas this classification has largely supplanted all others, achieving one of the original intents. Unfortunately, the OTA classification has not achieved some of its originally stated goals. It has not been modified since 1996 and therefore it has not been the flexible, evolving classification envisioned when it was published. It also has not become a truly universal language of communication because multiple other anatomically specific classifications still exist and are part of commonly used fracture language, and for some areas of the skeleton they are still preferred. Since 1996, considerable new scientific information has been published about fracture classification in general and the OTA system in particular. Factors leading to poor reliability and reproducibility of fracture classifications have been intensively studied. These studies have led to important new information on how clinicians interpret images of fractures on radiographs and the process by which fractures are classified. Unfortunately, difficulties with classification reliability have led to some loss of enthusiasm with the classification process. It is now widely recognized that, to ensure that any classification is suitably reliable, it must undergo an intense and rigorous scientific scrutiny. The effort required is considerable, and this difficult process has either been ignored or avoided in favor of popular and widely used classifications.
J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007
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Introduction
Journal of Orthopaedic Trauma Volume 21, Number 10 Supplement, November/December 2007
The purpose of this new classification compendium is to republish the OTA classification. There are many reasons to do this. It will further a cohesive collaboration between the OTA Classification, Database and Outcomes Committee and the Arbeitsgemeinschaft fr Osteosynthesefragen Classification Task Force (AO/CTF) group and will publish the unified coding agreed upon by the two groups (Fig. 1). This will further the original goal of developing an internationally recognized uniform means to communicate about and perform clinical research on fractures and dislocations. This introductory chapter discusses the advantages and disadvantages of the uniform classification as it has existed for the past 10 years, reviews new scientific information on fracture classification, highlights the successes that have been realized, summarizes the drawbacks to systematic classification of fractures, and describes the process the OTA Classification, Database and Outcomes Committee has gone through to modify the existing classification and adopt a new uniform alpha-numeric code as proposed by the AO/CTF group.
FUNDAMENTALS OF FRACTURE CLASSIFICATION

Classification is the process by which related groups are organized based on similarities and differences.3 It condenses the language necessary to convey information among individuals with a similar understanding of the classification. A broad and diverse topic such as fractures lends itself well to the classification process. We all classify fractures as part of our standard description of an injury. In describing a fracture, we identify a bone, define a region in the bone, and routinely describe displacement and comminution and location of fracture lines with respect to relevant anatomy. In these ways we are verbally classifying the fracture as we describe it. Formal classification of fractures systematizes this descriptive process and replaces words with categories and numbers or letters that convey the same information. Fracture classification allows information about fractures to be stored in a way that facilitates comparisons among different groups or among similar groups treated differently. A good fracture classification fulfills some fundamental objectives. It should provide a reliable and reproducible means of communication. Different observers (reliability) or the same observer on repeated viewings (reproducibility) presented with the same material (for example, a radiograph) must agree on the classification of a fracture a high percentage of the time. If this is not the case, the classification has failed in its fundamental goala means to communicate information based on agreed similarities and differences. There should be clear clinical relevance for the groups within the classification that relate either to treatment guidelines, to prognosis, or to risk for complications. Without clinical relevance there is no good reason to define and separate different groups. To ensure that this relevance is present, prospective clinical research is necessary. Generally speaking, the hierarchy of a classification should proceed from less severe (as defined by energy of injury, difficulty of treatment, or patient outcome) to more severe, because classification is the fundamental way to convey information about injury severity. Another type of hierarchy used in both the OTA and the AO classification organizes fractures within a class from less to
more detailed injury descriptions. This enables a rater to utilize the appropriate complexity to suit his or her purposes. This characteristic is relatively unique to this classification but its utility has not been widely employed in the past 11 years. Most good fracture classifications are organized with these hierarchies. Ideally, a classification should be all-inclusive (all fractures within reason in a given region should be included) and mutually exclusive (a given fracture should fit in only one category). Finally, a classification should be logical, comprehensible, and should not contain an unmanageable number of categories, a problem that ensures poor reliability.4 Many different characteristics of fractures have been used as the basis of fracture classification systems. Most classifications, such as the OTA classification, are based on the anatomic location and the morphology of the fracture.1 These features can simply be observed or formal measurements may be necessary. Most commonly the observations and measurements are made on radiographs but in some circumstances information obtained on physical exam, history or intra-operative findings is considered as part of the classification process. Other features of a fracture, such as the mechanism of injury or associated injuries, may be used in determining how the fracture should be classified.5 Unless the information necessary to classify a fracture and how this information is assessed are precisely defined, observers will use the classification in different ways and reliability will suffer. To serve the purposes of populating large trauma databases, such as those used at many major trauma centers, and to provide a space efficient shorthand across languages, a standardized alpha-numeric code for all fractures is necessary and has always been a part of this system, another relatively unique feature. Site-specific classifications must be replaced with a systematic, orderly classification system that encompasses fractures of the entire skeleton. This is absolutely necessary for multi center collaboration, retrospective comparison of results, international communication and for ease of accomplishing the task of recording information about all fractures in a trauma database. Although site-specific research is possible without a comprehensive classification, the more one system is used consistently for all purposes, the closer we come to a uniform universal language for fracture care. We believe that this is a goal that continues to be worth pursuing and is one of the fundamental advances of the comprehensive classifications of Mller at al2 and the OTA classification.1
ADVANTAGES OF A COMPREHENSIVE CLASSIFICATION OF FRACTURES

The publication of the English edition of The Comprehensive Classification of Fractures of Long Bones by Mller at al in 1990 and the subsequent publication of the OTA classification in the 1996 JOT compendium were landmark advances in fracture classification compared to the state of the art that was current at that time.1,2 Before these publications, a systematic classification of fractures throughout the skeleton was not available. Eponyms were rampantColles fracture is an example used to designate diverse patterns of distal radius fractures variably including intra-articular and extra-articular patterns, partial and total articular comminution, and variable amounts of angulation and displacement. Trauma databases were essentially not possible. Classifications were developed by individ 2007 Lippincott Williams & Wilkins
S2
Introduction
ual investigators to suit their own purposes and were widely disseminated not only in publications but in book chapters and other non scientific works. There was no uniform language that related to injury severity. Some of the terminology of these classifications has now become commonplace, such as partial and total articular fractures. The vision of Mller and colleagues and the collaboration of the OTA dramatically changed the field of fracture classification.1,2 These widely adopted classifications are now used internationally and have partially achieved a universal language for fracture communication. They are all-inclusive with all bones and all fractures included, and each category, with only a very few exceptions, is mutually exclusive. They include common criteria (extra-articular, partial articular, total articular) throughout the skeleton, which makes it possible for even relatively inexperienced practitioners to achieve the basics of using the classification at the type and group level. However, experience has shown that this should not be pushed to an extreme because certain areas of the skeleton are amenable and others are not. For this reason, in some anatomic areas in this revision we have used criteria that are anatomically specific and clinically relevant. Another advantage of the comprehensive classifications is that there are clear definitions of the various groups and subgroups. For example, the localization within a long bone is defined by the rule of squares to define the three areas in the bone (proximal, shaft, distal).2 This may appear simplistic, but most other commonly used classifications do not adequately define the fracture types or groups or even what fractures belong in the classification. For example, the Schatzker classification is of proximal tibia fractures but fails to define how a proximal tibia fracture should be distinguished from a shaft fracture.6 Therefore, not only is there uncertainty within the groups but exactly which fractures are chosen to be classified and which ones are not is not clearly communicated. Investigators are free to use the classification in whatever way suits their purpose. There have also been criticisms of the comprehensive classification systems and areas in which the original goals have not been achieved. With 27 subgroups in each of the areas, it is easy to conclude that it is too complex and overwhelming for the average user. As the complexity increases observer reliability decreases. Although these concerns are valid, one of the advantages of the design of this classification is that it lends itself to use of as much or as little of the increasing complexity of the types, groups, and subgroups as is needed for a given purpose or a given user. For example, research projects may require more detail, whereas routine database entries may have less detail. Another problem is that many of the criteria that distinguish among groups and subgroups may be of unknown or little clinical significance, rendering the complexity of the classification of minimal value. Further clinical research is necessary to refine groups into those that have maximal clinical significance for either treatment techniques, risks of complications, or clinical outcomes.
FRACTURE CLASSIFICATION: ISSUES WITH OBSERVER RELIABILITY

The importance of careful scrutiny of the observer reliability of fracture classifications became increasingly apparent in the early 1990s and remains a major issue for fracture
2007 Lippincott Williams & Wilkins
classification. The language and assumptions we use to group fractures was seriously questioned, and the lessons learned continue to be of utmost importance today. In a 1993 publication in the Journal of Bone and Joint Surgery, Siebenrock and Gerber assessed the observer reliability of the Neer classification of proximal humerus fractures.7 This important classification was and still is one of the most commonly used classifications in fracture care. It fulfills many of the goals of a good classification because it provides a way to communicate critically important information about proximal humerus fractures. Decisions on treatment and determinants of outcome are based on categories determined by defining the relationships between four typical fracture parts of the proximal humerus. Unfortunately this important work demonstrated that the observer reliability of this classification was much poorer than expected. This data created a wave of controversy, with many surgeons criticizing the data and the methods. However, further publications on the Neer and many other fracture classifications have demonstrated that the use of categorical classifications is generally not highly reliable, and that these problems must be acknowledged and the issues that lead to them carefully studied.812 The fact that reliability is far less than perfect in many common fracture classifications is no longer a disputed issue. The reasons for poor reliability have been extensively investigated, and together these investigations constitute a significant body of work produced over the past 10-14 years. Investigators have studied the effect on classification reliability of clinician experience,811 complex imaging studies,8,1215 traced lines on radiographs,16 multiple radiographic views,10,17 number of categories,8,1822 binary decision making,23 ability to measure displacements,24,25 and to determine basic fracture assessments (comminuted or not; displaced or not).24 These investigations have demonstrated that even under the most ideal conditions with experienced clinicians, clear group definitions, and excellent imaging studies, observer disagreement still occurs. It can be decreased but not eliminated. There are many reasons for observer disagreement in classifying fractures. Some of them can be improved through validated development of a classification and determining categories but others present limitations to the degree that observer reliability can be achieved with categorical classifications. Observers have inherent biases based on their personal experiences that lead them to different conclusions on the basis of the same information. Even without this bias they make errors such as failing to see a fracture line that others agree is present.26 These problems are inevitable and cannot be overcome. Another fundamental issue is that fracture classification is in many ways an assessment of injury severity. Classifying a fracture and therefore its severity places it within a specific category whereas in reality fracture severity occurs on a continuous spectrum.21,27,28 Some injuries are on the border between one category and another, making observer disagreement inevitable. Despite these issues, observer reliability is better in some circumstances than in others and for some classifications than for others. Not surprisingly most studies have shown that experienced clinicians usually classify fractures more reliably than less experienced clinicians, although the effect is variable in different studies.911 Reliability can be improved by modifications of existing classifications or during the development of new classifications by a systematic methodological approach.29
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Introduction
Through these methods, problems that are now known to increase observer error and disagreement can be readily identified and minimized as much as possible. Categories within a classification should be as discrete as possible because less discrete categories lead to wide gray zones and thus increase observer disagreement. For example, if a category is defined by asking if a fracture line enters the articular surface, a clear judgment can be made. However, if the category is defined by the presence or absence of fracture comminution, this less clear assessment (how is comminuted defined?) increases the chances for disagreement.24 Similarly, subjective assessments perform poorly, such as a category defined by a high energy mechanism especially without definition of what this phrase means.24 To the extent possible, categories should be uniquely defined. As an example, assessing whether the physis is either involved with a fracture or is not is a more uniquely defined assessment than whether the fracture is angulated or not. The latter leaves room for various interpretations of angulation. If measurements are used to define categories the degree of error in measuring must be considered and minimized. For example, the degree of displacement of the articular surface in millimeters has been shown to have high observer error, which means that this commonly used assessment is a poor way to define categories.24,30 Some measurements are impossible to make. A category defined as greater or less than 1 centimeter of displacement between fragments (eg, the greater tuberosity from the rest of the humerus) requests an observer to measure something on radiographs that are often exposed in a plane that makes this measurement impossible, relegating the assignment of a fracture category to a guess unless multiple, carefully exposed radiographs in various degrees of rotation are evaluated.17 Moreover, categories are sometimes defined according to a pre-defined cut-off regarding a continuous diagnostic parameter. For example, the obliquity of diaphyseal fractures is reduced to a dichotomous variable ( 30 vs 30) in the comprehensive long bone classification. Any such cut-off values ideally should be chosen so that they are reliably measured and clinically important, but this may not be the case. The Comprehensive Classification developed by Mller at al and modified and adopted by the OTA has not been immune to these problems with observer reliability.1,2 Studies in the distal radius, distal tibia, proximal tibia, proximal femur8,1822 and elsewhere have demonstrated that the observer reliability of the system falls off significantly between the type and group level and again at the group to subgroup level. It has generally been conceded that for the purposes of clinical research it has excellent reliability only at the type level.20,21
NEW INITIATIVES IN CLASSIFICATION OVER 10 YEARS

There have been initiatives in fracture assessment designed to improve classification rather than merely to define problems.25 The rank order method has been used in studies in other clinical areas where categorical classification has proved to be difficult.27 To avoid problems with classification, Buckwalter et al assessed residents clinical performance by having faculty rank them in relation to each other and then correlated the rankings with in-training exam scores.31 They found high levels of faculty agreement for relative ranks of resident performance indicating that the rank order method was an excel-
lent substitute for classification. As problems with categorical classification of fractures became apparent, rank order methods have been applied to fractures. This method avoids the problem with reliability that occurs when a continuous variable, such as fracture severity, is arbitrarily assigned to categories. Instead, a number of fractures are ranked in relation to each other by experienced clinicians for severity or for any variable of interest. DeCoster et al and Williams et al have demonstrated that the rank order method to assess fracture severity leads to high levels of observer agreement in the relative rank between cases.27,28 This indicates that observers agree on the relative order of injury severity but when asked to assign categories they have much greater disagreement. In both of these studies, the rank order method was used to predict clinical outcomes.27,28 Unfortunately, this method is only amenable to use within a defined series of patients because the results cannot be transposed out of the series. It therefore has applicability only for research purposes where it can be used as a more reliable way to assign relative severity than classification. Nork et al have recently used this method to assess injury severity in a series of bicondylar tibial plateau fractures and have applied the results to determine factors that predict outcome after treatment.32 Considering the problems with previous classifications another new initiative in fracture classification has been developed by the AO/CTF group, which has been working on several site-specific projects to develop new classifications using a systematic methodology in three phases.33 The first development phase involves clinical experts developing proposals for the classification system, as well as defining the classification process. This phase is related solely to diagnostics and defines a common language with which surgeons should be able to identify and classify fractures similarly. Successive pilot agreement studies are conducted to ensure that clinical experts can do this, and if they cannot, the proposed system and classification process is appropriately changed and reevaluated. Such a systematic process has been applied for the development of a pediatric long bone classification with very encouraging results.34 An innovative approach using latent class modeling for the analysis of classification data has been proposed, particularly when an acceptable reference standard classification process is lacking.35 The second phase involves a multicenter agreement study to ensure that future users with less clinical experience can also classify fractures similarly. Depending on the results, some modifications toward improvement of the system may still be proposed.36,37 This creates the basis for a reliable classification tool to be used in the context of prospective clinical studies for evaluation of fracture treatment options and outcomes in a third validation phase. The AO/CTF group and the OTAs Classification, Database and Outcomes Committee are collaborating in the development, validation, and promotion of clinically relevant and widely accepted classification systems. Internationally recognized classification review groups for different body sites are being created as an important step forward. Modifications of new and existing systems should be evidence-based, ie, proposed and supported on the basis of solid validation data. The AO/CTF group has also integrated approved classification systems into a software named AO COIAC (AO Comprehensive Injury Automatic Classifier) to support teaching and to facilitate diagnosis and coding of injuries. A skeleton interface provides access to one of several area-specific
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Introduction
A Mller-AO classification system
B OTA classification system
C New unified classification system Figure 2: Proposal for a unified numbering AO/OTA system
FIGURE 1. Designation of bone location
classification modules. Drawing fracture lines or clicking with the mouse on standard bone drawings aids the classification process for the user, with successive drop-down menus and classification options. Data can be saved in a relational database and exported for further analyses and presentations, or printed for the patients files. For each injury the classification data can be collected by several different surgeons and/or at different times, hence supporting research and validation efforts.33 The groups initial publications have been on a pediatric long bone classification.34
THE PROCESS OF REVISING THE COMPENDIUM

At the time of the original publication of the OTA classification the committee classified additional bones that were not
included in the original Comprehensive Classification proposed by Mller et al.1,2 This led the committee to make some changes in the overall numeric code which over the past 10 years resulted in two somewhat different codes, one used by the AO and one by the OTA. For example, in the original AO system clavicle was 91.2 and in the OTA system it was 06, patella 91.1 AO and 34 OTA, and the wrist and hand were 7 in AO and 24, 25 and 26 for OTA. In early 2006 the AO/CTF group proposed a new unified numbering scheme to replace both of the previous versions. This proposal was considered and then accepted by the Classification, Database and Outcomes Committee of the OTA. Now clavicle (15), scapula (14), patella (34), hand (7), and foot (8) will be the same for both groups. Through this agreement there is now one universal alpha-numeric code that promotes the concept of a universal language for fractures. The original AO
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Introduction
and OTA numbering schemes and the new unified numbering scheme are reproduced in Figure 1 A-C. The body of this compendium uses the new unified alpha-numeric code. There are no changes to the long bone sections (humerus, radius and ulna, femur, and tibia) originally published by Mller et al,2 which further promotes a unified fracture code accepted universally by both groups. In addition to accepting and incorporating the unified numbering format, other revisions of the OTA classification were produced with the help of member volunteers from the organization. Members participating were asked to independently review assigned sections of the classification and to make suggestions for improvement in language, descriptions, style and format. All suggestions were collated anatomically and then reviewed by the Classification, Database and Outcomes Committee at a full day meeting. Committee members submitted additional suggestions. All suggestions from the member volunteers and committee members were individually considered. Extra consideration was given to suggestions that were received from multiple individuals. After discussion, if the committee unanimously agreed that suggested revisions were improvements, they were adopted and included in this volume. The major change that is immediately apparent relates to format, where many members suggested and the committee agreed that all groups (A,B,C) should be presented on the same page rather than split as in the 1996 publication. The long bone sections 14 were not changed. The advantages of addressing difficulties with language and categories identified in these areas by OTA members and the committee were offset by the important goal of furthering a unified international fracture language. The sections other than long bone (14, 15, 58) were updated. We have made extensive revisions to the foot and carpus. Metacarpal and metatarsal and phalanges are now exactly aligned in both the foot and the hand. Dislocations were expanded on an anatomic basis and designated with a zero code
in the second digit. Dislocations will be coded separately (other than in the pelvis, forearm, and talus), and this section has been completely revised. A new part of the classification, the pediatric long bone classification, has been incorporated directly from the work of the AO/CTF group and is the result of their meticulous scientific effort. We sincerely hope that future republications of the OTA classification will be able to incorporate additional changes resulting from this type of rigorous scientific method and will therefore need to depend less on committee review.
SUMMARY
Since the original publication of the OTA Fracture Classification in the 1996 JOT Compendium, there has been important progress in fracture classification. We are farther along toward the goal of a universally accepted fracture language, but more progress remains to be made. New knowledge has helped us to understand how classifications work, or sometimes do not work. Much of this new knowledge has been enlightening; some of it has highlighted areas in which additional work is necessary. Advances in fracture care are possible only through an organized grouping of the pathology presented by the myriad of fracture patterns and associated injuries. Republication of the OTA classification in this compendium combined with advances in fracture classification software and scientific methodology by the AO/CTF group, will serve to further this goal. We hope to reinvigorate interest in the language we use to communicate and record information about fractures and dislocations, because it is only through this language that we can collectively learn from our experiences to provide better care for future fracture patients. We encourage those interested in fracture care to utilize this classification and to participate in further classification improvements that will lead to the publishing of yet another improved version 10 years from now.
Listing of references can be found on page S133.
Introductory Message from the AO Classification Supervisory Committee

The AO Classification Supervisory Committee welcomes the opportunity to participate with the Orthopaedic Trauma Association (OTA) in the revision of the Compendium on Fracture Classification. The original cooperative effort on this Compendium was started to standardize the classification system for fractures based upon the work of Maurice Mller through the Comprehensive Classification of Fractures. The collaboration of AO with the OTA ensured that this system has a basic worldwide readership and distribution. This opportunity to attempt to standardize the terminology for fractures and classifications has now led to a revision of the Compendium to deal with any potential change. Two major events have occurred. First, a truly validated classification for pediatric fractures is now available. This classification has gone through two critical stages of internal validation and evaluation and has now been published in pediatric peer-reviewed journals. This is a major landmark in the classification literature and development, in that a classification system has now been validated by accepted methodology. The OTA and the AO Classification Supervisory Committee are continuing this work by developing a validated scapular fracture classification. This has just begun its first stages of validation. Consequently, it will not appear in this edition of the Compendium but when it has been completed, probably within the next year or year and a half, it will be available as a supplement. The OTA and AO are firm in their conviction that all new classifications must be developed on the basis of broad, internationally recognized expertise and that appropriate validation and verification by the accepted methodology should be carried out before publication and use. It is also hoped that over the next year or two, there will be an attempt to validate the comprehensive classification. Dr. Theddy F. Slongo Chairman of the AO Classification Supervisory Committee Inselspital 3010 Bern, Switzerland
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HUMERUS
BONE: HUMERUS (1)
Location: Proximal segment (11)
Types: A. Extra-articular, unifocal fracture (11-A)
B. Extra-articular, bifocal fracture (11-B)
C. Articular fractures (11-C)
Groups: Humerus proximal segment, extra-articular unifocal (11-A) 1. Avulsion of 3. Non2. Impacted tuberosity impacted metaphysis (11-A1) metaphysis (11-A2) fracture (11-A3)
Humerus, proximal segment, extra-articular bifocal (11-B) 2. Without 1. With meta3. With metaphyseal physeal glenohumeral impaction impaction dislocation (11-B2) (11-B1) (11-B3)
Humerus, proximal segment, articular fractures (11-C) 1. Articular 3. Articular 2. Articular fracture with fracture with fracture imslight displace- pacted with glenoment impacted marked dishumeral disvalgus fracture location placement (11-C1) (11-C3) (11-C2)
These fractures represent three part fractures, or fracture dislocations by the Neer classification.
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Humerus
Subgroups and Qualifications: Humerus, proximal, extra-articular, unifocal tuberosity (11-A1) 2. Greater tuberosity displaced 1. Greater tuberosity not displaced (11-A1.2) (11-A1.1) (1) superior, (2) posterior
3. With glenohumeral dislocation (11-A1.3) (1) anterior and medial plus posterior cephalic notch (2) anterior and medial plus greater tuberosity (3) erecta and greater tuberosity (4) posterior and lesser tuberosity
A1
Humerus, proximal, extra-articular, unifocal, impacted metaphyseal (11-A2) 1. Without frontal malalignment 2. With varus malalignment (11-A2.2) (11-A2.1) (1) pure medial impaction (1) without sagittal malalignment (2) posterior and medial impaction (2) posterior impaction (3) anterior and medial impaction (3) anterior impaction
3. With valgus malalignment (11-A2.3) (1) pure lateral impaction (2) posterior and lateral impaction (3) anterior and lateral impaction
A2
Humerus, proximal, extra-articular, unifocal, non-impacted metaphyseal (11-A3) 2. Simple with translation (11-A3.2) 1. Simple with angulation (11-A3.1) (1) lateral (2) medial (3) with glenohumeral dislocation
3. Multifragmentary (11-A3.3) (1) wedge (2) complex (3) glenohumeral dislocation
A3
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J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Humerus, proximal, extra-articular, bifocal, with metaphyseal impaction (11-B1) 2. Medial plus lesser tuberosity 1. Lateral plus greater tuberosity (11-B1.2) (11-B1.1) (1) pure lateral impaction (1) pure lateral impaction (2) posterior and lateral impaction (2) posterior and lateral impaction (3) anterior and lateral impaction (3) anterior and lateral impaction
Humerus
3. Posterior plus greater tuberosity (11-B1.3)
B1
Humerus, proximal, extra-articular, bifocal, without metaphyseal impaction (11-B2) 1. Without rotatory displacement of 2. With rotatory displacement of the the epiphyseal fracture fragment epiphyseal fragment (11-B2.2) (11-B2.1) (1) greater tuberosity separated (2) lesser tuberosity separated
3. Multifragmentary metaphysis plus one of the tuberosities (11-B2.3) (1) lesser tuberosity (2) greater tuberosity
B2
Humerus, proximal, extra-articular, bifocal 1. Vertical cervical line plus greater tuberosity intact plus anterior medial dislocation (11-B3.1)
with glenohumeral dislocation (11-B3) 2. Vertical cervical line plus greater tuberosity fracture plus anterior medial dislocation (11-B3.2)
3. Lesser tuberosity fracture plus posterior dislocation (11-B3.3) (1) without anterior cephalic notch (2) with anterior cephalic notch
B3
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Humerus
Humerus, proximal, articular fracture with slight displacement (11-C1) 1. Cephalotubercular with valgus 2. Cephalotubercular with varus malalignment (11-C1.1) malalignment (11-C1.2)
3. Anatomical neck (11-C1.3) (1) nondisplaced (2) displaced
C1
Humerus, proximal, articular fracture impacted with marked displacement (11-C2) 1. Cephalotubercular with valgus 2. Cephalotubercular with varus malalignment (11-C2.1) malalignment (11-C2.2)
3. Transcephalic (double profile image on x-ray) and tubercular, with varus malalignment (11-C2.3)
C2
Humerus, proximal, articular fracture dislocated (11-C3) 2. Anatomical neck and tuberosities 1. Anatomical neck (11-C3.2) (11-C3.1) (1) head impacted (1) anterior (2) head not impacted (2) posterior
3. Cephalotubercular fragmentation (11-C3.3) (1) head intact (2) head fragmented
C3
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Humerus
BONE: HUMERUS (1)
Location: Diaphyseal segment (12)
Types: A. Simple fracture (12-A)
B. Wedge fracture (12-B)
C. Complex fracture (12-C)
Groups: Humerus diaphyseal, simple (12-A) 1. Spiral 2. Oblique (12-A1) (30) (12-A2)
3. Transverse (30) (12-A3)
Humerus diaphyseal, wedge (12-B) 1. Spiral wedge 2. Bending (12-B1) wedge (12-B2)
3. Fragmented wedge (12-B3)
Humerus diaphyseal, complex (12-C) 3. Irregular 1. Spiral 2. Segmental (12-C3) (12-C1) (12-C2)
S11
Humerus
Subgroups and Qualifications: Humerus diaphyseal, simple, spiral (12-A1) 2. Middle zone (12-A1.2) 1. Proximal zone (12-A1.1)
3. Distal zone (12-A1.3)
A1
Humerus diaphyseal, simple, oblique (30) (12-A2) 1. Proximal zone (12-A2.1) 2. Middle zone (12-A2.2)
A2
Humerus diaphyseal, simple, transverse (30) (12-A3) 1. Proximal zone (12-A3.1) 2. Middle zone (12-A3.2)
A3
S12
J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Humerus diaphyseal, wedge, spiral (12-B1) 2. Middle zone (12-B1.2) 1. Proximal zone (12-B1.1)
Humerus
3. Distal zone (12-B1.3)
B1
Humerus diaphyseal, wedge, bending (12-B2) 1. Proximal zone (12-B2.1) 2. Middle zone (12-B2.2)
B2
Humerus diaphyseal, wedge, fragmented (12-B3) 2. Middle zone (12-B3.2) 1. Proximal zone (12-B3.1)
B3
S13
Humerus
Humerus diaphyseal, complex, spiral (12-C1) (1) pure diaphyseal (2) proximal diaphysio-metaphyseal (3) distal diaphysio-metaphyseal 2. With 3 intermediate fragments 1. With 2 intermediate fragments (12-C1.2) (12-C1.1)
3. With more than 3 intermediate fragments (12-C1.3)
C1
Humerus, diaphyseal, complex segmental 1. With 1 intermediate segmental fragment (12-C2.1) (1) pure diaphyseal (2) proximal diaphysio-metaphyseal (3) distal diaphysio-metaphyseal (4) oblique lines (5) transverse and oblique lines
(12-C2) 2. With 1 intermediate segmental and additional wedge fragments (12-C2.2) (1) pure diaphyseal (2) proximal diaphysio-metaphyseal (3) distal diaphysio-metaphyseal (4) distal wedge (5) 2 wedges, proximal and distal
3. With 2 intermediate segmental fragments (12-C2.3) (1) pure diaphyseal (2) proximal diaphysio-metaphyseal (3) distal diaphysio-metaphyseal
C2
Humerus, diaphyseal, complex irregular (12-C3) 1. With 2 or 3 intermediate 2. With limited shattering (4cm) fragments (12-C3.1) (12-C3.2) (1) 2 main intermediate fragments (1) proximal zone (2) 3 main intermediate fragments (2) middle zone (3) distal zone
3. With extensive shattering (4cm)(12-C3.3) (1) pure diaphyseal (2) proximal diaphysio-metaphyseal (3) distal diaphysio-metaphyseal
C3
S14
Humerus
BONE: HUMERUS (1)
Location: Distal segment (13)
Types: A. Extra-articular fracture (13-A)
B. Partial articular fracture (13-B)
C. Complete articular fracture (13-C)
Groups: Humerus distal segment, extra-articular (13-A) 1. Apophyseal 3. Meta2. Metaavulsion (13-A1) physeal physeal multisimple (13-A2) fragmentary (13-A3)
Humerus distal segment, partial articular (13-B) 1. Lateral 3. Frontal (13-B3) 2. Medial sagittal (13-B1) sagittal (13-B2)
Humerus distal segment, complete 2. Articular 1. Articular simple, metasimple, physeal multimetaphyseal simple (13-C1) fragmentary (13-C2)
articular (13-C) 3. Articular, metaphyseal multifragmentary (13-C3)
S15
Humerus
Subgroups and Qualifications: Humerus, distal, extra-articular apophyseal avulsion (13-A1) 2. Medial epicondyle, non-incarcerated 3. Medial epicondyle, incarcerated 1. Lateral epicondyle (13-A1.1) (13-A1.3) (13-A1.2) (1) non-displaced (2) displaced (3) fragmented
A1
Humerus, distal, extra-articular metaphyseal simple (13-A2) 1. Oblique downwards 2. Oblique down3. Transverse (13-A2.3) and inwards (13-A2.1) wards and outwards (2) juxta-epiphyseal (1) transmetaphyseal (13-A2.2) with posterior displacement (Kocher I)
(3) juxta-epiphyseal with anterior displacement (Kocher II)
A2
Humerus, distal, extra-articular metaphyseal multifragmentary (13-A3) 1. With intact wedge (13-A3.1) 2. With fragmented wedge (13-A3.2) (1) lateral (1) lateral (2) medial (2) medial
3. Complex (13-A3.3)
A3
S16
Humerus
Humerus, distal, partial articular lateral sagittal (13-B1) 1. Capitellum (13-B1.1) 2. Transtrochlear simple (13-B1.2) (1) through the capitellum (Milch I) (1) medial collateral ligament intact (2) between capitellum and trochlea (2) medial collateral ligament ruptured (3) metaphyseal simple (classic Milch II) lateral condyle (4) metaphyseal wedge (5) metaphysio-diaphyseal
3. Transtrochlear multifragmentary (13-B1.3) (1) epiphysio-metaphyseal (2) epiphysio-metaphyseal-diaphyseal
B1
Humerus, distal, partial articular, medial sagittal (13-B2) 1. Transtrochlear simple, through 2. Transtrochlear simple, through the medial side (Milch I) (13-B2.1) groove (13-B2.2)
3. Transtrochlear multifragmentary (13-B2.3) (1) epiphysio-metaphyseal (2) epiphysio-metaphyseal-diaphyseal
B2
Humerus, distal, partial articular, frontal (13-B3) 2. Trochlea (13-B3.2) 1. Capitellum (13-B3.1) (1) simple (1) incomplete (Kocher-Lorenz) (2) fragmented (2) complete (Hahn-Steinthal 1) (3) with trochlear component (Hahn-Steinthal 2) (4) fragmented
3. Capitellum and trochlea (13-B3.3)
B3
S17
Humerus
Humerus, distal complete, articular simple, metaphyseal simple (13-C1) 1. With slight displacement (13-C1.1) 2. With marked displacement (1) Y-shaped (13-C1.2) (2) T-shaped (1) Y-shaped (3) V-shaped (2) T-shaped (3) V-shaped
3. T-shaped epiphyseal (13-C1.3)
C1
Humerus, distal, complete articular simple metaphyseal multifragmentary (13-C2) 2. With a fragmented wedge (13-C2.2) 1. With intact wedge (13-C2.1) (1) metaphyseal lateral (1) metaphyseal lateral (2) metaphyseal medial (2) metaphyseal medial (3) metaphysio-diaphyseal-lateral (3) metaphysio-diaphyseal-lateral (4) metaphysio-diaphyseal-medial (4) metaphysio-diaphyseal-medial
3. Complex (13-C2.3)
C2
Humerus, distal, complete multifragmentary (13-C3) 2. Metaphyseal wedge (13-C3.2) 1. Metaphyseal simple (13-C3.1) (1) intact (2) fragmented
3. Metaphyseal complex (13-C3.3) (1) localized (2) extending into diaphysis
C3
S18
RADIUS/ULNA
BONE: RADIUS/ULNA (2)
Types: A. Extra-articular (21-A)
B. Articular fracture involving articular surface of only 1 of the 2 bones (21-B)
C. Articular fracture involving articular surface of 2 bones (21-C)
Groups: Radius/ulna, proximal, extra-articular (21-A) 1. Ulna only (21-A1) 2. Radius only (21-A2) 3. Radius and ulna (21-A3)
Radius/ulna, proximal, articular surface one bone (21-B) 1. Ulna fractured, 2. Radius frac3. Articular of tured, ulna inradius intact 1 bone, extratact (21-B2) (21-B1) articular of other (21-B3)
Radius/ulna, proximal, articular both bones (21-C) 1. Simple of both 2. Simple of bones (21-C1) 1, multifragmentary of other (21-C2) 3. Multifragmentary of both (21-C3)
S19
Radius/Ulna
Subgroups and Qualifications: Radius/ulna, proximal, extra-articular ulna fractured (21-A1) 2. Metaphyseal simple (21-A1.2) 1. Avulsion of triceps insertion from olecranon (21-A1.1)
3. Metaphyseal multifragmentary (21-A1.3)
A1
Radius/ulna, proximal, extra-articular radius fractured (21-A2) 2. Neck simple (21-A2.2) 1. Avulsion of bicipital tuberosity of radius (21-A2.1)
3. Neck multifragmentary (21-A2.3)
A2
Radius/ulna, proximal, extra-articular, fracture both bones (21-A3) 1. Simple of both bones (21-A3.1) 2. Multifragmentary of 1 bone and simple of other (21-A3.2) (1) multifragmentary ulna (2) multifragmentary radius
3. Multifragmentary of both bones (21-A3.3)
A3
S20
J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Radius/ulna, proximal, articular fracture ulna (21-B1) 1. UnifocaI (21-B1.1) 2. Bifocal (21-B1.2) (1) olecranon 1 line (2) olecranon 2 lines (3) olecranon multifragmentary (4) coronoid process alone
Radius/Ulna
3. Bifocal multifragmentary (21-B1.3) (1) multifragmentary olecranon (2) multifragmentary coronoid process (3) multifragmentary of both
B1
Radius/ulna, proximal, articular, radial fracture (21-B2) 1. Simple (21-B2.1) 2. Multifragmentary without depression (21-B2.2) (1) nondisplaced (2) displaced
3. Multifragmentary with depression (21-B2.3)
B2
Radius/ulna, proximal, articular of 1, extra-articular of other (21-B3) 1. Ulna articular simple (21-B3.1) 2. Radius articular simple (21-B3.2) (1) radius extra-articular simple (1) ulna extra-articular simple (2) radius extra-articular multifragmentary (2) ulna extra-articular multifragmentary
3. Articular multifragmentary (21-B3.3) (1) ulna, radius extra-articular simple (2) ulna, radius extra-articular multifragmentary (3) radius, ulna extra-articular simple (4) radius, ulna extra-articular multifragmentary
B3
S21
Radius/Ulna
Radius/ulna, proximal, articular both simple (21-C1) 2. Coronoid process and radial head 1. Olecranon and radial head (21-C1.2) (21-C1.1)
C1
Radius/ulna, proximal, articular, both bones, 1 simple the other multifragmentary (21-C2) 1. Olecranon multifragmentary, radial 2. Olecranon simple, radial head multi- 3. Coronoid process simple, radial head multifragmentary (21-C2.3) fragmentary (21-C2.2) head, simple (21-C2.1)
C2
Radius/ulna, proximal, articular multifragmentary both bones (21-C3) 1. 3 fragments both bones (21-C3.1) 2. Ulna, more than 3 fragments (21-C3.2) (1) radius, 3 fragments (2) radius, more than 3 fragments
3. Radius, more than 3 fragments (21-C3.3) (1) ulna, 3 fragments (2) ulna, epiphysio-diaphyseal
C3
S22
Radius/Ulna
Location: Diaphyseal (22)
Types: A. Simple (22-A)
B. Wedge (22-B)
C. Complex (22-C)
Groups: Radius/ulna, diaphyseal, simple (22-A) 1. Ulna simple, 3. Simple frac2. Radius simradius intact ple, ulna intact ture both (22-A1) bones (22-A3) (22-A2)
Radius/ulna, diaphyseal, wedge fracture (22-B) 3. Wedge 1. Ulna fracture, 2. Radius fracfracture, simture, ulna inradius intact ple or wedge tact (22-B2) (22-B1) of other bone (22-B3)
Radius/ulna, diaphyseal, complex (22-C) 3. Complex of 1. Complex of 2. Complex of both bones ulna (22-C1) radius (22-C2) (22-C3)
S23
Radius/Ulna
Subgroups and Qualifications: Radius/ulna, diaphyseal, simple fracture of ulna (22-A1) 2. Transverse (22-A1.2) 1. Oblique (22-A1.1)
3. With dislocation of radial head (Monteggia) (22-A1.3)
A1
Radius/ulna, diaphyseal, simple fracture of radius (22-A2) 1. Oblique (22-A2.1) 2. Transverse (22-A2.2)
3. With dislocation of distal radioulnar joint (Galeazzi) (22-A2.3)
A2
Radius/ulna, diaphyseal, simple fracture of both bones (22-A3) (1) without dislocation (2) with dislocation of radial head (Monteggia) (3) with dislocation of distal radioulnar joint (Galeazzi) (based on level of radial fracture) 1. Radius, proximal zone (22-A3.1) 2. Radius, middle zone (22-A3.2)
3. Radius, distal zone (22-A3.3)
A3
S24
J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Radius/ulna, diaphyseal, wedge fracture of ulna (22-B1) 1. Intact wedge (22-B1.1) 2. Fragmented wedge (22-B1.2)
Radius/Ulna
3. With dislocation of radial head (Monteggia) (22-B1.3)
B1
Radius/ulna, diaphyseal, wedge fracture of radius (22-B2) 1. Intact wedge (22-B2.1) 2. Fragmented wedge (22-B2.2)
3. With dislocation of distal radioulnar joint (Galeazzi) (22-B2.3)
B2
Radius/ulna, diaphyseal, wedge of 1, simple or wedge of other (22-B3) (1) without dislocation (2) with dislocation of radial head (Monteggia) (3) with dislocation of distal radioulnar joint (Galeazzi) 1. Ulna wedge, simple fracture radius 2. Radial wedge, simple fracture of (22-B3.1) ulna (22-B3.2)
3. Radial and ulnar wedge (22-B3.3)
B3
S25
Radius/Ulna
Radius/ulna, diaphyseal, complex fracture 1. Bifocal, radius intact (22-C1.1) (1) without dislocation (2) with radial head dislocated (Monteggia)
of ulna (22-C1) 2. Bifocal with radial fracture (22-C1.2) (1) radius simple (2) radius wedge
3. Irregular of ulna (22-C1.3) (1) radius intact (2) radius simple (3) radius wedge
C1
Radius/ulna, diaphyseal, complex fracture 1. Bifocal, ulna intact (22-C2.1) (1) without dislocation (2) with dislocation of distal radioulnar joint (Galeazzi)
of radius (22-C2) 2. Bifocal, ulna fracture (22-C2.2) (1) simple ulna (2) wedge ulna
3. Irregular (22-C2.3) (1) ulna intact (2) ulna simple (3) ulna wedge
C2
Radius/ulna, diaphyseal, complex of both bones (22-C3) 1. Bifocal (22-C3.1) 2. Bifocal of 1, irregular of other (22-C3.2) (1) bifocal radius, irregular ulna (2) bifocal ulna, irregular radius
3. Irregular (22-C3.3)
C3
S26
Radius/Ulna
B. Partial articular fracture of radius (23-B)
C. Complete articular fracture of radius (23-C)
Groups: Radius/ulna, distal, extra-articular (23-A) 1. Extra-articular 2. Extra-artic3. Extra-articuulna fracture, lar, multifragular simple radius intact mentary radius frac(23-A1) radius fracture ture, ulna (23-A3) intact (23-A2)
Radius/ulna, distal, partial articular radius (23-B) 1. Partial 2. Partial artic- 3. Partial articular articular radius, ular radius, radius, volar rim sagittal (23-B1) dorsal rim (reverse Barton, Goyrand Smith (Barton) II) (23-B3) (23-B2)
Radius/ulna, distal, complete articular (23-C) 2. Complete 1. Complete 3. Complete articular radius, articular raarticular rasimple articular dius, simple dius, multiand metaphysis articular, fragmentary metaphyseal (23-C1) (23-C3) multifragmentary (23-C2)
S27
Radius/Ulna
Subgroups and Qualifications: Radius/ulna, distal, extra-articular fracture of ulna (23-A1) 2. Metaphyseal simple (23-A1.2) 1. Ulna styloid process (23-A1.1)
3. Metaphyseal multifragmentary (23-A1.3) (1) wedge (2) complex
A1
Radius/ulna, distal, extra-articular fracture of radius, simple metaphyseal and impacted (23-A2) (1) radioulnar dislocation (fracture of styloid process) (2) simple fracture of ulnar neck (3) multifragmentary fracture of ulnar neck (4) fracture of ulna head (5) fracture of ulna head and neck (6) fracture proximal to ulnar neck 1. Transverse, no tilt, but may be 2. With dorsal tilt, oblique fracture up- 3. Volar tilt, oblique upwards and foraxially shortened (23-A2.1) ward and back (Pouteau-Colles) ward (Goyrand-Smith) (23-A2.3) (23-A2.2)
A2
Radius/ulna, distal, extra-articular fracture of radius, multifragmentary (23-A3) (1) radioulnar dislocation (fracture of styloid process) (2) simple fracture of ulnar neck (3) multifragmentary fracture of ulnar neck (4) fracture of ulna head (5) fracture of ulna head and neck (6) fracture proximal to ulnar neck 2. With a wedge (23-A3.2) 1. Impacted with axial shortening (23-A3.1)
3. Complex (23-A3.3)
A3
S28
Radius/Ulna
Radius/ulna, distal, partial articular fracture of radius, sagittal (23-B1) (1) radioulnar dislocation (fracture of styloid process) (2) simple fracture of ulnar neck (3) multifragmentary fracture of ulnar neck (4) fracture of ulna head (5) fracture of ulna head and neck (6) fracture proximal to ulnar neck 1. Lateral simple (23-B1.1) 2. Lateral multifragmentary (23-B1.2)
3. Medial (23-B1.3)
B1
Radius/ulna, distal, partial articular fracture of radius, dorsal rim (Bartons) (23-B2) (1) radioulnar dislocation (fracture of styloid process) (2) simple fracture of ulnar neck (3) multifragmentary fracture of ulnar neck (4) fracture of ulna head (5) fracture of ulna head and neck (6) fracture proximal to ulnar neck 1. Simple (23-B2.1) 2. With lateral sagittal fracture (23-B2.2)
3. With dorsal dislocation of carpus (23-B2.3)
B2
Radius/ulna, distal, partial articular fracture of radius, volar rim (reverse Bartons, Goyrand-Smith II) (23-B3) (1) radioulnar dislocation (fracture of styloid process) (2) simple fracture of ulnar neck (3) multifragmentary fracture of ulnar neck (4) fracture of ulna head (5) fracture of ulna head and neck (6) fracture proximal to ulnar neck 1. Simple with small fragment 3. Multifragmentary (23-B3.3) 2. Simple with larger fragment (23-B3.1) (23-B3.2)
B3
S29
Radius/Ulna
Radius/ulna, distal, complete articular fracture of radius, articular simple, metaphyseal simple (23-C1) (1) radioulnar dislocation (fracture of styloid process) (2) simple fracture of ulnar neck (3) multifragmentary fracture of ulnar neck (4) fracture of ulna head (5) fracture of ulna head and neck (6) fracture proximal to ulnar neck 1. Posteromedial articular fragment 2. Sagittal articular fracture line 3. Frontal articular fracture line (23-C1.1) (23-C1.2) (23-C1.3)
C1
Radius/ulna, distal, complete articular fracture of radius, articular simple, metaphyseal multifragmentary (23-C2) (1) radioulnar dislocation (fracture of styloid process) (2) simple fracture of ulnar neck (3) multifragmentary fracture of ulnar neck (4) fracture of ulna head (5) fracture of ulna head and neck (6) fracture proximal to ulnar neck 1. Sagittal articular fracture line 2. Frontal articular fracture line 3. Extending into diaphysis (23-C2.3) (23-C2.1) (23-C2.2)
C2
Radius/ulna, distal, complete articular fracture of radius, multifragmentary (23-C3) (1) radioulnar dislocation (fracture of styloid process) (2) simple fracture of ulnar neck (3) multifragmentary fracture of ulnar neck (4) fracture of ulna head (5) fracture of ulna head and neck (6) fracture proximal to ulnar neck 2. Metaphyseal multifragmentary 1. Metaphyseal simple (23-C3.1) (23-C3.2)
3. Extending into diaphysis (23-C3.3)
C3
S30
FEMUR
BONE: FEMUR (3)
Types: A. Trochanteric area (31-A)
B. Neck fractures (31-B)
C. Head fractures (31-C)
Groups: Femur, proximal trochanteric (31-A) 1. Pertro3. Intertro2. Pertrochanteric simple chanteric chanteric (31-A1) (31-A3) multifragmentary (31-A2)
Femur, proximal, neck fracture (31-B) 2. Transcer1. Subcapital 3. Subcapital vical (31-B2) with slight with marked displacement displacement (31-B1) (31-B3)
Femur, proximal, head fracture (31-C) 1. Split (31-Cl) 3. With neck 2. With defracture pression (31-C3) (31-C2)
S31
Femur
Subgroups and Qualifications: Femur, proximal, pertrochanteric simple (only 2 fragments) (31-A1) 2. Through the greater trochanter 1. Along intertrochanteric line (31-A1.2) (31-A1.1) (1) nonimpacted (2) impacted
3. Below lesser trochanter (31-A1.3) (1) high variety, medial fracture line at lower limit of lesser trochanter (2) low variety, medial fracture line in diaphysis below lesser trochanter
A1
Femur proximal, trochanteric fracture, pertrochanteric multifragmentary (always have posteromedial fragment with lesser trochanter and adjacent medial cortex) (31-A2) 1. With 1 intermediate fragment 3. Extending more than 1 cm below 2. With several intermediate frag(31-A2.1) lesser trochanter (31-A2.3) ments (31-A2.2)
A2
Femur, proximal, trochanteric area, intertrochauteric fracture (31-A3) 1. Simple oblique (31-A3.1) 2. Simple transverse (31-A3.2)
3. Multifragmentary (31-A3.3) (1) extending to greater trochanter (2) extending to neck
A3
S32
J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Femur, proximal, neck fracture, slight displacement (31-B1) 2. Impacted in valgus 15 1. Impacted in valgus 15 (31-B1.2) (Garden 1/2) (31-B1.1) (Garden 1) (1) posterior tilt 15 (1) posterior tilt 15 (2) posterior tilt 15 (2) posterior tilt 15
Femur
3. Nonimpacted (31-B1.3) (Garden 2)
B1
Femur, proximal, neck fracture, transcervical (31-B2) 1. Basicervical (31-B2.1) 2. Midcervical adduction (31-B2.2)
3. Midcervical shear (31-B2.3)
B2
Femur, proximal, neck fracture, sub-capital, nonimpacted displaced (31-B3) 1. Moderate displacement in varus and 2. Moderate displacement with vertiexternal rotation (31-B3.1) (Garden 3) cal translation and external rotation (31-B3.2) (Garden 4)
3. Marked displacement (31-B3.3) (Garden 3/4) (1) in varus (2) with translation
B3
S33
Femur
Femur, proximal, head fracture, split (31-C1) 1. Avulsion of ligamentum teres 2. With rupture of ligamentum teres (31-C1.1) (31-C1.2)
3. Large fragment (31-C1.3)
C1
Femur, proximal, head fracture, with depression (31-C2) 1. Posterior and superior (31-C2.1) 2. Anterior and superior (31-C2.2)
3. Split depression (31-C2.3)
C2
Femur, proximal, head fracture with neck fracture (31-C3) 1. Split and transcervical neck fracture 2. Split and subcapital neck fracture (31-C3.2) (31-C3.1)
3. Depression and neck fracture (31-C3.3)
C3
S34
Femur
BONE: FEMUR (3)
B. Wedge (32-B)
C. Complex (32-C)
Groups: Femur, diaphyseal, simple fracture (32-A) 1. Spiral (32-A1) 2. Oblique 3. Transverse (30) (32-A2) (30) (32-A3)
Femur, diaphyseal, wedge fracture (32-B) 1. Spiral wedge 2. Bending 3. Fragmented (32-B1) wedge (32-B3) wedge (32-B2)
Femur, diaphyseal, complex (32-C) 1. Spiral (32-C1) 2. Segmental (32-C2)
3. Irregular (32-C3)
S35
Femur
Subgroups and Qualifications: Femur, diaphyseal, simple spiral (32-A1) 1. Subtrochanteric zone (32-A1.1)
2. Middle zone (32-A1.2)
A1
Femur, diaphyseal, simple oblique (30) (32-A2) 1. Subtrochanteric zone (32-A2.1) 2. Middle zone (32-A2.2)
A2
Femur, diaphyseal, transverse (30) (32-A3) 2. Middle zone (32-A3.2) 1. Subtrochanteric zone (32-A3.1)
A3
S36
J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Femur, diaphyseal, wedge spiral (32-B1) 1. Subtrochanteric zone (32-B1.1)
Femur
2. Middle zone (32-B1.2)
B1
Femur, diaphyseal, wedge, bending (32-B2) 1. Subtrochanteric zone (32-B2.1) 2. Middle zone (32-B2.2)
B2
Femur, diaphyseal, wedge fragmented (32-B3) 1. Subtrochanteric zone (32-B3.1) 2. Middle zone (32-B3.2)
B3
S37
Femur
Femur, diaphyseal, complex spiral (32-C1) (1) pure diaphyseal (2) proximal diaphysio-metaphyseal (3) distal diaphysio-metaphyseal 2. With 3 intermediate fragments 1. With 2 intermediate fragments (32-C1.2) (32-C1.1)
C1
Femur, diaphyseal, complex segmental (32-C2) 1. With 1 intermediate segmental 2. With 1 intermediate segmental and fracture (32-C2.1) additional wedge fragments (32-C2.2) (1) pure diaphyseal (1) pure diaphyseal (2) proximal diaphysio-metaphyseal (2) proximal diaphysio-metaphyseal (3) distal diaphysio-metaphyseal (3) distal diaphysio-metaphyseal (4) oblique lines (4) distal wedge (5) transverse and oblique lines (5) 2 wedges, proximal and distal
C2
Femur, diaphyseal, complex irregular (32-C3) 1. With 2 or 3 intermediate fragments 2. With limited shattering (5cm) (32-C3.1) (32-C3.2) (1) 2 main intermediate fragments (1) proximal zone (2) 3 main intermediate fragments (2) middle zone (3) distal zone
3. With extensive shattering (5cm) (32-C3.3) (1) pure diaphyseal (2) proximal diaphysio-metaphyseal (3) distal diaphysio-metaphyseal
C3
S38
Femur
BONE: FEMUR (3)
B. Partial articular (33-B)
C. Complete articular (33-C)
Groups: Femur, distal, extra-articular (33-A) 1. Simple 2. Meta(33-A1) physeal wedge (33-A2)
3. Metaphyseal complex (33-A3)
Femur, distal, partial articular (33-B) 2. Medial 3. Frontal 1. Lateral condyle, (33-B3) condyle, sagittal (33-B1) sagittal (33-B2)
Femur, distal, complete articular (33-C) 1. Articular 3. Multifrag2. Articular simple, metamentary simple, metaphyseal simple physeal multiarticular (33-C1) fracture fragmentary (33-C3) (33-C2)
S39
Femur
Subgroups and Qualifications: Femur, distal, extra-articular simple (33-A1) 1. Apophyseal (33-A1.1) 2. Metaphyseal oblique or spiral (1) avulsion lateral epicondyle (33-A1.2) (2) avulsion medial epicondyle
3. Metaphyseal transverse (33-A1.3)
A1
Femur, distal, extra-articular, metaphyseal wedge (33-A2) 1. Intact wedge (33-A2.1) 2. Fragmented lateral (33-A2.2) (1) lateral (2) medial
3. Fragmented medial (33-A2.3)
A2
Femur, distal, extra-articular, metaphyseal complex (33-A3) 1. With an intermediate split segment 2. Irregular limited to metaphysis (33-A3.1) (33-A3.2)
3. Irregular extending to diaphysis (33-A3.3)
A3
S40
Femur
Femur, distal, partial articular, lateral condyle, sagittal (33-B1) 1. Simple through the notch (33-B1.1) 2. Simple through load bearing surface (33-B1.2)
3. Multifragmentary (33-B1.3)
B1
Femur, distal, partial articular, medial condyle, sagittal (33-B2) 1. Simple through notch (33-B2.1) 2. Simple through load bearing surface (33-B2.2)
B2
Femur, distal, partial articular, frontal (33-B3) 2. Unicondylar posterior (Hoffa) 1. Anterior and lateral flake fracture (33-B3.2) (33-B3.1) (1) lateral (2) medial
3. Bicondylar posterior (33-B3.3)
B3
S41
Femur
Femur, distal, complete articular, articular simple, metaphyseal simple (33-C1) 1. T- or Y-shaped with slight displace- 2. T- or Y-shaped with marked disment (33-C1.1) placement (33-C1.2)
3. T-shaped epiphyseal (33-C1.3)
C1
Femur, distal, complete articular, articular simple, metaphyseal multifragmentary (33-C2) 1. With intact wedge (33-C2.1) 2. With fragmented wedge (33-C2.2) 3. Complex (33-C2.3) (1) lateral (1) lateral (2) medial (2) medial
C2
Femur, distal, complete articular, articular multifragmentary (33-C3) 1. Metaphyseal simple (33-C3.1) 2. Metaphyseal multifragmentary (33-C3.2)
3. Metaphysio-diaphyseal multifragmentary (33-C3.3)
C3
S42
TIBIA/FIBULA
BONE: TIBIA/FIBULA (4)
Groups: Tibia/fibula, proximal, extra-articular 1. Avulsion 2. Metaphy(41-A1) seal simple (41-A2)
(41-A) 3. Metaphyseal multifragmentary (41-A3)
Tibia/fibula, proximal, partial articular (41-B) 2. Pure de1. Pure split 3. Split depression (41-B1) pression (41-B2) (41-B3)
Tibia/fibula, proximal, complete articular (41-C) 1. Articular 3. Articular 2. Articular simple, metamultifragsimple, metaphyseal simple physeal multimentary (41-C1) (41-C3) fragmentary (41-C2)
S43
Tibia/Fibula
Subgroups and Qualifications: Tibia/fibula, proximal, extra-articular, avulsion (41-A1) 2. Of tibial tuberosity (41-A1.2) 1. Of fibular head (41-A1.1)
3. Of cruciate insertion (41-A1.3) (1) anterior (2) posterior
A1
Tibia/fibula, proximal, extra-articular, simple metaphysis (41-A2) 1. Oblique in frontal plane (41-A2.1) 2. Oblique in sagittal plane (41-A2.2)
3. Transverse (41-A2.3)
A2
Tibia/fibula, proximal, extra-articular, multifragmentary metaphysis (41-A3) 2. Fragmented wedge (41-A3.2) 1. Intact wedge (41-A3.1) (1) lateral (1) lateral (2) medial (2) medial
3. Complex (41-A3.3) (1) slightly displaced (2) significantly displaced
A3
S44
J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Tibia/fibula, proximal, partial articular, split (41-B1) 1. Of lateral surface (41-B1.1) 2. Of medial surface (41-B1.2) (1) marginal (1) marginal (2) sagittal (2) sagittal (3) frontal anterior (3) frontal anterior (4) frontal posterior (4) frontal posterior
Tibia/Fibula
3. Oblique, involving the tibial spines and 1 of the surfaces (41-B1.3) (1) lateral (2) medial
B1
Tibia/fibula, proximal, partial articular, depression (41-B2) 1. Lateral total (41-B2.1) 2. Lateral limited (41-B2.2) (1) 1 piece (1) peripheral (2) mosaic-like (2) central (3) anterior (4) posterior
3. Medial (41-B2.3) (1) central (2) anterior (3) posterior (4) total
B2
Tibia/fibula, proximal, partial articular, split depression (41-B3) 2. Medial (41-B3.2) 1. Lateral (41-B3.1) (1) antero-lateral depression (1) antero-lateral depression (2) postero-lateral depression (2) postero-lateral depression (3) antero-medial depression (3) antero-medial depression (4) postero-medial depression (4) postero-medial depression
3. Oblique involving the tibial spines and 1 of the surfaces (41-B3.3) (1) lateral (2) medial
B3
S45
Tibia/Fibula
Tibia/fibula, proximal, complete articular, simple articular, simple metaphysis (41-C1) (1) intact anterior tibial tubercle and intercondylar eminence (2) anterior tibial tubercle involved (3) intercondylar eminence involved 2. 1 condyle displaced (41-C1.2) 3. Both condyles displaced (41-C1.3) 1. Slight displacement (41-C1.1)
C1
Tibia/fibula, proximal, complete articular, articular simple, metaphysis multifragmentary (41-C2) 3. Complex (41-C2.3) 2. Fragmented wedge (41-C2.2) 1. Intact wedge (41-C2.1) (1) lateral (1) lateral (2) medial (2) medial
C2
Tibia/fibula, proximal, complete articular, articular multifragmentary (41-C3) (1) metaphyseal simple (2) metaphyseal lateral wedge (3) metaphyseal medial wedge (4) metaphyseal complex (5) metaphysio-diaphyseal complex 1. Lateral (41-C3.1) 2. Medial (41-C3.2)
3. Lateral and medial (41-C3.3)
C3
S46
Tibia/Fibula
B. Wedge (42-B)
C. Complex (42-C)
Groups: Tibia/fibula, diaphyseal, simple (42-A) 1. Spiral (42-A1) 2. Oblique 3. Transverse (30) (42-A2) (30) (42-A3)
Tibia/fibula, diaphyseal, wedge (42-B) 1. Spiral wedge 2. Bending 3. Frag(42-B1) mented wedge (42-B2) wedge (42-B3)
Tibia/fibula, diaphyseal, complex (42-C) 3. Irregular 1. Spiral 2. Segmented (42-C3) (42-C1) (42-C2)
S47
Tibia/Fibula
Subgroups and Qualifications: Tibia/fibula, diaphyseal, simple, spiral (42-A1) (1) proximal zone (2) middle zone (3) distal zone 1. Fibula intact (42-A1.1) 2. Fibula fracture at different level (42-A1.2)
3. Fibula fracture at same level (42-A1.3)
A1
Tibia/fibula, diaphyseal, simple, oblique (30) (42-A2) (1) proximal zone (2) middle zone (3) distal zone 1. Fibula intact (42-A2.1) 2. Fibula fracture at different level (42-A2.2)
A2
Tibia/fibula, diaphyseal, simple, transverse (<30) (42-A3) (1) proximal zone (2) middle zone (3) distal zone 1. Fibula intact (42-A3.1) 2. Fibula fracture at different level (42-A3.2)
A3
S48
J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Tibia/fibula, diaphyseal, wedge, spiral (42-B1) (1) proximal zone (2) middle zone (3) distal zone 1. Fibula intact (42-B1.1) 2. Fibula fracture at different level (42-B1.2)
Tibia/Fibula
3. Fibula fracture at same level (42-B1.3)
B1
Tibia/fibula, diaphyseal, wedge, bending (42-B2) (1) proximal zone (2) middle zone (3) distal zone 2. Fibula fracture at different level 1. Fibula intact (42-B2.1) (42-B2.2)
B2
Tibia/fibula, diaphyseal, wedge fragmented (42-B3) (1) proximal zone (2) middle zone (3) distal zone 2. Fibula fracture at different level 1. Fibula intact (42-B3.1) (42-B3.2)
B3
S49
Tibia/Fibula
Tibia/fibula, diaphyseal, complex, spiral (42-C1) (1) pure diaphyseal (2) proximal diaphysio-metaphysis (3) distal diaphysio-metaphysis 1. With 2 intermediate fragments 2. With 3 intermediate fragments (42-C1.1) (42-C1.2)
C1
Tibia/fibula, diaphyseal, complex segmental (42-C2) 2. With an intermediate segmental 1. With an intermediate segmental and additional wedge fragment(s) fragment (42-C2.1) (42-C2.2) (1) pure diaphyseal (1) pure diaphyseal (2) proximal diaphysio-metaphyseal (2) proximal diaphysio-metaphyseal (3) distal diaphysio-metaphyseal (3) distal diaphysio-metaphyseal (4) oblique lines (4) distal wedge (5) transverse and oblique lines (5) 3 wedges, proximal and distal
C2
Tibia/fibula, diaphyseal, complex, irregular (42-C3) 1. With 2 or 3 intermediate fragments 2. Limited shattering (4cm) (42-C3.1) (42-C3.2) (1) 2 intermediate fragments (2) 3 intermediate fragments
3. Extensive shattering (4cm) (42-C3.3) (1) pure diaphyseal (2) proximal diaphysio-metaphyseal (3) distal diaphysio-metaphyseal
C3
S50
Tibia/Fibula
Groups: Tibia/fibula, distal, extra-articular (43-A) 1. Metaphyseal 2. Metaphy3. Metaphysimple (43-A1) seal complex seal wedge (43-A3) (43-A2)
Tibia/fibula, distal, partial articular (43-B) 1. Pure split 3. Multifragmen2. Split de(43-B1) tary depression pression (43-B3) (43-B2)
Tibia/fibula, distal, complete articular (43-C) 2. Articular 1. Articular 3. Articular simple, metasimple, metamultifragmenphysis multiphysis simple tary (43-C3) fragmentary (43-C1) (43-C2)
S51
Tibia/Fibula
Subgroups and Qualifications: Tibia/fibula, distal, extra-articular, simple (43-A1) (1) fibula intact (2) simple fracture of fibula (3) multifragmentary fracture of fibula (4) bifocal fracture of fibula 1. Spiral (43-A1.1) 2. Oblique (43-A1.2)
A1
Tibia/fibula, distal, extra-articular, wedge (43-A2) (1) fibula intact (2) simple fracture of fibula (3) multifragmentary fracture of fibula (4) bifocal fracture of fibula 2. Anteromedial wedge (43-A2.2) 1. Posterolateral impaction (43-A2.1)
3. Extending into diaphysis (43-A2.3)
A2
Tibia/fibula, distal, extra-articular, complex (43-A3) (1) fibula intact (2) simple fracture of fibula (3) multifragmentary fracture of fibula (4) bifocal fracture of fibula 1. With 3 intermediate fragments 2. More than 3 intermediate frag(43-A3.1) ments (43-A3.2)
3. Extending into diaphysis (43-A3.3)
A3
S52
Tibia/Fibula
Tibia/fibula, distal, partial articular, pure split (43-B1) (1) fibula intact (2) simple fracture of fibula (3) multifragmentary fracture of fibula (4) bifocal fracture of fibula 1. Frontal (43-B1.1) 2. Sagittal (43-B1.2) (5) anterior (5) lateral (6) posterior (Volkmann) (6) medial (medial malleolus)
3. Metaphyseal multifragmentary (43-B1.3)
B1
Tibia/fibula, distal, partial articular, split depression (43-B2) (1) fibula intact (2) simple fracture of fibula (3) multifragmentary fracture of fibula (4) bifocal fracture of fibula 1. Frontal (43-B2.1) 2. Sagittal (43-B2.2) (5) anterior (5) lateral (6) posterior (6) medial
3. Of the central fragment (43-B2.3)
B2
Tibia/fibula, distal, partial articular, depression (43-B3) (1) fibula intact (2) simple fracture of fibula (3) multifragmentary fracture of fibula (4) bifocal fracture of fibula 1. Frontal (43-B3.1) 2. Sagittal (43-B3.2) (5) anterior (5) lateral (6) posterior (6) medial
3. Metaphyseal, multifragmentary (43-B3.3)
B3
S53
Tibia/Fibula
Tibia/fibula, distal, complete articular, articular simple, metaphyseal simple (43-C1) (1) fibula intact (2) simple fracture of fibula (3) multifragmentary fracture of fibula (4) bifocal fracture of fibula 1. Without impaction (43-C1.1) 2. With epiphyseal depression (5) frontal plane (43-C1.2) (6) sagittal plane
3. Extending into diaphysis (43-C1.3)
C1
Tibia/fibula, distal, complete articular, articular simple, multifragmentary metaphysis (43-C2) (1) fibula intact (2) simple fracture of fibula (3) multifragmentary fracture of fibula (4) bifocal fracture of fibula 3. Extending into diaphysis (43-C2.3) 2. Without asymmetric impaction 1. With asymmetric impaction (43-C2.2) (43-C2.1) (5) frontal plane split (6) sagittal plane split
C2
Tibia/fibula, distal, complete articular, articular multifragmentary (43-C3) (1) fibula intact (2) simple fracture of fibula (3) multifragmentary fracture of fibula (4) bifocal fracture of fibula 2. Epiphysio-metaphyseal (43-C3.2) 1. Epiphyseal (43-C3.1)
3. Epiphysio-metaphysio-diaphyseal (43-C3.3)
C3
S54
Tibia/Fibula
Location: Malleolar segment (44)
Types: A. Infrasyndesmotic lesion (44-A)
B. Transsyndesmotic fibula fracture (44-B)
C. Suprasyndesmotic lesion (44-C)
Groups: Tibia/fibula, malleolar, infrasyndesmotic lesions (44-A) 3. With 2. With me1. Isolated postero-medial dial malleolar (44-A1) fracture fracture (44-A3) (44-A2)
Tibia/fibula, malleolar, transsyndesmotic fibula fracture (44-B) 2. With me1. Isolated 3. With medial lesion (44-B1) dial lesion (44-B2) and Volkmann (fracture of the posterolateral rim) (44-B3)
Tibia/fibula, malleolar, suprasyndesmotic (44-C) 1. Simple dia2. Multifragphyseal fibular mentary fracfracture (44-C1) ture of fibular diaphysis (44-C2) 3. Proximal fibula (44-C3)
S55
Tibia/Fibula
Subgroups and Qualifications: Tibia/fibula, malleolar, infrasyndesmotic, isolated (44-A1) 2. Avulsion of tip of lateral malleolus 1. Rupture of lateral collateral (44-A1.2) ligament (44-A1.1)
3. Transverse fracture of lateral malleolus (44-A1.3)
A1
Tibia/fibula, malleolar, infrasyndesmotic lesion with medial malleolar fracture (44-A2) (1) transverse (2) oblique (3) vertical 1. Rupture of lateral collateral 2. Avulsion of tip of lateral malleolus 3. Transverse fracture of lateral malleligament (44-A2.1) (44-A2.2) olus (44-A2.3)
A2
Tibia/fibula, malleolar, infrasyndesmotic lesion with postero-medial fracture (44-A3) 2. Avulsion of tip of lateral malleolus 1. Rupture of lateral collateral (44-A3.2) ligament (44-A3.1)
3. Transverse fracture of lateral malleolus (44-A3.3)
A3
S56
Tibia/Fibula
Tibia/fibula, malleolar, transsyndesmotic, isolated (44-B1) 1. Simple (44-B1.1) 2. Simple with rupture of anterior syndesmosis (44-B1.2) (1) in substance (2) Chaput (anterior tibia) (3) Lefort (anterior fibula)
B1
Tibia/fibula, malleolar, transsyndesmotic fracture with medial lesion (44-B2) 1. Simple, rupture of medial collateral 2. Simple with fracture of medial and anterior syndesmosis (44-B2.1) malleolus and rupture of anterior syn(1) in substance desmosis (44-B2.2) (2) Chaput (1) in substance (3) Lefort (2) Chaput (3) Lefort
3. Multifragmentary (44-B2.3) (1) rupture of medial collateral ligament (2) fracture of medial malleolus
B2
Tibia/fibula, malleolar, transsyndesmotic with medial lesion and a Volkmann (fracture of posterolateral rim) (44-B3) (1) extra-articular avulsion (2) peripheral articular fragment (3) significant articular fracture 1. Fibula simple with medial collateral 2. Simple fibula fracture with fracture 3. Multifragmentary with fracture of ligament rupture (44-B3.1) of medial malleolus (44-B3.2) medial malleolus (44-B3.3)
B3
S57
Tibia/Fibula
Tibia/fibula, malleolar, susprasyndesmotic, simple diaphyseal fracture of fibula (44-C1) 2. With fracture of medial malleolus 3. With fracture of medial malleolus 1. Rupture of medial collateral (44-C1.2) and a Volkmann (Dupuytren) ligament (44-C1.1) (44-C1.3) (1) extra-articular avulsion (2) peripheral articular fragment (3) significant articular fragment
C1
Tibia/fibula, malleolar, suprasyndesmotic, multifragmentary fibular diaphyseal fracture (44-C2) 2. With fracture of medial malleolus 3. With fracture of medial malleolus 1. With rupture of medial collateral (44-C2.2) and a Volkmann (Dupuytren) ligament (44-C2.1) (44-C2.3) (1) extra-articular avulsion (2) peripheral articular fragment (3) significant articular fragment
C2
Tibia/fibula, malleolar, suprasyndesmotic, proximal fibular lesion (44-C3) (1) fracture through neck (2) fracture through head (3) proximal tibiofibular dislocation (4) rupture of medial collateral ligament (5) fracture of medial malleolus (6) articular fragment 1. Without shortening, without 2. With shortening, without Volkmann (44-C3.1) Volkmann (44-C3.2)
3. Medial lesion and a Volkmann (44-C3.3)
C3
S58
PELVIS
BONE: PELVIS (6)
Location: Pelvic ring (61)
Types: A. Lesion sparing (or with no displacement of) posterior arch (61-A)
B. Incomplete disruption of posterior arch, partially stable (61-B)
C. Complete disruption of posterior arch, unstable (61-C)
The classification of pelvic ring and acetabular fractures is based on the work of Pennal and Tile and Judet and Letournel. This classification was developed to accommodate the alphanumeric system of The Comprehensive Long Bone System. DEFINITIONS Pelvic ring has two arches: (a) posterior arch is behind acetabular surface and includes sacrum, sacroiliac joints and their ligaments and posterior ilium, and (b) anterior arch is in front of acetabular surface and includes pubic rami bone and symphyseal joint. Anterior column of acetabulum extends from the anterior half of the iliac crest to the pubis (iliopubic). Posterior column of acetabulum extends from the greater sciatic notch to the ischium (ilioischial). Unilateral: only 1 hemipelvis involved posteriorly. Bilateral: both hemipelvis involved posteriorly. Contralateral: the side opposite the major posterior lesion. Ipsilateral: the side of the more severe lesion. Stable: lesion sparing the posterior arch; pelvic floor intact and able to withstand normal physiological stresses without displacement.
Partially stable: posterior osteoligamentous integrity partially maintained and pelvic floor intact. Unstable: complete loss of posterior osteoligamentous integrity; pelvic floor disrupted. Where appropriate, the Young-Burgess classification has been added to the Subgroup and Qualification section. Although these terms are not part of the alpha-numeric code, they are added so that those using this classification can easily code into the alpha-numeric system for documentation. The following are the definitions of the Young-Burgess System: APC: anterior-posterior compression; LC: lateral compression; SI: sacroiliac; VS: vertical shear; CMI: combined mechanical instability.
ACKNOWLEDGEMENTS The O.T.A. Coding and Classification Committee gratefully acknowledges the following individuals for their significant contributions to the development of systematic universal pelvic and acetabular classifications: Emile Letournel, MD; Marvin Tile, MD; Balz Isler, MD; David Helfet, MD; Serge Nazarian, MD
S59
Pelvis
Groups: Pelvis, ring, stable (61-A) 1. Fracture of innominate bone, avulsion (61-A1)
2. Fracture of innominate bone, direct blow (61-A2)
3. Transverse fracture of sacrum and coccyx (61-A3)
Pelvis, ring, partially stable (61-B) 1. Unilateral, partial disruption of posterior arch, external rotation (open-book injury) (61-B1)
2. Unilateral, partial disruption of posterior arch, internal rotation (lateral compression injury) (61-B2)
3. Bilateral, partial lesion of posterior arch (61-B3)
Pelvis, ring, complete disruption of posterior arch unstable (61-C) 1. Unilateral, complete disruption of 2. Bilateral, ipsilateral complete, conposterior arch (61-C1) tralateral incomplete (61-C2)
3. Bilateral, complete disruption (61-C3)
S60
J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Subgroups and Qualifications: Pelvis, ring, stable, avulsion of innominate bone (61-A1) 2. Iliac crest (61-A1.2) 1. Iliac spine (61-A1.1) (1) anterior superior (2) anterior inferior (3) pubic spine
Pelvis
3. Ischial tuberosity (61-A1.3)
A1
Pelvis, ring, stable, innominate bone, direct blow (61-A2) 2. Unilateral fracture of anterior arch 1. Iliac wing (61-A2.1) (61-A2.2) (1) 1 fragment (1) through pubic bone/rami (2) more than 1 fragment (2) through pubic bone involving symphysis pubis
3. Bifocal fracture of anterior arch (61-A2.3) (1) bilateral pubic rami (2) pubic rami on 1 side and symphysis pubis
A2
Pelvis, ring, stable, transverse fracture of sacrum and coccyx (61-A3) 1. Sacrococcygeal dislocation (61-A3.1) 2. Sacrum undisplaced (61-A3.2)
3. Sacrum displaced (61-A3.3)
A3
S61
Pelvis
Pelvis, ring, partially stable, unilateral, external rotation (open book, APC-II) (61-B1) (1) ipsilateral (2) contralateral (3) anterior lesion 1. Sacroiliac joint anterior disruption 2. Sacral fracture (61-B1.2, c*) (61-B1.1)
B1
Pelvis, ring, partially stable, unilateral, internal rotation (lateral compression) (61-B2) 1. Anterior compression fracture of 2. Partial sacroiliac joint fracture/subsacrum (LC-I) (61-B2.1) luxation (LC-II) (61-B2.2) (1) anterior lesion ipsilateral (1) anterior lesion ipsilateral (2) anterior lesion contralateral (2) anterior lesion contralateral (bucket (bucket handle) handle)
3. Incomplete posterior iliac fracture (LC-II) (61-B2.3) (1) anterior lesion ipsilateral (2) anterior lesion contralateral (bucket handle)
B2
Pelvis, ring, partially stable, bilateral (61-B3) 1. Bilateral B1 (open book, external 2. B1 and B2 (LC-III) (61-B3.2, a*, b**, rotation) (APC-II) (61-B3.1) c*) (1) bilateral sacroiliac joint anterior disruption (2) bilateral sacral fracture (3) unilateral partial SI joint disruption/ contralateral sacral fracture (c*)
3. Bilateral B2 (61-B3.3, a*, b**, c*)
B3
S62
Pelvis
Pelvis, ring, complete disruption, unilateral (APC-III) (61-C1) 2. Through sacroiliac joint (61-C1.2, c*) 3. Through the sacrum (61-C1.3, c*) 1. Through ilium (61-C1.1, c*) (a1) lateral (ala) (a1) transiliac fracture dislocation (a2) pure dislocation (a2) foraminal 3 (a ) transsacral fracture dislocation (a3) medial to foramen
C1
Pelvis, ring, unstable, bilateral, ipsilateral complete, contralateral incomplete (LC-III) (61-C2) 2. Complete through sacroiliac joint 1. Complete through ilium 3. Complete through the sacrum (61-C2.2, b*, c*) (61-C2.1, b*, c*) (61-C2.3, b*, c*) (a1) transiliac fracture dislocation (a1) lateral (ala) (a2) pure dislocation (a2) foraminal (a3) transsacral fracture dislocation (a3) medial to foramen
C2
Pelvis, ring, unstable, bilateral (APC-III) (61-C3, b***, c*) 1. Extrasacral on both sides (61-C3.1) 2. Sacral one side, extra sacral other (a1) ilium; (a2) SI joint, transiliac fracture/ side (61-C3.2, b***, c*) dislocation; (a3) SI joint, transsacral (a1) sacral ala; (a2) sacral foraminal; fracture/dislocation; (a4) SI joint (a3) sacral medial to foramen dislocation
3. Sacral both sides (61-C3.3, c*) (a) a1) lateral alar; a2) foraminal; a3) medial (b) b1) lateral alar; a2) foraminal; a3) medial
C3
Footnotes: *a: Ipsilateral posterior pelvic lesion: a1) sacroiliac joint anterior disruption; a2) sacral fracture; a3) anterior compression fracture sacrum; a4) partial sacroiliac joint fracture/subluxation; a5) incomplete posterior iliac fracture. *b: Contralateral pelvic lesion: b1) external rotation, open book partial disruption: .1) sacroiliac joint anterior disruption; .2) sacral fracture 2 b ) internal rotation, lateral compression partial disruption: .1) anterior compression fracture of
the sacrum; .2) partial sacroiliac joint fracture/subluxation; .3) incomplete posterior iliac fracture **b: Contralateral posterior pelvic lesion: bl) sacroiliac joint anterior disruption; b2) sacral fracture; b3) anterior compression fracture sacrum; b4) partial sacroiliac joint fracture/subluxation; b5) incomplete posterior iliac fracture. ***b: Contralateral pelvic lesion: b1) ilium; b2) sacroiliac joint, transiliac fracture dislocation; b3) sacroiliac joint, transsacral fracture dislocation; b4) sacroiliac joint, pure dislocation.
*c: Anterior pelvic lesion: cl) unilateral pubis/rami fracture, ipsilateral: c2) unilateral pubis/rami fracture, contralateral; c3) bilateral pubis/rami fracture; c4) symphysis pubis disruption, pure < 2.5 cm; c5) symphysis pubis disruption, pure > 2.5 cm; c6) symphysis pubis disruption, pure, locked; c7) symphysis and ipsilateral pubis/rami fracture (tilt); c8) symphysis and contralateral pubis/rami fracture; c9) symphysis and bilateral pubis/rami fracture; c10) no anterior lesion.
S63
Pelvis
BONE: PELVIS (6) Modifiers to describe articular surfaces: 1) femoral head subluxation, anterior; 2) femoral head subluxation, medial; 3) femoral head subluxation, posterior. 1) femoral head dislocation, anterior; 2) femoral head dislocation, medial; 3) femoral head dislocation, posterior. 1) acetabular surface, chondral lesion; 2) acetabular surface, impacted. 1) femoral head, chondral lesion; 2) femoral head, impacted; 3) femoral head, osteochondral fracture. 1) intraarticular fragment requiring surgical removal. 1) nondisplaced fracture of the acetabulum.
Location: Acetabulum (62)
Types: A. Partial articular, 1 column (62-A)
B. Partial articular, transverse (62-B)
C. Complete articular, both columns (62-C)
Groups: Pelvis, acetabulum, partial articular, one column (62-A) 1. Posterior wall 2. Posterior 3. Anterior (62-A1) (62-A3) column (62-A2)
Pelvis, acetabulum, partial articular, transverse (62-B) 2. T-shaped 1. Transverse 3. Anterior (62-B2) (62-B1) column, posterior hemitransverse (62-B3)
Pelvis, acetabulum, complete articular, both columns (62-C) 1. High (62-C1) 2. Low 3. Involving sacroiliac (62-C2) joint (62-C3)
S64
Pelvis
Subgroups and Qualifications: Pelvis, acetabulum, partial articular, 1 column posterior wall (62-A1) 2. Pure fracture dislocation, multifrag1. Pure fracture dislocation, 1 mentary (62-A1.2, a*) fragment (62-A1.1) (1) posterior (1) posterior (2) posterior superior (2) posterior superior (3) posterior inferior (3) posterior inferior
3. Fracture dislocation with marginal impaction (62-A1.3, a*) (1) posterior (2) posterior superior (3) posterior inferior
A1
Pelvis, acetabulum, partial articular, 1 column posterior column (62-A2) 2. Through obturator ring (62-A2.2) 1. Through ischium (62-A2.1) (1) preserving tear drop (2) involving tear drop
3. Associated with posterior wall (62-A2.3, a*) (1) pure fracture dislocation: .1) posterior; .2) posterior superior; .3) posterior inferior (2) with marginal impaction: .1) posterior; .2) posterior superior; .3) posterior inferior
A2
Pelvis, acetabulum, partial articular, one column anterior (62-A3, a**) 1. Anterior wall (62-A3.1) 2. Anterior column, high (fracture to iliac crest) (62-A3.2)
3. Low (fracture to anterior border) iliac crest (62-A3.3)
A3
*a: a1) 1 fragment; a2) 2 fragments; a3) more than 2 fragments. **a: a1) anterior column in 1 fragment; a2) anterior column in 2 fragments; a3) anterior column in more than 2 fragments.
S65
Pelvis
Pelvis, acetabulum, partial articular, transverse (62-B1) 2. Juxtatectal (62-B1.2, a*) 1. Infratectal (62-B1.1, a*)
3. Transtectal (62-B1.3, a*)
B1
Pelvis, acetabulum, partial articular, transverse T-type (62-B2) 2. Juxtatectal (62-B2.2, a*) 1. Infratectal (62-B2.1, a*) (1) stem posterior (1) stem posterior (2) stem through obturator foramen (2) stem through obturator foramen (3) stem anterior (3) stem anterior
3. Transtectal (62-B2.3, a*) (1) stem posterior (2) stem through obturator foramen (3) stem anterior
B2
Pelvis, acetabulum, partial articular, transverse posterior hemitransverse, anterior column (62-B3) 3. Anterior column low (62-B3.3, a**) 2. Anterior column high (62-B3.2, a**) 1. Anterior wall (62-B3.1)
B3
*a: a1) pure transverse; a2) and posterior wall, single fragments; a3) and posterior wall, multifragmentary; a4) and posterior wall, multifragmentary with marginal impaction. **a: a1) anterior column in 1 fragment; a2) anterior column in 2 fragments; a3) anterior column in more than 2 fragments.
S66
Pelvis
Pelvis, acetabulum, complete, both columns high (62-C1) 2. Posterior column simple, anterior 1. Each column simple (62-C1.1) column multifragmentary (62-C1.2)
3. Posterior column and posterior wall (62-C1.3, a**, b*)
C1
Pelvis, acetabulum, complete articular, both columns low (62-C2) 2. Posterior column simple, anterior 1. Each column simple (62-C2.1) column multifragmentary (62-C2.2)
3. Posterior column and posterior wall (62-C2.3, a**, b*)
C2
Pelvis, acetabulum, complete articular, both columns involving sacroiliac joint (62-C3) 3. Posterior column multifragmen1. Anterior wall (62-C3.1) 2. Posterior column multifragmentary, anterior column low (62-C3.3, (a1) anterior column simple, high tary, anterior column high a***, b**) (a2) anterior column simple, low (62-C3.2, a***, b**) (a3) anterior column multifragmentary, high (a4) anterior column multifragmentary, low
C3
**a: a1) anterior column in 1 fragment; a2) anterior column in 2 fragments; a3) anterior column in more man 2 fragments. ***a: a1) anterior column simple; a2) anterior column multifragmentary. *b: b1) posterior wall, single fragment; b2) posterior wall, multifragmentary without impaction; b3) posterior wall, multifragmentary with marginal impaction. **b: b1) pure separation; b2) and posterior wall, single fragment; b3) and posterior wall, multifragmentary without impaction; b4) and posterior wall, multifragmentary with marginal impaction.
S67
SCAPULA
BONE: SCAPULA (14)
Types: A. Extra-articular (not glenoid) (14-A)
B. Partial articular (glenoid) (14-B)
C. Total articular (glenoid) (14-C)
Groups: Scapula, extra-articular (not glenoid) (14-A) 3. Body 2. Coracoid 1. Acromion (14-A3) (14-A2) (14-A1)
Scapula, partial articular (glenoid) (14-B) 1. Anterior rim 2. Posterior 3. Inferior rim (14-B1) rim (14-B2) (14-B3)
Scapula, total articular (glenoid) (14-C) 1. Extra-articular 2. Intra-artic- 3. Intra-articglenoid neck ular with neck ular with (14-C1) (14-C2) body (14-C3)
S68
J Orthop Trauma Volume 21, Number 10, November/December 2007
Scapula
Subgroups: Scapula extra-articular (not glenoid) (14-A) Acromion (14-A1) 2. Acromion, comminuted (14-A1.2) 1. Acromion, noncomminuted (14-A1.1)
A1
Coracoid (14-A2) 1. Coracoid, noncomminuted (14-A2.1) 2. Coracoid, comminuted (14-A2.2)
A2
Body (14-A3) 1. Body, noncomminuted (14-A3.1)
2. Body, comminuted (14-A3.2)
A3
S69
Scapula
Subgoups: Scapula extra-articular (glenoid) (14-B) Anterior rim (14-B1) 1. Anterior rim, noncomminuted (14-B1.1)
2. Anterior rim, comminuted (14-B1.2)
B1
Posterior rim (14-B2) 1. Posterior rim, noncomminuted (14-B2.1)
2. Posterior rim, comminuted (14-B2.2)
B2
Inferior rim (14-B3) 1. Inferior rim, noncomminuted (14-B3.1)
2. Inferior rim, comminuted (14-B3.2)
B3
S70
Scapula
Subgoups: Scapula extra-articular (glenoid) (14-C) Extra-articular glenoid neck (14-C1) 1. Extra-articular glenoid neck, noncomminuted (14-C1.1)
2. Extra-articular glenoid neck, comminuted (14-C1.2)
C1
Intra-articular with neck (14-C2) 2. Intra-articular with neck, commin1. Intra-articular with neck, articular noncomminuted, neck noncomminuted uted, articular noncomminuted (14-C2.2) (14-C2.1)
3. Intra-articular with glenoid neck, articular comminuted (14-C2.3)
C2
Intra-articular with body (14-C3)
C3
S71
CLAVICLE
BONE: CLAVICLE (15)
Location: Medial end (15-A) Type: A. Clavicle, medial end (15-A)
Location: Diaphysis (15-B) Type: B. Clavicle, diaphysis (15-B)
Location: Lateral end (15-C) Type: C. Clavicle, lateral end (15-C)
Group: Clavicle, medial end (15-A) 1. Extra-articular (15-A1)
Clavicle, diaphysis (15-B) 1. Simple (15-B1)
Clavicle, lateral end (15-C) 1. Extra-articular (15-C1)
2. Intra-articular (15-A2)
2. Wedge (15-B2)
2. Intra-articular (15-C2)
3. Comminuted (15-A3)
3. Complex (15-B3)
Note for clavicle: There are no subgroups of A.
S72
Clavicle
BONE: CLAVICLE
Location: Diaphysis (15-B)
Groups: Clavicle, diaphysis, noncomminuted (15-B1) Subgroups: 1. Spiral (15-B1.1)
Clavicle, diaphysis, wedge (15-B2) 1. Spiral wedge (15-B2.1)
Clavicle, diaphysis, segmental (15-B3) 1. Spiral (15-B3.1)
2. Oblique (15-B1.2)
2. Bending wedge (15-B2.2)
2. 2 transverse (15-B3.2)
3. Transverse (15-B1.3)
3. Comminuted (15-B2.3)
3. Complex comminuted (15-B3.3)
S73
Clavicle
BONE: CLAVICLE
Location: Lateral end (15-C)
Groups: Clavicle, lateral end, extra-articular (15-C1)
Clavicle, lateral end, intra-articular (15-C2)
Subgroups: 1. Impacted (C-C ligament intact) (15-C1.1)
1. With slight displacement (C-C ligament intact) (15-C2.1)
2. Noncomminuted (C-C ligament disrupted) (15-C1.2)
2. Noncomminuted (C-C ligament disrupted) (15-C2.2)
3. Comminuted (C-C ligament disrupted) (15-C1.3)
3. Comminuted (C-C ligament disrupted) (15-C2.3)
S74
HAND AND CARPUS
AREA: HAND AND CARPUS (71-79)
Bones: Lunate (71)
Scaphoid (72)
Capitate (73)
Hamate (74)
Ulnar carpal bones (75)
Radial carpal bones (76)
Metacarpals (77)
Phalanges (78)
Multiple hand and carpal fractures (79) A. Carpal (79-A) B. Metacarpal (79-B) C. Phalanges (79-C)
S75
Hand and Carpus
Location: Carpus (71-76) Types: A. Noncomminuted B. Comminuted Lunate (71) A. Noncomminuted (71-A) B. Comminuted (71-B)
Scaphoid (72) A. Noncomminuted (72-A) 1. Proximal Pole (72-A1) B. Comminuted (72-B) 1. Proximal Pole (72-B1)
2. Waist (72-A2)
2. Waist (72-B2)
3. Distal pole (72-A3)
3. Distal Pole (72-B3)
Capitate (73) A. Noncomminuted (73-A) B. Comminuted (73-B)
S76
J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Hamate (74) A. Noncomminuted (74-A) B. Comminuted (74-B)
Hand and Carpus
Ulnar carpal bones (75) A. Noncomminuted (75-A) 1. Pisiform (75-A1) 2. Triquetrum (75-A2) B. Comminuted (75-B) 1. Pisiform (75-B1) 2. Triquetrum (75-B2)
Radial carpal bones (76) A. Noncomminuted (76-A) 1. Trapezium (76-A1) 2. Trapezoid (76-A2) B. Comminuted (76-B) 1. Trapezium (76-B1) 2. Trapezoid (76-B2)
S77
METACARPALS
BONE: METACARPALS (77) Modifiers for metacarpals: T, thumb; I, index; M, middle; R, ring; L, little.
Location: Metacarpals (77)
Types: A. Metacarpal proximal and distal nonarticular and diaphysis noncomminuted (77-A)
B. Metacarpal proximal and distal partial articular diaphysis wedge comminution (77-B)
C. Metacarpal proximal and distal complete articular diaphysis comminuted (77-C)
Groups: 1. Metacarpal, 2. Metaproximal extra- carpal, diapharticular (77-A1) ysis noncomminuted (77-A2)
3. Metacarpal, distal extraarticular (77-A3)
2. Metacarpal, 1. Metacarpal, proximal partial diaphysis articular (77-B1) wedge (77-B2)
3. Metacarpal, distal partial articular (77-B3)
1. Metacarpal, proximal complete articular (77-C1)
2. Metacarpal, diaphysis comminuted (77-C2)
3. Metacarpal, distal complete articular (77-C3)
S78
Metacarpals
Subgroups and Qualifications: Metacarpal, proximal extra-articular (77-A1) 2. Comminuted (77-A1.2) 1. Noncomminuted (77-A1.1) (1) wedge (2) complex
A1
Metacarpal, diaphysis noncomminuted (77-A2) 1. Spiral (77-A2.1) 2. Oblique (77-A2.2)
A2
Metacarpal, distal extra-articular (77-A3) 1. Noncomminuted (77-A3.1) 2. Comminuted (77-A3.2)
A3
S79
Metacarpals
Metacarpal, proximal partial articular (77-B1) 2. Depression (77-B1.2) 1. Avulsion OR Split (77-B1.1) (1) unicondyle medial (2) unicondyle lateral (3) coronal split volar fragment (4) coronal split dorsal fragment
3. Split/depression (77-B1.3) (1) unicondyle medial (2) unicondyle lateral (3) coronal split volar fragment (4) coronal split dorsal fragment
B1
Metacarpal, diaphysis wedge (77-B2) 1. Spiral (77-B2.1)
2. Bending (77-B2.2)
B2
Metacarpal, distal partial articular (77-B3) 1. Avulsion OR Split (77-B3.1) 2. Depression (77-B3.2) (1) unicondyle medial (2) unicondyle lateral (3) coronal split volar fragment (4) coronal split dorsal fragment
B3
S80
Metacarpals
Metacarpal, proximal articular (77-C1) 1. Noncomminuted articular and metaphysis (77-C1.1)
2. Noncomminuted articular, comminuted metaphysis (77-C1.2)
3. Comminuted articular (77-C1.3)
C1
Metacarpal, diaphysis comminuted (77-C2) 2. Complex comminuted (77-C2.2) 1. Segmental (77-C2.1)
C2
Metacarpal, distal articular (77-C3) 1. Simple articular/metaphysis (77-C3.1)
2. Simple articular/comminuted metaphysis (77-C3.2)
C3
S81
PATELLA
BONE: PATELLA (34)
Location: Patella (34)
Types: A. Patella extra-articular (34-A)
B. Partial articular, vertical (34-B)
C. Complete articular, non-vertical (34-C)
Groups: Patella, extra-articular (34-A) 1. Patella, extra- 2. Patella, extra-articuarticular, avulsion (34-A1) lar isolated body (34-A2)
Patella, partial articular, vertical (34-B) 2. Patella, partial 1. Patella, partial articular, vertical, articular, vertical, medial (34-B2) lateral (34-B1)
Patella, complete 1. Patella, articular, transverse (34-C1)
articular, non-vertical (34-C) 2. Patella, ar3. Patella, articular, transticular, comverse plus minuted second frag(34-C3) ment (34-C2)
Note for patella: There are no subgroups of A.
S86
Patella
Patella, partial articular, vertical, lateral (34-B1) 2. Comminuted (34-B1.2) 1. Noncomminuted (34-B1.1)
B1
Patella, partial articular, vertical, medial (34-B2) 2. Comminuted (34-B2.2) 1. Noncomminuted (34-B2.1)
B2
S87
Patella
Patella, complete articular, transverse (34-C1) 2. Proximal (34-C1.2) 1. Middle (34-C1.1)
3. Distal (34-C1.3)
C1
Patella, articular, transverse plus second fragment (34-C2) 2. Proximal (34-C2.2) 1. Middle (34-C2.1)
3. Distal (34-C2.3)
C2
Patella, articular, complex (34-C3) 1. With 3 fragments (34-C3.1)
2. More than 3 fragments (34-C3.2)
C3
S88
PHALANX - HAND
BONE: PHALANX (78) Modifiers for phalanx: T1 and T2, thumb 1/2; N1, N2 and N3, index 1/2/3; M1, M2 and M3, middle 1/2/3; R1, R2 and R3, ring 1/2/3; L1, L2 and L3, little 1/2/3.
Location: Phalanx (78)
Types: A. Phalanx proximal and distal extra-articular and diaphysis noncomminuted (78-A)
B. Phalanx proximal and distal partial articular and diaphysis wedge comminution (78-B)
C. Phalanx proximal and distal complete articular and diaphysis comminuted (78-C)
Groups: 1. Phalanx, 2. Phalanx diproximal extra- aphysis, nonarticular (78-A1) comminuted (78-A2)
3. Phalanx, distal extra-articular (78-A3)
2. Phalanx, 1. Phalanx, proximal partial diaphysis articular (78-B1) wedge (78-B2)
3. Phalanx, distal partial articular (78-B3)
1. Phalanx, proximal complete articular (78-C1)
2. Phalanx, diaphysis comminuted (78-C2)
3. Phalanx, distal complete articular (78-C3)
S82
Phalanx - Hand
Subgroups and Qualifications: Phalanx, proximal extra-articular (78-A1) 1. Noncomminuted (78-A1.1)
2. Comminuted (78-A1.2)
A1
Phalanx diaphyseal noncomminuted (78-A2) 1. Spiral (78-A2.1) 2. Oblique (78-A2.2)
A2
Phalanx, distal extra-articular (78-A3) 1. Spiral noncomminuted (78-A3.1)
A3
S83
Phalanx - Hand
Phalanx, proximal partial articular (78-B1) 2. Depression (78-B1.2) 1. Avulsion OR Split (78-B1.1) (1) unicondyle medial (2) unicondyle lateral (3) coronal split volar fragment (4) coronal split dorsal fragment
B1
Phalanx, diaphysis wedge (78-B2) 1. Spiral (78-B2.1)
3. Fragmented (78-B2.3)
B2
Phalanx, distal partial articular (78-B3) 1. Avulsion OR Split (78-B3.1) (1) unicondyle medial (2) unicondyle lateral (3) coronal split volar fragment (4) coronal split dorsal fragment
2. Depression (78-B3.2)
B3
S84
Phalanx - Hand
Phalanx, proximal complete articular (78-C1) 2. Noncomminuted articular/commin1. Noncomminuted articular/ uted metaphysis (78-C1.2) metaphysis (78-C1.1)
3. Comminuted articular and metaphysis (78-C1.3)
C1
Phalanx, diaphysis comminuted (78-C2) 1. Segmental (78-C2.1)
2. Complex comminuted (78-C2.2)
C2
Phalanx, distal articular (78-C3) 1. Noncomminuted articular/metaphysis (78-C3.1)
2. Noncomminuted articular/comminuted metaphysis (78-C3.2)
C3
S85
FOOT
AREA: FOOT (81-89)
Bones: Talus (81)
Calcaneus (82)
Navicular (83)
Cuboid (84)
Cuneiforms (85)
Metatarsals (87)
Phalanges (88)
Crush, multiple foot fractures (89) A. Hind Foot (89-A) B. Midfoot (89-B) C. Forefoot (89-C)
Note for foot: To stay as consistent with hand as possible, there are no bones coded for 86 allowing metacarpals and metatarsals and hand and foot phalanges each to be coded with the same last digit.
S89
Foot
Location: Foot (81-85)

BONE: TALUS (81)
Types: A. Avulsion or process or head fractures (81-A)
B. Neck fractures (81-B)
C. Body fractures (81-C)
Groups: Talus avulsions process, or head fractures (81-A) 3. Head frac2. Process 1. Avulsions tures (without (81-A2) (81-A1) neck fracture) (81-A3)
Neck fractures (81-B) 1. Nondisplaced 2. Displaced with subluxa(81-B1) tion of subtalar joint (81-B2)
3. Displaced with subluxation of subtalar and ankle joints (81-B3)
Body fractures (81-C) 2. Subtalar 1. Ankle joint joint involveinvolvment, dome fractures ment (81-C2) (81-C1)
3. Ankle and subtalar joint involvement (81-C3)
S90

Groups: Talus avulsions, process or head fractures (81-A) 1. Avulsions (81-A1) 1. Anterior (81-A1.1)
Foot
2. Process (81-A2) 1. Lateral (81-A2.1)
3. Head fractures (without neck fracture) (81-A3) 1. Noncomminuted (81-A3.1)
A
2. Other (81-A1.2) 2. Posterior (81-A2.2) 2. Comminuted (81-A3.2)
Groups: Neck fractures (81-B) 1. Nondisplaced (81-B1)
2. Displaced with subluxation of subtalar joint (81-B2) 1. Noncomminuted (81-B2.1)
3. Displaced with subluxation of subtalar and ankle joints (81-B3) 1. Noncomminuted (81-B3.1)
3. Involves talar head (81-B2.3)
3. Involves talar head (81-B3.3)
Groups: Body fractures (81-C) 1. Ankle joint involvement, dome fractures (81-C1) 2. Subtalar joint involvement (81-C2) 1. Noncomminuted (81-C2.1) 1. Noncomminuted (81-C1.1)
3. Ankle and subtalar joint involvement (81-C3) 1. Noncomminuted (81-C3.1)
2. Comminuted (81-C1.2)
S91
Foot
Location: Foot (81-85)
BONE: CALCANEUS (82)
Types: A. Avulsion or process or tuberosity (82-A)
B. Nonarticular body fractures (82-B)
C. Articular fractures involving posterior facet (82-C)
S92
Foot
Groups: Avulsion or process or tuberosity (82-A) 1. Anterior process (82-A1) 1. Noncomminuted (82-A1.1)
2. Medial, sustentaculum (82-A2) 1. Noncomminuted (82-A2.1)
3. Tuberosity (82-A3) 1. Noncomminuted (82-A3.1)
Groups: Nonarticular body fractures (82-B) 1. Noncomminuted (82-B1)
2. Comminuted (82-B2)
Groups: Articular fractures involving posterior facet (82-C) 1. Nondisplaced (82-C1)
2. 2-part fractures (82-C2)
3. 3-part fractures (82-C3)
4. 4 or more parts (82-C4)
S93
Foot
BONE: NAVICULAR (83) Types: A. Noncomminuted (83-A) B. Comminuted (83-B)
BONE: CUBOID (84) Types: A. Noncomminuted (84-A) B. Comminuted (84-B)
BONE: CUNEIFORM (85) Types: A. Noncomminuted (85-A) 1. Medial (85-A1) 2. Middle (85-A2) 3. Lateral (85-A3) B. Comminuted (85-B) 1. Medial (85-B1) 2. Middle (85-B2) 3. Lateral (85-B3)
CRUSH, MULTIPLE FRACTURES (89) Types: A. Hind Foot (89-A) B. Midfoot (89-B) C. Forefoot (89-C)
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METATARSALS
BONE: METATARSALS (87) Modifiers for metatarsals: T, thumb toe (great) (1); I, index toe (2); L, long toe (3); R, ring toe (4); S, small toe (5).
Location: Metatarsals (87)
Types: 1. Metatarsal proximal and distal nonarticular and diaphysis noncomminuted (87-A)
2. Metatarsal proximal and distal partial articular diaphysis wedge comminution (87-B)
3. Metatarsal proximal and distal complete articular diaphysis comminuted (87-C)
Groups: 1. Metatarsal, 2. Metatarsal, proximal extra- diaphysis articular (87-A1) noncomminuted (87-A2)
3. Metatarsal, distal extraarticular (87-A3)
2. Metatarsal, 1. Metatarsal, proximal partial diaphysis articular (87-B1) wedge (87-B2)
3. Metatarsal, distal partial articular (87-B3)
1. Metatarsal, proximal complete articular (87-C1)
2. Metatarsal, diaphysis comminuted (87-C2)
3. Metatarsal, distal complete articular (87-C3)
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Metatarsals
Subgroups and Qualifications: Metatarsal, proximal extra-articular (87-A1) 2. Comminuted (87-A1.2) 1. Noncomminuted (87-A1.1) (1) wedge (2) complex
A1
Metatarsal, diaphysis noncomminuted (87-A2) 1. Spiral (87-A2.1) 2. Oblique (87-A2.2)
A2
Metatarsal, distal extra-articular (87-A3) 1. Noncomminuted (87-A3.1)
A3
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J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Metatarsal, proximal partial articular (87-B1) 2. Depression (87-B1.2) 1. Avulsion OR Split (87-B1.1) (1) unicondyle medial (2) unicondyle lateral (3) coronal split volar fragment (4) coronal split dorsal fragment
Metatarsals
B1
Metatarsal, diaphysis wedge (87-B2) 1. Spiral (87-B2.1)
3. Comminuted wedge (87-B2.3)
B2
Metatarsal, distal partial articular (87-B3) 1. Avulsion OR Split (87-B3.1) 2. Depression (87-B3.2) (1) unicondyle medial (2) unicondyle lateral (3) coronal split volar fragment (4) coronal split dorsal fragment
B3
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Metatarsals
Metatarsal, proximal articular (87-C1) 1. Noncomminuted articular and metaphysis (87-C1.1)
2. Noncomminuted articular, comminuted metaphysis (87-C1.2)
C1
Metatarsal, diaphysis Comminuted (87-C2) 2. Complex comminuted (87-C2.2) 1. Segmental (87-C2.1)
C2
Metatarsal, distal articular (87-C3) 1. Simple articular/metaphysis (87-C3.1)
2. Simple articular/comminuted metaphysis (87-C3.2)
C3
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PHALANX - FOOT
BONE: PHALANX (88) Modifiers for phalanx: T1 and T2, thumb toe 1/2; N1, N2 and N3, index toe 1/2/3; M1, M2 and M3, middle toe 1/2/3; R1, R2 and R3, ring toe 1/2/3; L1, L2 and L3, little toe 1/2/3. Location: Phalanx (88)
Types: A. Phalanx proximal and distal extraarticular and diaphysis noncomminuted (88-A)
B. Phalanx proximal and distal partial articular and diaphysis wedge comminution (88-B)
C. Phalanx proximal and distal complete articular and diaphysis comminuted (88-C)
Groups: 1. Phalanx, 2. Phalanx diproximal extra- aphysis, nonarticular (88-A1) comminuted (88-A2)
3. Phalanx, distal extra-articular (88-A3)
2. Phalanx, 1. Phalanx, proximal partial diaphysis articular (88-B1) wedge (88-B2)
3. Phalanx, distal partial articular (88-B3)
1. Phalanx, proximal complete articular (88-C1)
2. Phalanx, diaphysis comminuted (88-C2)
3. Phalanx, distal complete articular (88-C3)
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Phalanx - Foot
Subgroups and Qualifications: Phalanx, proximal extra-articular (88-A1) 1. Noncomminuted (88-A1.1)
A1
Phalanx, diaphyseal noncomminuted (88-A2) 2. Oblique (88-A2.2) 1. Spiral (88-A2.1)
A2
Phalanx, distal extra-articular (88-A3) 1. Noncomminuted (88-A3.1)
A3
S100
Phalanx - Foot
Phalanx, proximal partial articular (88-B1) 2. Depression (88-B1.2) 1. Avulsion OR Split (88-B1.1) (1) unicondyle medial (2) unicondyle lateral (3) coronal split volar fragment (4) coronal split dorsal fragment
B1
Phalanx, diaphysis wedge (88-B2) 1. Spiral (88-B2.1)
3. Fragmented (88-B2.3)
B2
Phalanx, distal partial articular (88-B3) 1. Avulsion OR Split (88-B3.1) (1) unicondyle medial (2) unicondyle lateral (3) coronal split volar fragment (4) coronal split dorsal fragment
2. Depression (88-B3.2)
B3
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Phalanx - Foot
Phalanx, proximal complete articular (88-C1) 2. Noncomminuted articular/commin1. Noncomminuted articular/ uted metaphysis (88-C1.2) metaphysis (88-C1.1)
3. Comminuted articular and metaphysis (88-C1.3)
C1
Phalanx, diaphysis comminuted (88-C2) 1. Segmental (88-C2.1)
2. Complex comminuted (88-C2.2)
C2
Phalanx, distal articular (88-C3) 1. Noncomminuted articular/metaphysis (88-C3.1)
2. Noncomminuted articular comminuted metaphysis (88-C3.2)
C3
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DISLOCATIONS
Practical suggestions for the application of the OTA dislocation classification system. General principles. Although there are many different ways in which dislocations can be classified, the OTA dislocation classification system is based primarily upon the basic tenets of identification of the exact joint involved and the direction of the distal bone relative to the proximal bone. These two basic principles of classification are applicable throughout the skeletal system. The ligaments that are disrupted in each dislocation can be inferred from the classification but is not a specific component of the classification process. Fracture-dislocations are generally assigned 2 separate codes, 1 for the fracture (bone) and 1 for the dislocation (joint). In general, the first digit of the numerical code represents the body part and the second digit of the numerical code is 0 for dislocation. For example, 30 represents a hip dislocation with 3 indicating thigh and 0 dislocation of the hip (femoral-acetabular) joint. The third place (A,B,C,D and E) is utilized when there are more than 2 bones in the anatomic region and hence more than 1 joint. Each specific 2 bone joint is assigned a third place designation (eg, knee joint 40-A is tibiofemoral and 40-B is patellofemoral). In general, the dislocations are subclassified by the direction the distal bone is positioned relative to the proximal bone at the time of dislocation. In most instances, the subtypes are 1, 2, 3, 4 and 5: 1 = anterior, 2 = posterior, 3 = lateral, 4 = medial, and 5 = other. For example, 40 refers to dislocations about the knee with 40-A1 being an anterior dislocation of the knee joint (with the tibia anterior to the femur). The designation of other is used for various situations including spontaneous reduction of a presumed dislocation where the direction is not known (eg, a knee injury with disruption of the ACL and PCL but with the presentation radiographs demonstrating a reduced knee joint is 40A5). This other or 5 category is also used when direction of the dislocation does not meet the standard 4 anatomic directions (eg, 10-A5 for inferior dislocation of the shoulder or luxatio erecta). Some dislocations were included in the long bone fracture classification (eg, forearm), and there is the potential for more than 1 code to be appropriate for a given injury.
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Dislocations
DISLOCATION REGION: Shoulder (10)
Types by joint involved:
A. Glenohumeral (10-A)
B. Acromioclavicular (10-B)
C. Sternoclavicular (10-C)
D. Scapulothoracic (10-D)
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Dislocations
A. Glenohumeral (10-A)
Groups by direction: 1. Anterior (10-A1) 2. Posterior (10-A2)
3. Lateral (theoretical) (10-A3)
4. Medial (theoretical) (10-A4)
5. Other (inferior-luxatio erecta) (10-A5)
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Dislocations
B. Acromioclavicular (10-B)
Groups by direction: 1. Anterior (theoretical) (10-B1) 2. Posterior (10-B2) 3. Superior (10-B3) 4. Inferior (10-B4) 5. Other (10-B5)
Subgroups of 10-B3 by severity of displacement: 1. Grade 1 sprain (10-B3.1) 2. Grade 2, partial displacement (10-B3.2) 3. Grade 3, 100% displacement (10-B3.3) 4. Grade 4, grade 3 plus deltoid origin detached from clavicle (10-B3.4)
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Dislocations
C. Sternoclavicular (10-C)
Groups by direction: 1. Anterior (10-C1) 2. Posterior (10-C2) 3. Lateral (theoretical) (10-C3) 4. Medial (theoretical) (10-C4) 5. Other (10-C5)
D. Scapulothoracic (10-D)
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Dislocations
DISLOCATION REGION: Elbow (20):
Types by joint involved: A. Ulnohumeral with radiohumeral* (20-A) B. Isolated radiohumeral (20-B) C. Distal radioulnar dislocation (20-C) D. Other (20-D)
Notes for classification of elbow dislocations: * For the purposes of elbow dislocation the radiohumeral joint is presumed to be dislocated as well as the ulnohumeral joint with the radius going in the same direction as the ulna for types 20-A120-A4 and in different directions in 20-A5. 20-B is reserved for radiohumeral dislocations in which the ulnohumeral articulation is not dislocated. Monteggia fracture dislocations should be coded as 20-B plus 22-A1, B1 or C1 (ulna shaft). Galeazzi fracture dislocations should be coded as 20-C plus 22-A2, B2 or C2 (radial shaft) 20-C (distal radioulnar dislocations) used here rather than 70 to remain consistent with the lower extremity where 40-C and 40-D are used for proximal and distal tibiofibular dislocations. Isolated proximal radioulnar dislocations (20-C) probably do not occur but 20-D could be used. The long bone classification system also identifies alternative codes for some fracture dislocations in this anatomic region and the codes 22-A3, 22-B3 and 22-C3 represent an alternative way to classify these injuries. With the 2007 version of the classification system we generally recommend that fractures and dislocations be separately coded.
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Dislocations
A. Ulnohumeral (20-A)
Groups by direction: 1. Anterior (20-A1) 2. Posterior (20-A2) 3. Medial (20-A3) 4. Lateral (20-A4) 5. Divergent (20-A5)
B. Radiohumeral (20-B)
Groups by direction: 1. Anterior (20-B1) 2. Posterior (20-B2) 3. Medial (20-B3) 4. Lateral (20-B4)
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Dislocations
C. Distal radioulnar dislocations (20-C)
Groups by direction: 1. Anterior (volar) (20-C1) 2. Posterior (dorsal) (20-C2) 3. Other (20-C3)
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Dislocations
DISLOCATION REGION: Spine dislocation (50) Types by area of spine: A. Cervical (50-A) B. Thoracic (50-B) C. Lumbar (50-C)
Groups: Name the levels starting at Occiput-C1 Occiput-C1 dislocation (50-A1) C1-C2 (50-A2) C2-3 (50-A3) C3-4 (50-A4) C4-5 (50-A5) C5-6 (50-A6) C6-7 (50-A7)
C7-T1 dislocation (50-B1) T1-2 (50-B2) T2-3 (50-B3) T3-4 (50-B4) T4-5 (50-B5) T5-6 (50-B6) T6-7 (50-B7) T7-8 (50-B8) T8-9 (50-B9) T9-10 (50-B10) T10-11 (50-B11) T11-12 (50-B12)
T12-L1 dislocation (50-C1) L1-2 (50-C2) L2-3 (50-C3) L3-4 (50-C4) L4-5 (50-C5) L5-S1 dislocation (50-C6)
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Dislocations
DISLOCATION REGION: Hip (30):
Types by joint involved: Hip joint (30-A)
Groups by direction: 1. Anterior (30-A1) 2. Posterior (30-A2) 3. Medial or central (30-A3) 4. Obturator (30-A4) 5. Other (30-A5)
Notes for classification of hip dislocations: A dislocation associated with an acetabular wall fracture should be coded with a fracture code (62) AND a dislocation code 30-A. It is left to the discretion of the coder to decide what constitutes a 30-A3 which is necessarily associated with a displaced fracture of the central acetabulum. Although commonly referred to as a medial or central dislocation of the hip, the 30-A3 injury is a particular pattern of fracture displacement rather than a true dislocation. It is left to the discretion of the coder to decide when, if ever, to utilize 30-A3 in addition to the fracture code (62). There are no current injury patterns appropriate for 30-B designation.
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Dislocations
DISLOCATION REGION: Knee (40)
Types by joint involved: A. Tibiofemoral (40-A) B. Patellofemoral (40-B) C. Tibiofibular (proximal) (40-C) D. Tibiofibular (distal) (40-D)
Notes for classification of knee dislocations: The classification committee recognizes that distal tibiofibular dislocations are NOT knee dislocations but they fit well here and ARE dislocations associated with the leg bone segment 4. Distal tibiofibular dislocations (as well as DRUJ) could reasonably be moved to 80 foot and ankle dislocations (and DRUJ to 70 wrist and hand dislocations). However, those segments already have many codes because there are so many joints in these body parts with small bones. Therefore for practical and consistency reasons distal tibiofibular dislocations are assigned to the 40 section. Knee dislocations in which the direction is unknown, for example bicruciate ligament tears, should be coded as 40-A5 (other) Quadriceps and patellar tendon tears can be coded as patellofemoral dislocations 40-B1 and 40-B2. The patella is considered the more distal bone for 40-B. The fibula is considered the more distal bone for tibiofibular dislocations.
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Dislocations
A. Tibiofemoral (40-A)
Groups by direction: 1. Anterior (40-A1) 2. Posterior (40-A2) 3. Medial (40-A3) 4. Lateral (40-A4) 5. Other (40-A5)
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Dislocations
B. Patellofemoral (40-B)
Groups by direction of the patella: 1. Distal (quadriceps tendon disruption) (40-B1) 2. Proximal (patellar tendon disruption) (40-B2)
3. Medial patellofemoral dislocation (40-B3)
4. Lateral patellofemoral dislocation (40-B4)
5. Other (40-B5)
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Dislocations
C. Proximal tibiofibular dislocation (40-C)
Groups by direction: 1. Anterior (40-C1) 2. Posterior (40-C2) 3. Lateral (40-C3) 4. Medial (40-C4) 5. Other (40-C5)
Subgroups of 40-C5: 1. Superior (40-C5.1) 2. Inferior (40-C5.2)
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Dislocations
D. Distal tibiofibular dislocation (40-D)
Groups by the direction of the fibula: 1. Anterior (40-D1) 2. Posterior (40-D2) 3. Lateral (40-D3) 4. Other (40-D5)
Subgroups of 40-D5: 1. Superior (40-D5.1) 2. Inferior (40-D5.2)
S117
Dislocations
DISLOCATION REGION: Pelvic dislocation (60)
Types by joint involved: A. Sacroiliac right (60-A) B. Sacroiliac left (60-B) C. Symphysis pubis (60-C)
Groups by direction: A. Sacroiliac right (60-A) 1. Anterior (60-A1) 2. Posterior (60-A2) 3. Lateral (60-A3) 4. Other (eg proximal) (60-A4)
Notes for classification of pelvic dislocations: Because pubic diastasis and sacroiliac (SI) joint dislocations and fracture dislocations are such an integral component of pelvic ring disruption, pelvic fracture codes (61), the 60 codes are restricted to pure dislocations without fracture. 61 codes are to be used for fracture dislocations or pelvic ring injuries that include fractures AND SI or symphysis disruptions. Therefore the following: 60 codes are for pure dislocations. Pelvic ring disruptions with fractures (with or without SI and symphysis joint injuries) should be classified by the 61 codes. Each joint should be coded separately. Thus a single patient with pure dislocations (no fractures) of both SI joints and the pubic symphysis would be coded 60-B2 (left SI posterior dislocation), 60-A1 (right SI dislocation with ilium anteriorly displaced) and 60-C3 (pubic symphysis dislocation with the right side displaced proximal to the left).
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Dislocations
B. Sacroiliac left (60-B) 1. Anterior (60-B1) 2. Posterior (60-B2) 3. Lateral (60-B3) 4. Other (eg proximal) (60-B4)
C. Symphysis pubis (60-C) 1. Right side anterior (60-C1) 2. Right side posterior (60-C2) 3. Right side proximal (60-C3)
4. Right side distal (60-C4)
5. Open or wide (60-C5)
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Dislocations
DISLOCATION REGION: Hand and Wrist (70)
Types by area or joints involved: A. Radiocarpal (70-A) B. Intercarpal (70-B) C. Carpal-metacarpal (70-C) D. Phalanx (70-D)
Carpal bones
Notes for classification of wrist and hand dislocations: Distal radioulnar dislocations are classified under section 20-D. The classification is designed to be as consistent as possible between hand and foot. The designation of 9 in the fourth digit is available to code multiple injuries to the small bones and joints of the foot, hand and wrist and are available to coders desiring a more general level of specificity. If more specific designation is desired, then individual codes can be applied to each specific dislocation. There are no subgroups of 70-B. If there is associated fracture, use fracture code in addition to dislocation code.
S120
Dislocations
A. Radiocarpal (wrist joint) (70-A)
Groups by direction of the distal fragment: 1. Anterior (volar) (70-A1) 2. Posterior (dorsal) (70-A2) 3. Radial (70-A3) 4. Ulnar (70-A4) 5. Other (70-A5)
B. Intercarpal dislocations (70-B)
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Dislocations
C. Carpal-metacarpal joints (70-C)
Groups by joint involved radial to ulnar:
1. 1st metacarpal-trapezial dislocation (70-C1)
2. 2nd metacarpal-trapezium dislocation (70-C2)
3. 3rd metacarpal capitate dislocation (70-C3)
4. 4th metacarpal hamate dislocation (70-C4)
5. 5th metacarpal triquetrum dislocation (70-C5)
6. Multiple carpal-metacarpal dislocations (70-C9)
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Dislocations
D. Phalangeal dislocations (70-D)
Groups by level involved: 1. Metacarpal phalangeal (70-D1) 2. Proximal interphalangeal (70-D2) 3. Distal interphalangeal (70-D3)
4. Sesamoid dislocation (70-D4)
5. Multiple finger dislocations (70-D9)
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Dislocations
1. Metacarpal phalangeal joint (70-D1) Subgroups by joint involved radial to ulnar: 1. 1st metacarpal phalangeal joint (70-D1.1) 2. 2nd metacarpal phalangeal joint (70-D1.2) 3. 3rd metacarpal phalangeal joint (70-D1.3) 4. 4th metacarpal phalangeal joint (70-D1.4) 5. 5th metacarpal phalangeal joint (70-D1.5)
2. Proximal interphalangeal joint (70-D2) Subgroups by joint involved radial to ulnar: 1. Thumb (1st) (70-D2.1) 2. Index (2nd) (70-D2.2) 3. Long (3rd) (70-D2.3) 4. Ring (4th) (70-D2.4) 5. Small (5th) (70-D2.5)
3. Distal interphalangeal joint (70-D3) Subgroups by joint involved radial to ulnar: 1. None 2. Index (2nd) (70-D3.2) 3. Long (3rd) (70-D3.3) 4. Ring (4th) (70-D3.4) 5. Small (5th) (70-D3.5)
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Dislocations
DISLOCATION REGION: Foot and Ankle (80)
Types by area or joint involved: A. Ankle (talotibial) (80-A) B. Hindfoot (subtalar) (80-B) C. Midfoot (80-C) D. Forefoot (80-D)
A. Ankle (80-A)
Groups by direction: 1. Anterior (80-A1) 2. Posterior (80-A2) 3. Medial (80-A3) 4. Lateral (80-A4) 5. Other (80-A5)
Notes for classification of foot and ankle dislocations: Distal tibiofibula dislocations are classified under section 40-D. Talar neck fracture classification is intimately related to associated dislocations and therefore are included in the fracture codes for talus (81). 2007 Lippincott Williams & Wilkins
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Dislocations
B. Subtalar (80-B)
Groups by direction: 1. Anterior (80-B1) 2. Posterior (80-B2) 3. Medial (80-B3) 4. Lateral (80-B4) 5. Other (80-B5)
C. Midfoot (80-C)
Groups by joint involved: 1. Talonavicular (80-C1) 2. Calcaneocuboid (80-C2) 3. Navicular-cuneiform dislocation (80-C3)
4. Intercuneiform dislocation (80-C4)
5. Tarsal-metatarsal dislocation (80-C5)
6. Multiple midfoot dislocations (80-C9)
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Dislocations
Tarsal-metatarsal dislocation (80-C5) Subgroups by joint involved medial to lateral:
1st metatarsal medial cuneiform dislocation (80-C5.1)
2nd metatarsal second cuneiform dislocation (80-C5.2)
3rd metatarsal lateral cuneiform dislocation (80-C5.3)
4th metatarsal cuboid dislocation (80-C5.4)
5th metatarsal cuboid dislocation (80-C5.5)
6. multiple metatarsal-tarsal dislocations (80-C5.9)
Note. Subclassification by direction is not given specific codes.
D. Forefoot (80-D)
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Dislocations
Groups by level involved: 1. Metatarsal-phalangeal (80-D1) 2. Proximal interphalangeal (80-D2) 3. Distal interphalangeal (80-D3)
4. Sesamoid dislocation (any) (80-D4)
5. Multiple forefoot dislocations (80-D9)
1. Metatarsal-phalangeal joint (80-D1) Subgroups by joint medial to lateral: 1. 2. 3. 4. 5. 1st metatarsal phalangeal joint (80-D1.1) 2nd metatarsal phalangeal joint (80-D1.2) 3rd metatarsal phalangeal joint (80-D1.3) 4th metatarsal phalangeal joint (80-D1.4) 5th metatarsal phalangeal joint (80-D1.5)
2. Proximal interpahalangeal joint (80-D2) Subgroups by joint medial to lateral: 1. 1st toe (IP joint as there is no PIP in big toe) (80-D2.1) 2. 2nd toe (80-D2.2) 3. 3rd toe (80-D2.3) 4. 4th toe (80-D2.4) 5. 5th toe (80-D2.5)
3. Distal interphalangeal joint (80-D3) Subgroups by joint medial to lateral: 1. 2. 3. 4. 5. No code as there is no DIP in big toe 2nd toe (80-D3.2) 3rd toe (80-D3.3) 4th toe (80-D3.4) 5th toe (80-D3.5)
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SPINE
BONE: SPINE (5)
Location: Cervical (51)
Location: Thoracic (52)
Location: Lumbar (53)
Types: A. Compression injuries of the body (compressive forces) (5_-A)
B. Distraction injuries of the anterior and posterior elements (tensile forces) (5_-B)
C. Multidirectional injuries with translation affecting the anterior and posterior elements (axial torque causing rotation injuries) (5_-C)
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Spine
BONE: SPINE (5)
Types: A. Compression injuries of the body (compressive forces) (5_-A)
Groups: Vertebral body compression type (5_-A) 1. Impaction fractures (5_-A1)
2. Split fractures (5_-A2)
3. Burst fractures (5_-A3)
Subgroups and Qualifications: Vertebral body compression fractures, impaction injury (5_-A1) 1. End plate impaction (5_-A1.1) 2. Wedge impaction (5_-A1.2) 3. Vertebral body collapse (5_-A1.3)
Vertebral body compression fractures, split (5_-A2) 1. Sagittal (5_-A2.1) 2. Coronal (5_-A2.2) 3. Pincer (5_-A2.3)
Vertebral body compression burst fractures (5_-A3) 1. Incomplete burst (5_-A3.1) 2. Burst-split (5_-A3.2) 3. Complete burst (5_-A3.3)
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BONE: SPINE (5) B. Distraction injuries of the anterior and posterior elements (tensile forces) (5_-B)
Spine
Groups: Anterior or posterior element injury with distraction (5_-B) 1. Posterior disruption predominantly ligamentous (flexiondistraction injury) (5_-Bl)
2. Posterior disruption predominantly osseous (flexiondistraction injury) (5_-B2)
3. Anterior disruption through the disc (hyperextension-shear injury) (5_-B3)
Subgroups and Qualifications: Posterior disruption ligamentous (5_-B1) 1. With transverse disruption of the disc (5_-B1.1) 2. Vertebral body compression fracture (5_-B1.2)
Posterior disruption osseous (5_-B2) 1. Transverse bicolumn fracture (5_-B2.1) 2. With transverse disruption of the disc (5_-B2.2) 3. With vertebral body compression (5_-B2.3)
Anterior disruption through the disc (5_-B3) 1. Hyperextension-subluxation (5_-B3.1) 2. Hyperextension-spondylolysis (5_-B3.2) 3. Posterior dislocation (5_-B3.3)
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Spine
BONE: SPINE (5)
C. Multidirectional injuries with translation affecting the anterior and posterior elements (axial torque causing rotation injuries) (5_-C)
Groups: Anterior or posterior element injury with rotation (5_-C) 1. Rotational wedge, split, and burst fractures (5_-C1)
2. Flexion subluxation with rotation (5_-C2)
3. Rotational shear injuries (Holdsworth slice rotation fracture) (5_-C3)
Subgroups and Qualifications: Rotational wedge, split and burst fractures (5_-C1) 1. Rotational wedge fractures (5_-C1.1) 2. Rotational split fractures (5_-C1.2) 3. Rotational burst fractures (5_-C1.3)
Flexion subluxation with rotation (5_-C2) 1. Flexion-distraction injuries with rotation (5_-C2.1) 2. B2 with rotation (5_-C2.2) 3. Hyperextension-shear-rotation of spine (5_-C2.3)
Rotational shear injuries (5_-C3) 1. Slice (5_-C3.1) 2. Oblique (5_-C3.2)
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REFERENCES
1. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma. 1996:10 (Suppl 1):v-ix, 1154. 2. Mller ME, Nazarian S, Koch P, et al. The Comprehensive Classification of Fractures of Long Bones. Berlin, Germany: Springer-Verlag;1990. 3. Websters New Riverside University Dictionary. Boston, MA: Riverside Publishing; 1984:268. 4. Martin JS, Marsh JL. Current classification of fractures. Rationale and utility. Radiol Clin North Am. 1997;35:491506. 5. Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am. 1994;76: 11621166. 6. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 19681975. Clin Orthop Relat Res. 1979;138: 94104. 7. Siebenrock KA. Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus. J Bone Joint Surg Am. 1993;75:17511755. 8. Martin JS, Marsh JL, Bonar SK, et al. Assessment of the AO/ASIF fracture classification for the distal tibia. J Orthop Trauma. 1997;11: 477483. 9. Sidor ML, Zuckerman JD, Lyon T, et al. The Neer classification system for proximal humeral fractures. An assessment of interobserver reliability and intraobserver reproducibility. J Bone Joint Surg Am. 1993;75: 17451750. 10. Petrisor BA, Bhandari M, Orr RD, et al. Improving reliability in the classification of fractures of the acetabulum. Arch Orthop Trauma Surg. 2003;123:228233. 11. Kristiansen B, Andersen UL, Olsen CA, et al. The Neer classification of fractures of the proximal humerus. An assessment of interobserver variation. Skeletal Radiol. 1988;17:420422. 12. Bernstein J, Adler LM, Blank JE, et al. Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs. J Bone Joint Surg Am. 1996;78: 13711375. 13. Flikkil T, Nikkola-Sihto A, Kaarela O, et al. Poor interobserver reliability of AO classification of fractures of the distal radius. Additional computed tomography is of minor value. J Bone Joint Surg Br. 1998;80: 670672. 14. Humphrey CA, Dirschl DR, Ellis TJ. Interobserver reliability of a CTbased fracture classification system. J Orthop Trauma. 2005;19:616622. 15. Barker L, Anderson J, Chesnut R, et al. Reliability and reproducibility of dens fracture classification with use of plain radiography and reformatted computer-aided tomography. J Bone Joint Surg Am. 2006;88: 106112. 16. Dirschl DR, Adams GL. A critical assessment of factors influencing reliability in the classification of fractures, using fractures of the tibial plafond as a model. J Orthop Trauma. 1997;11:471476. 17. Parsons BO, Klepps SJ, Miller S, et al. Reliability and reproducibility of radiographs of greater tuberosity displacement. A cadaveric study. J Bone Joint Surg Am. 2005;87:5865. 18. Schipper IB, Steyerberg EW, Castelein RM, et al. Reliability of the AO/ASIF classification for pertrochanteric femoral fractures. Acta Orthop Scand. 2001;72:3641.
19. Walton NP, Harish S, Roberts C, et al. AO or Schatzker? How reliable is classification of tibial plateau fractures? Arch Orthop Trauma Surg. 2003;123:396398. 20. Andersen DJ, Blair WF, Steyers CM, et al. Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility. J Hand Surg [Am]. 1996:21:574582. 21. Swiontkowski MF, Sands AK, Agel J, et al. Interobserver variation in the AO/OTA fracture classification system for pilon fractures: is there a problem? J Orthop Trauma. 1997;11:467470. 22. Kreder HJ, Hanel DP, McKee M, et al. Consistency of AO fracture classification for the distal radius. J Bone Joint Surg Br. 1996;78:726731. 23. Craig WL 3rd, Dirschl DR. Effects of binary decision making on the classification of fractures of the ankle. J Orthop Trauma. 1998;12: 280283. 24. Kreder HJ, Hanel DP, McKee M, et al. Radiographic fracture assessments: which ones can we reliably make? J Orthop Trauma. 2000;14: 379385. 25. Follmann D, Wittes J, Cutler JA. The use of subjective rankings in clinical trials with an application to cardiovascular disease. Stat Med. 1992;11:427437; discussion 439454. 26. Oskam J, Kingma J, Klasen HJ. Interrater reliability for the basic categories of the AO/ASIFs system as a frame of reference for classifying distal radial fractures. Percept Mot Skills. 2001;92:589594. 27. Williams TM, Nepola JV, DeCoster TA, et al. Factors affecting outcome in tibial plafond fractures. Clin Orthop Relat Res. 2004;423:9398. 28. DeCoster TA, Willis MC, Marsh JL, et al. Rank order analysis of tibial plafond fractures: does injury or reduction predict outcome? Foot Ankle Int. 1999;20:4449. 29. Audig L, Bhandari M, Kellam J. How reliable are reliability studies of fracture classifications? A systematic review of their methodologies. Acta Orthop Scand. 2004;75:184194. 30. Kreder HJ, Hanel DP, McKee M, et al. X-ray film measurements for healed distal radius fractures. J Hand Surg [Am]. 1996;21:3139. 31. Buckwalter JA, Schumacher R, Albright JP, et al. The validity of orthopaedic in-training examination scores. J Bone Joint Surg Am. 1981; 63:10011006. 32. Barei DP, Nork SE, Mills WJ, et al. Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg Am. 2006;88:171321. 33. Audig L, Bhandari M, Hanson B, et al. A concept for the validation of fracture classifications. J Orthop Trauma. 2005;19:401406. 34. Slongo T, Audig L, Schlickewei W, et al. Development and validation of the AO pediatric comprehensive classification of long bone fractures by the Pediatric Expert Group of the AO Foundation in collaboration with AO Clinical Investigation and Documentation and the International Association for Pediatric Traumatology. J Pediatr Orthop. 2006;26:4349. 35. Audig L, Hunter J, Weinberg AM, et al. Development and evaluation process of a pediatric long-bone fracture classification proposal. Eur J Trauma. 2004;30:248254. 36. Slongo T, Audig L, Clavert JM, et al. The AO comprehensive classification of pediatric long-bone fractures: a web-based multicenter agreement study. J Pediatr Orthop. 2007;27:171180 37. Slongo T, Audig L, Lutz N, et al. Documentation of fracture severity with the AO classification of pediatric long-bone fractures. Acta Orthop. 2007;78:247253.
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PEDIATRIC LONG BONE FRACTURES
Fracture and Dislocation Classification Compendium for Children

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)1
Theddy F. Slongo, MD* and Laurent Audig, DVM,PhD on behalf of the AO Pediatric Classification Group
Research into the healing patterns of paediatric fractures assumes a common language that must be the prerequisite for comprehensive documentation as the basis for treatment and research. Th. Slongo, 2007
1
Original publications
Audig L, Hunter J, Weinberg A, Magidson J, Slongo T. Development and Evaluation Process of a Paediatric Long-Bone Fracture Classification Proposal. European Journal of Trauma. 2004;30:248254. Slongo T, Audig L, Schlickewei W, Clavert J-M, Hunter J. Development and Validation of the AO Pediatric Comprehensive Classification of Long Bone Fractures by the Pediatric Expert Group of the AO Foundation in Collaboration With AO Clinical Investigation and Documentation and the International Association for Pediatric Traumatology. Journal of Pediatric Orthopaedics. 2006;26:4349. Slongo T, Audig L, Clavert J-M, Nicolas L, Frick S, Hunter J. The AO Comprehensive Classification of Pediatric Long-bone Fractures: A Web-based Multicenter Agreement Study. Journal of Pediatric Orthopaedics. 2007;27:171180. Slongo T, Audig L, Lutz N, Frick S, Schmittenbecher P, Hunter J, Clavert J-M. Documentation of Fracture Severity with the AO Classification of Pediatric Long-bone Fractures. Acta Orthopaedica. 2007;78:247253.
Summary: The AO Pediatric Expert Group and the AO Pediatric Classification Group, in cooperation with the AO Investigation and Documentation Group introduce and present the first comprehensive classification of pediatric long bone fractures. The anatomy is related to the 4 long bones and their 3 segments defined as proximal (1), shaft (2) and distal (3). It is further described by the fracture subsegment recorded as epiphyseal (E), metaphyseal (M) and diaphyseal (D), whereby proximal and distal fractures are classified as E or M and shaft fractures are always D. The distinction between metaphyseal and diaphyseal fractures is achieved by localizing the center of fracture lines with regard to a square drawn over the respective growth plates. The morphology of the fracture is documented by a subsegment-specific child pattern code, a severity code as well as an additional code for displacement of specific fractures such as supracondylar fractures and radial heads. The classification process requires trained observers to read standard radiographic images. J Orthop Trauma 2007;21(Suppl.): S135-S160
INTRODUCTION
The need to compile a classification of pediatric fractures arises, on the one hand, from an obligation to perform quality control and, on the other hand, from a desire to pursue basic research in the form of prospective and retrospective studies. In contrast to adult fractures, the primary difficulty with regard to pediatric fractures is not their complexity or severity, but rather the phenomenon of growth. This is driven by mechanisms, still not fully understood, that may alter the course of healing depending on the fracture pattern and the age of the patient. Among these mechanisms, the epiphyseal cartilage is considered most distinctive. Any classification or documentation must do justice to the two phenomena of injury pattern and growth. The wellknown classifications of childrens fractures in the literature take into account only particular aspects of the bones, eg, the SalterHarris classification for epiphyseal fractures,1 Baumann,2 Gartland3 and L.v. Laer4 for supracondylar fractures or Judets classification for radial neck/head fractures,5 while other classifications have attempted to include all fracture patterns by simplifications.6 However, none of these classifications have been scientifically validated.7 In addition, no classification system is available for diaphyseal long bone fractures. To perform appropriate clinical data auditing (quality control) and well-documented studies, there is an inescapable need for a comprehensive classification of pediatric fractures. A documentation system for fractures in childhood based on the AO classification for adults,8 has been implemented during the past decade.9 This experience has shown that an adaptation of the classification of pediatric fractures including all well-known and currently applied systems, is necessary.
From the *Department of Paediatric Surgery, Paediatric Trauma and Orthopaedics, University Childrens Hospital, Bern, Switzerland; and AO Clinical Investigation and Documentation, Dbendorf, Switzerland. Members of the AO Pediatric Classification Group are listed in the Appendix on page S160. Disclosure: The authors report no conflicts of interest. Correspondence: Theddy F. Slongo, MD, Paediatric Trauma and Orthopaedics, University Childrens Hospital, Department of Paediatric Surgery, CH-3010 Bern, Switzerland (e-mail: Theddy.Slongo@insel.ch). Copyright 2007 by Lippincott Williams & Wilkins
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Pediatric Long Bone Fractures
The need for clinical relevance dictates that a system different from those for adults must be developed, and that already known pediatric classifications must be considered.1,4-6 However, the structures of both adult and pediatric classifications of similar bones should remain similar to facilitate their application in the clinical setting. In addition, the classification process (ie, the fracture diagnosis) should be reliable and valid,7,10,11 underscoring the need to start early with such evaluation in the development process.12 Audig et al11 have recommended that 3 research phases should be completed before a classification can be considered as validated. The first development phase involves clinical experts who develop a first proposal for the classification system and define the classification process. This phase has delineated a common language with which surgeons should be able to view and describe fractures similarly. Successive pilot studies are conducted to ensure agreement among clinical experts. The second phase involves a multicenter study to ensure agreement among future users. This phase establishes the basis for a classification tool to be used for documentation and evaluation of treatment options. Only after these first two phases are completed can recommendations for patient care based on the classification be developed in a third phase, after the implementation of a prospective clinical study. To meet these needs, the AO Pediatric Expert Group (PAEG) and the AO Pediatric Classification Group, in cooperation with the AO Investigation and Documentation (AOCID) Group introduce and present the first comprehensive classification of pediatric long bone fractures.1315
FIGURE 1. Designation of bone location

Code 23r E/2.1 Fracture Salter-Harris II fracture of the distal radius
23u E/2.1
Salter-Harris II fracture of the distal ulna
PEDIATRIC LONG BONE CLASSIFICATION Glossary

The terms and definitions in the glossary of the classification of pediatric fractures follow the meanings that have been established by Mllerss Long Bone Comprehensive Classification of Fractures. The glossary therefore comprises an extension of this internationally accepted classification of adult fractures, which has proven its worth over a period of more than 30 years.
FIGURE 2. Coding of same fracture but different bone in paired bones.
Description of the Classification Definition

The current classification proposal is based on the Mller AO classification for adults8 and considers child-specific relevant fracture features. The original unifying principle of the CCF, valid for all fractures, is an anatomic and morphologic organization divided mostly into triads. The anatomy is related to the four long bones and their three segments. It is further described by the fracture subsegment recorded as E, M, or D (see below). The morphology of the fracture is documented by a location-specific child code, a severity code, and an additional code for displacement of specific fractures.
be used, with the severity code referring to the more badly fractured of the two bones. When a single bone is fractured, a small letter describing that bone (ie, r, u, t, or f) should be added after the segment code (eg, the code 22u identifies an isolated diaphyseal fracture of the ulna). When the paired bones Radius/Ulna or Tibia/Fibula are fractured with different pediatric patterns (eg, a complete fracture of the radius and a bowing fracture of the ulna), each bone must be coded separately including the corresponding small letter (Figure 2). This will allow a detailed documentation of combined fractures of the radius and ulna, or those of the tibia and fibula, in clinical studies so that their relative influence on treatment outcomes can be properly evaluated. A list of the most common combinations of paired fractures is presented at the end of this article.
Location Bone
Following the Mller AO classification for adults, the bones are similarly coded: 1 = Humerus, 2 = Radius/Ulna, 3 = Femur, 4 = Tibia/Fibula (Figure 1). Except for the known Monteggia and Galeazzi lesions, when the paired bones Radius/Ulna or Tibia/Fibula are fractured with the same pediatric pattern (see below), a single classification code should
Segments
The segments within the bones also follow a similar coding scheme, ie, 1 = proximal, 2 = diaphyseal, 3 = distal, but their identification differs from that in adults. For the latter, the proximal and distal metaphyseal fragments are identified via a square whose sides are the same length as the widest part of the epiphysis.8 However, we know that the metaphysis in pediatric fractures extends much further into the shaft, as can be observed with the typical pediatric metaphyseal fractures (eg,
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buckle and torus fractures). Furthermore, the width of the growth plate is almost visible in younger children, whereas the epiphysis itself cannot be used because of the different agedependent ossification stages. This makes the same use of squares in children clinically inappropriate. For pediatric long bone fractures, the metaphysis is identified by a square whose side has the same length as the widest part of the physis in question (Figure 3). For the pairs of bones radius/ulna and tibia/ fibula, both bones must be included in the square. Consequently, the three segments can be defined as follows: Segment 1: Segment 2: Segment 3: Proximal, including subsegments epiphysis (E) and metaphysis (M) Shaft/Diaphysis (D) Distal, including subsegments metaphysis (M) and epiphysis (E)
on a transparency and applied to the anteroposterior (AP) radiographic view (Figure 4). For the pairs of bones radius/ulna and tibia/fibula, both bones must be included in the square. This square definition is not applicable to the proximal femur where metaphyseal fractures are located between the physis of the head and the intertrochanteric line (see below). In applying the square definition, surgeons should be aware that if this view is not strictly on the AP plane, eg, if the plane is slightly rotated the applied square will be smaller than expected, leading to risk of misclassification. In such cases, the classification process should be checked after fracture reduction. When a metaphyseal fragment is severely angulated in the frontal plane, the square will be correctly chosen, but the length of the fragment will appear smaller than it really is. In this situation, the same square should be used on the lateral radiographic view to assess the length of the metaphyseal fragment.
Malleolar fractures in adults are classified with a specific code 44 because they have a very special pattern.8 However, such fractures are not so common in children and their characteristics do not justify a specific coding. Therefore, they are simply coded as distal tibia fractures (for example the fracture of the medial malleolus is a typical Salter-Harris III or IV fracture of the distal tibia coded, as 43).
Morphology Child Code

Specific pediatric features (also called child patterns) are transformed into a child code. For easier recognition, this code is preceded by a forward slash / throughout the entire classification code (Figure 5). Relevant child patterns are specific to one of the fracture subsegments E, M, or D and hence are grouped accordingly. Regardless of fracture type,
Subsegment
The original severity coding A-B-C used in adults is replaced by a classification of fractures according to diaphysis (D), metaphysis (M) and epiphysis (E) (Figure 3). This terminology is known and accepted worldwide and is relevant to pediatric fractures. The most common fracture subsegments in children are the shaft fractures (segment 2), and the epimetaphyseal subsegment (segments 1 and 3). Use of the E-MD coding identifies intra-articular and extra-articular fractures without ambiguity because epiphyseal fractures are intra-articular fractures by definition. The metaphyseal fractures are identified through the position of the square (the center of the fracture lines must be located in the square) with one side over the physis (Figures 3 and 4). For easier and more accurate application of the squares and, consequently, more reliable classification, a series of pre-drawn squares are copied
FIGURE 3. Definition of bone segments and subsegments; For children, the square must be placed over the larger part of the physis. 2007 Lippincott Williams & Wilkins
FIGURE 4. Use of the square patterns to classify a fracture as epiphyseal (E), metaphyseal (M) or diaphyseal (D).
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FIGURE 5. Overall structure of the paediatric fracture classification.
child patterns having a similar morphology are given the same child code for simplification and consistency. Internationally known and accepted child patterns are considered. Patterns of epiphyseal fractures include the known epiphyseal injuries I to IV according to Salter and Harris1 using the child codes E/1 to E/4. These codes resulted from intensive discussion within the AO Pediatric Expert Group and among other surgeons about whether Salter-Harris I and II fractures should be classified as metaphyseal fractures (M), since they have very similar characteristics to these fractures.6 However, surgeons worldwide traditionally recognize these fractures as epiphyseal fractures (E) (Figure 6). Other child codes E/5 to E/9 are used to identify Tillaux (two plane) fractures (E/5), tri-plane fractures (E/6), ligament avulsions (E/7), and flake fractures (E/8). Three child patterns are identified for metaphyseal fractures, ie, the buckle or torus greenstick fractures (M/2), complete fracture (M/3) and osteo-ligamentous, musculoligamentous avulsion or only avulsion injuries (M/7) (Figure 7). Child patterns within segment 2 (diaphyseal fractures) are presented in Figure 8. They include bowing fractures (D/1), greenstick fractures (D/2), complete transverse fracture (angle <30, D/4), complete oblique/spiral fracture (angle >30, D/5), Monteggia lesions (D/6) and Galeazzi lesions (D/7). Similar to adult fractures, oblique fractures are identified when the angle between the fracture line and the line transverse to the bone axis is above 30. A 30 angle should be drawn on the transparency sheet mentioned above and should be applied to the radiographs for more reliable classification. The angle should be measured according to the longitudinal axis of the main fragment and on the radiographic view showing the most severe angle (lateral or AP view)
FIGURE 7. Definition of child patterns for metaphyseal fractures.
(Figure 9). Similarly the code /9 should be used for fractures that may not belong to well-defined categories.
Severity Code
A grade of fracture severity is considered, not so much because of its influence on healing, as in adults, but because of the need to investigate the indications for various methods of osteosynthesis. This code distinguishes between simple (.1), wedge (partially unstable fracture with 3 fragments including a fully separated fragment) and complex (totally unstable fracture with more than 3 fragments) (.2), as shown in Figure 10.
Exceptions and Additional Codes

As for adult fractures, not all pediatric fractures can simply be classified according to the above scheme, and a few more definitions and rules were agreed on: Fractures of the apophysis are recognized as metaphyseal injuries. Transitional fractures with or without metaphyseal wedge are classified as epiphyseal fractures. Intra- and extra-articular ligament avulsions are epiphyseal and metaphyseal injuries, respectively.
FIGURE 6. Definition of child patterns for epiphyseal fractures.
FIGURE 8. Definition of child patterns for diaphyseal fractures. 2007 Lippincott Williams & Wilkins
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Supracondylar Fractures
Supracondylar humerus fractures (code 13 M/3) are given an additional code regarding the grade of displacement at 4 levels (I to IV) as defined below and presented in an algorithm (Figure 12). Type I Incomplete fracture. In a strict lateral view, the Rogers line still intersects the capitellum. In the AP view there is no more than a 2mm valgus/varus fracture gap. Type II Incomplete fracture: Antecurvation or recurvation with continuity of the posterior (extension fracture) or anterior cortex (flexion fracture). The Rogers line does not intersect the capitellum.
FIGURE 9. Measurement of the fracture angle.
Supracondylar humerus fractures (code 13 M/3) are given an additional code regarding the grade of displacement at 4 levels (I to IV) (see supracondylar fractures). Radial head (21-E/1 or /2) and neck fractures (21-M/2 or M/3) are given an additional code (I III) regarding the axial deviation and level of displacement (see radial neck fractures). Femoral neck fractures. Epiphysiolysis and epiphysiolysis with a metaphyseal wedge are coded as normal Type E epiphyseal SH I and II fractures E/1 and E/2. Fractures of the femoral neck are coded as normal type M metaphyseal fractures code I to III (see femoral neck fractures). The intertrochanteric line limits the metaphysis. The side of ligament avulsion fractures of the distal humerus and distal femur is indicated by the small letter u (ulnar/medial) or r (radial/lateral) for the humerus and by t (tibial/medial) or f (fibular/lateral) for the femur. The full classification code therefore includes 5 or 6 fracture entities depending on the use of an exception code. Two typical classification examples are presented in Figure 11.
FIGURE 11. Example of a supracondylar fracture (a) and a tibia shaft fracture (b).
FIGURE 10. Severity implies anticipated difficulties and method of treatment, not the prognosis. 2007 Lippincott Williams & Wilkins
FIGURE 12. Algorithm for supracondylar fracture classification.
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Type III Complete fracture: No bone continuity (broken cortex), but still some contact between the fracture planes, independent of the type of displacement. Type IV Complete fracture: No bone continuity (broken cortex), and no contact between the fracture planes, independent of the type of displacement.
Radial Neck (Head) Fractures

Radial head (21-E/1 or /2) and neck fractures (21-M2 or M/3) are given an additional code regarding the axial deviation and level of displacement: no angulation and no displacement (I), angulation with displacement up to half of the bone diameter (II) and angulation with displacement more than half of the bone diameter (III) as shown in Figure 13.
FIGURE 13. Classification of radial neck (head) fractures.
Femoral Neck Fractures

Femoral neck fractures. Epiphysiolysis and epiphysiolysis with a metaphyseal wedge are coded as subsegment E epiphyseal SH I and II fractures E/1 and E/2. Fractures of the femoral neck are coded as subsegment M metaphyseal fractures: midcervical (I), basocervical (II), and transtrochanteric (III). The intertrochanteric line limits the methaphysis (Figure 14).
Detailed Presentation and Definitions

In the following sections, only the most common pediatric fractures are described, illustrated and coded.
FIGURE 14. Classification of femoral neck fractures.
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HUMERUS (1)
Proximal epiphyseal fractures (11-E) Simple fractures Code 11 E/1.1 Figure Description Simple epiphysiolysis Code Wedge/complex fractures Figure Description
11 E/2.1
Simple epiphysiolysis with metaphyseal wedge
11 E/2.2
Epiphysiolysis with multifragmentary metaphyseal wedge
11 E/3.1
Simple epiphyseal fracture SH III
11 E/3.2
Multifragmentary epiphyseal fracture SH III
11 E/4.1
Simple epimetaphyseal fracture SH IV
11 E/4.2
Multifragmentary epimetaphyseal fracture SH IV
11 E/8.1
Single intraarticular flake fracture
11 E/8.2 fracture
Multiple intraarticular flake
Proximal metaphyseal fractures (11-M) Simple fractures Code 11 M/2.1 Figure Description Metaphyseal torus / buckle fracture Code Wedge/complex fractures Figure Description
11 M/3.1
Complete, simple metaphyseal
11 M/3.2
Complete, multifragmetary metaphyseal
Diaphyseal fractures (12-D) Simple fractures Code 12 D/4.1 Figure Description Simple, transverse (>30) diaphyseal Code 12 D/4.2 Wedge/complex fractures Figure Description Multifragmentary, transverse (>30) diaphyseal
12 D/5.1
Simple, oblique or spiral (< 30) diaphyseal
12 D/5.2
Multifragmentary oblique or spiral (<30) diaphyseal
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Distal metaphyseal fractures (13-M) Simple fractures Code 13 M/2.1 Figure Description Torus, buckle metaphyseal, supracondylar fracture Code Wedge/complex fractures Figure Description
13 M/3.1
Incomplete supracondylar fracture
13 M/3.2
Multifragmentary complete fracture
13u M/7.1
Avulsion of the ulnar epicondyle (extra-articular)
Distal epiphyseal fractures (13-E) Simple fractures Code 13 E/1.1 Figure Description Simple epiphysiolysis SH I Code Wedge/complex fractures Figure Description
13 E/2.1
Simple epiphysiolysis with metaphyseal wedge SH II
13 E/3.1
13r E/4.1
Simple epiphyseal fracture with metaphyseal wedge SH IV
13 E/4.2
Complex epimetaphyseal ( Y or T fracture )
13r E/7.1
Avulsion of the radial collateral ligament
13r E/8.1
Simple flake fracture of the radial condyle
13r E/8.2
Multifragmentary flake fracture of the radial condyle
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Radius/Ulna (2)
Proximal epiphyseal fractures/radial head (21-E) Simple fractures Code 21r E/1.1 I Figure Description Simple epiphysiolysis radial head SH I no displacement Simple epiphysiolysis radial head SH I angulation and displacement 1 /2 shaft Simple epiphysiolysis radial head SH I displacement >1 /2 shaft or complete epiphysiolysis radial head with simple metaphyseal wedge SH II no displacement epiphysiolysis radial head with simple metaphyseal wedge SH II angulation and displacement 1 /2 shaft epiphysiolysis radial head with simple metaphyseal wedge SH II displacement >1 /2 shaft or complete Simple epiphyseal radial head fracture SH III 21r E/2.2 I epiphysiolysis radial head with multifragmentary metaphyseal wedge SH II no displacement epiphysiolysis radial head with multifragmentary metaphyseal wedge SH II angulation and displacement 1 /2 shaft epiphysiolysis radial head with multifragmentary metaphyseal wedge SH II displacement >1 /2 shaft or complete multifragmentary epiphyseal radial head fracture SH III Code Wedge/multifragmentary fractures Figure Description
21r E/1.1 II
21r E/1.1 III
21r E/2.1 I
21r E/2.1 II
21r E/2.2 II
21r E/2.1 III
21r E/2.2 III
21r E/3.1
21r E/3.2
21r E/4.1
Simple epimetaphyseal radial head fracture SH IV
21r E/4.2
multifragmentary epimetaphyseal radial head fracture SH IV
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Proximal metaphyseal fractures radius/ulna (21-M) Simple fractures Code 21r M/2.1 Figure Description Metaphyseal torus/buckle fracture radial neck Code Wedge/multifragmentary fractures Figure Description
21r M/3.1 I
Complete, simple metaphyseal radial neck no displacement Complete, simple metaphyseal radial neck angulation and displacement 1 /2 shaft Complete, simple metaphyseal radial neck displacement >1 /2 shaft or complete Metaphyseal torus / buckle olecranon
21r M/3.2 I
Complete, multifragmentary metaphyseal radial neck no displacement Complete, multifragmentary metaphyseal radial neck angulation and displacement 1 /2 shaft Complete, multifragmentary metaphyseal radial neck displacement >1 /2 shaft or complete
21r M/3.1 II
21r M/3.2 II
21r M/3.1 III
21r M/3.2 III
21u M/2.1
21u M/3.1
Complete, simple metaphyseal olecranon
21u M/3.2
Complete, multifragmentary metaphyseal olecranon
21u M/7.1
Avulsion of the olecranon apophysis
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Diaphyseal fractures radius/ulna (22-D)

Simple fractures Code 22 D/1.1 Figure Description Bowing diaphyseal Code Wedge/multifragmentary fractures Figure Description
22 D/2.1
Greenstick diaphyseal
22 D/4.1
Complete simple forearm transverse
22 D/4.2
Complete multifragmentary forearm transverse
22 D/5.1
Complete simple forearm oblique or spiral
22 D/5.2
Complete multifragmentary forearm oblique or spiral
22 D/6.1
Monteggia lesion, ulna simple
22 D/6.2
Monteggia lesion, ulna multifragmentary
22 D/7.1
Galeazzi lesion, radius simple
22 D/7.2
Galeazzi lesion, radius multifragmentary
22r D/1.1
Bowing radius
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Simple fractures Code 22r D/2.1 Figure Description Greenstick radius Code
Wedge/multifragmentary fractures Figure Description
22r D/4.1
Radius complete, single transverse
22r D/4.2
Radius complete, multifragmentary, transverse
22r D/5.1
Radius complete, single oblique or spiral
22r D/5.2
Radius complete, multifragmentary oblique or spiral
22u D/1.1
Bowing ulna
22u D/2.1
Greenstick ulna
22u D/4.1
Ulna complete, single transverse
22u D/4.2
Ulna complete, multifragmentary transverse
22u D/5.1
Ulna complete, single oblique or spiral
22u D/5.2
Ulna complete, multifragmentary oblique or spiral
S146

Distal metaphyseal fractures radius/ulna (23-M) Simple fractures Code 23 M/2.1 Figure Description Torus, buckle metaphyseal, distal radius/ulna Code
23 M/3.1
Complete simple distal radius/ulna
23 M/3.2
Complete multifragmentary distal radius/ulna
23r M/2.1
Torus/buckle distal radius
23r M/3.1
Complete simple distal radius
23r M/3.2
Complete multifragmentary distal radius
23u M/2.1
Torus/buckle distal ulna
23u M/3.1
Complete simple distal ulna
23u M/3.2
Complete multifragmentary distal ulna
S147
Distal epiphyseal fractures radius/ulna (23-E)

Simple fractures Code 23 E/1.1 Figure Description Simple epiphysiolysis SH I Code Wedge/multifragmentary fractures Figure Description
23 E/2.1
Simple epiphysiolysis with metaphyseal wedges SH II
23 E/2.2
Epiphysiolysis with multifragmentary metaphyseal wedges SH II
23 E/3.1
23 E/4.1
23 E/7.1
Radioulnar ligament avulsion
23r E/1.1
Simple epiphysiolysis SH I radius
23r E/2.1
Simple epiphysiolysis with metaphyseal wedge SH II radius
23r E/2.2
Multifragmentary epiphysiolysis radius SH II
23r E/3.1
Simple epiphyseal fracture SH III radius
23r E/4.1
Simple epiphyseal fracture with metaphyseal wedge SH IV radius
23r E/4.2
Multifragmentary epiphyseal fracture with metaphyseal wedge SH IV radius
S148
Simple fractures Code 23u E/1.1 Figure Description Simple epiphysiolysis SH I ulna Code
23u E/2.1
Simple epiphysiolysis with metaphyseal wedge SH II ulna
23u E/2.2
multifragmentary epiphysiolysis with metaphyseal wedge SH II ulna
23u E/3.1
Simple epiphyseal fracture SH III ulna
23u E/4.1
Simple epimetaphyseal fracture SH IV ulna
23u E/4.2
multifragmentary epimetaphyseal fracture SH IV ulna
23u E/7.1
Ligament avulsion ulnar styloid process
S149
Femur (3)
Proximal epiphyseal fractures (31-E) Simple fractures Code 31 E/1.1 Figure Description Epiphysiolysis (SUFE/SCFE) SH I Code Wedge/multifragmentary fractures Figure Description
31 E/2.1
Epiphysiolysis (SUFE/SCFE) with metaphyseal wedge SH I
31 E/7.1
Ligament avulsion (ligam. capitis femoris)
31 E/8.1
Single flake fracture
31 E/8.2
Multiple flake fracture
Proximal metaphyseal fracture/femoral neck (31-M) Simple fractures Code Figure Exception femoral neck fractures 31 M/2.1 I Incomplete midcervical Description Code Wedge/multifragmentary fractures Figure Exception femoral neck fractures Description
31 M/3.1 I
Simple complete midcervical
31 M/3.2 I
Multifragmentary midcervical
31 M/2.1 II
Incomplete basocervical
S150
Simple fractures Code Figure Description Code Exception femoral neck fractures 31 M/3.1 II Simple complete basocervical
31 M/3.2 II
Multifragmentary basocervical
31 M/2.1 III
Incomplete transtrochanteric
31 M/3.1 III
Simple complete transtrochanteric
31 M/3.2 III
Multifragmentary transtrochanteric
31 M/7.1
Ligament avulsion of greater OR lesser trochanter
Diaphyseal fractures femur (32-D) Simple fractures Code 32 D/4.1 Figure Description Simple complete transverse (30) Code 32 D/4.2 Wedge/multifragmentary fractures Figure Description Multifragmentary transverse (30)
32 D/5.1
Simple complete oblique or spiral (>30)
32 D/5.2
Multifragmentary oblique or spiral
(>30)
S151
Distal metaphyseal fractures femur (33-M) Simple fractures Code 33 M/2.1 Figure Description Torus/buckle metaphyseal distal femur Code Wedge/multifragmentary fractures Figure Description
33 M/3.1
Simple complete distal femur
33 M/3.2
Multifragmentary distal femur
33 M/7.1
Ligament avulsion bilateral
33t M/7.1
t tibial/medial
33f M/7.1
f fibular/lateral
Distal epiphyseal fractures femur (33-E) Simple fractures Code 33 E/1.1 Figure Description Simple epiphysiolysis Code Wedge/multifragmentary fractures Figure Description
33 E/2.1
Simple epiphysiolysis with metaphyseal wedge SH II
33 E/2.2
Epiphysiolysis with multifragmenatry metaphyseal wedge SH II Multifragmentary epiphyseal fracture SH III
33 E/3.1
33 E/3.2
33 E/4/1
33 E/4.2
33 E/8.1
Single intraarticular flake fracture
33 E/8.2
Multiple intraarticular flake fracture
S152
Tibia/Fibula (4)
Proximal epiphyseal fractures tibia/fibula (41-E) Simple fractures Code Figure Description Only tibia 41t E/1.1 Simple epiphysiolysis tibia SH I Code Wedge/multifragmentary fractures Figure Description
41t E/2.1
Simple tibial epiphysiolysis, simple metaphyseal wedge SH II
41t E/2.2
Tibial epiphysiolysis, multifragmentary metaphyseal wedges SH II
41t E/3.1
Simple tibial epiphyseal fracture SH III
41t E/3.2
Multifragmentary tibial epiphyseal fracture SH III
41t E/4.1
Simple tibial epi-metaphyseal fracture SH IV
41t - E/4.2
Multifragmentary tibial epimetaphyseal fracture SH IV
41t E/7.1
Tibial spine fracture
41t E/8.1
Flake fracture tibial plateau
S153
Proximal metaphyseal fractures tibia/fibula (41-M) Simple fractures Code 41 M/2.1 Figure Description Torus/buckle fracture tibia/ fibula Code Wedge/multifragmentary fractures Figure Description
41 M/3.1
Simple complete tibia and fibula
41 M/3.2
Multifragmentary tibia and fibula
Only tibia 41t M/2.1 Torus/buckle fracture tibia
41t M/3.1
Tibia simple complete
41t M/3.2
Tibia multifragmentary
41t M/7.1
Fracture of the tibial apophysis
Only fibula 41f M/2.1 Torus/buckle fibula
41f M/3.1
Fibula simple complete
41f M/3.2
Fibula multifragmentary
S154
Disphyseal fractures tibia/fibula (42-D) Simple fractures Code 42 D/1.1 Figure Description Bowing tibia and fibula Code Wedge/multifragmentary fractures Figure Description
42 D/2.1
Greenstick tibia and fibula
42 D/4.1
Transverse simple tibia and fibula (30)
42 D/4.2
Transverse multifragmentary tibia and fibula (30)
42 D/5.1
Simple oblique or spiral tibia and fibula (30)
42 D/5.2
Multifragmentary oblique or spiral tibia and fibula (30)
Only tibia 42t D/1.1 Bowing tibia
42t D/2.1
Greenstick tibia
42t D/4.1
Transverse simple tibia (30)
42t D/4.2
Transverse multifragmentary tibia (30)
42t D/5.1
Oblique or spiral tibia (30)
42t D/5.2
Oblique or spiral multifragmentary tibia (30)
S155
Simple fractures Code Figure Description Only fibula 42f D/1.1 Bowing fibula Code
42f D/2.1
Greenstick fibula
42f D/4.1
Transverse simple fibula (30)
42f D/4.2
Transverse multifragmentary fibula (30)
42f D/5.1
Oblique or spiral simple fibula (30)
42f D/5.2
Oblique or spiral multifragmentary fibula (30)
Distal metaphyseal fractures tibia/fibula (43-M) Simple fractures Code 43 M/2.1 Figure Description Torus/buckle tibia and fibula Code Wedge/multifragmentary fractures Figure Description
43 M/3.1
Complete simple tibia and fibula
43 M/3.2
Multifragmentary tibia and fibula
Only tibia 43t M/2.1 Torus/buckle tibia
43t M/3.1
Complete simple tibia
43t M/3.2
Multifragmentary tibia
S156
Simple fractures Code Figure Description Only fibula 43f M/2.1 Torus/buckle fibula Code
43f M/3.1
43f M/3.2
Multifragmentary fibula
Distal epiphyseal fractures tibia/fibula (43-E) Simple fractures Code 43 E/1.1 Figure Description Simple epiphysiolysis tibia and fibula Code Wedge/multifragmentary fractures Figure Description
Only tibia 43t E/1.1 Simple epiphysiolysis tibia SH I
43t E/2.1
Simple epimetaphyseal fracture tibia SH II
43t E/2.2
Multifragmentary epimetaphyseal fracture tibia SH II
43t E/3.1
Simple metaphyseal fracture tibia SH III
43t E/4.1
43t E/4.2
43t E/5.1
Tillaux (two plane) fracture SH III
S157
Simple fractures Code 43t E/6.1 Figure Description Tri-plane fracture SH IV Code
43t E/8.1
Intra-articular flake tibia
Only fibula 43f E/1.1 Simple epiphysiolysis fibula SH I
43f E/2.1
Simple epiphysiolysis with metaphyseal wedge fibula SH II Simple epiphyseal fracture fibula SH III
43f E/3.1
43f E/4.1
Simple epimetaphyseal fractrue fibula SH IV
43f E/7.1
Osteoligament avulsion fibula
43f E/8.1
Intra-articular flake fibula
S158
Frequent fracture combinations in paired bones

Codes Combinations Tibia/fibula 41t E/2.1 41f M/3.1 Proximal lower leg SH II tibia and complete metaphyseal fibula Description
42t D/4.1 42f D/1.1
Complete diaphyseal tibia and bowing of the fibula
42t D/5.2 42f D/2.1
Multifragmentary diaphyseal tibia and greenstick fibula
43t E/4.1 43f E/1.1
Combined fracture: SH III tibia and SH I fibula
43t E/4.2 43f E/1.1
Multifragmentary epiphyseal fracture tibia SH III and SH I fibula
43t E/2.1 43f M/3.1
Distal lower leg SH II tibia and complete metaphyseal fibula
Radius/Ulna 21r M/3.1 III 21u M/3.1 Complete radial neck Type III and olecranon fracture
22r D/5.1 22u D/1.1
Simple oblique or spiral complete radius and bowing of the ulna
23r E/2.1 23u E/7.1
Radial SH II and fracture of the ulnar styloid
S159
Codes
Combinations Radius/Ulna
Description
23r M/2.1 23u M/3.1
Torus/buckle of the radius and complete metaphyseal ulna
23r M/2.1 23u E/7.1
Torus/buckle of the radius and fracture of the ulnar styloid
APPENDIX
The AO Pediatric Classification Group consists of: T. Slongo, L. Audig, P. Schmittenbecher, N. Lutz, J-M. Clavert, S. Frick, J. Hunter, and W. Schlickewei.
REFERENCES
1. 2. 3. 4. 5. 6. 7. Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg Am. 1963;45:587622. Baumann E. Ellbogen. In: Nigst H, ed. Spezielle Frakturen- und Luxationslehre. Stuttgart: Thieme, 1965. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959;109:145154. von Laer, L., Frakturen und Luxationen im Wachstumsalter. 4. berarbeitete und aktualisierte Auflage ed. 2001. Judet J, Judet R, Lefranc J. Fractures du col radial chez lenfant. Ann Chir. 1952;16:13771385. von Laer L, Gruber R, Dallek M, et al. Classification and documentation of childrens fractures. Eur J Trauma. 2000;26:0214. Audig L, Bhandari M, Kellam J. How reliable are reliability studies of fracture classifications? A systematic review of their methodologies. Acta Orthop Scand. 2004;75:184194. Mller ME, Nazarian S, Koch P, et al. The Comprehensive Classification of Fractures of Long Bones. Berlin, Germany: Springer-Verlag, 1990.
8.
Slongo T, Schaerli AF, Koch P, et al. Klassifikation und Dokumentation der Frakturen im KindesalterPilotstudie der internationalen Arbeitsgemeinschaft fr Kindertraumatologie. Zentralbl Kinderchir. 1995;157163. 10. Garbuz DS, Masri BA, Esdaile J, et al. Classification systems in orthopaedics. J Am Acad Orthop Surg. 2002;10:290297. 11. Audig L, Hunter J, Weinberg AM, et al. Development and evaluation process of a pediatric long-bone fracture classification proposal. Eur J Trauma. 2004;30:248254. 12. Audig L, Bhandari M, Hanson B, et al. A concept for the validation of fracture classifications. J Orthop Trauma. 2005;19:401406. 13. Slongo T, Audig L, Lutz N, et al. Documentation of fracture severity with the AO classification of pediatric long-bone fractures. Acta Orthop. 2007;78:247253. 14. Slongo T, Audig L, Clavert JM, et al. The AO comprehensive classification of pediatric long-bone fractures: a web-based multicenter agreement study. J Pediatr Orthop. 2007;27:171180. 15. Slongo T, Audig L, Schlickewei W, et al. Development and validation of the AO pediatric comprehensive classification of long bone fractures by the Pediatric Expert Group of the AO Foundation in collaboration with AO Clinical Investigation and Documentation and the International Association for Pediatric Traumatology. J Pediatr Orthop. 2006;26:4349.
9.
S160
INDEX
A Acetabulum anterior column, S59 posterior column, S59 Acromioclavicular dislocation, S104, S106 Acromion. See Scapula Ankle dislocations, S125 AO pediatric comprehensive classification of long bone fractures (PCCF). See Pediatric comprehensive classification of long bone fractures Avulsion of tuberosity, S7S8 C Calcaneus articular fractures involving posterior facet, S92S93 avulsion, process or tuberosity fractures, S92S93 bones, S92 nonarticular body fractures, S92S93 Capitate bones, S75 fractures, S76 Capitellum fracture, S17 Carpal-metacarpal dislocations, S120, S122 Carpus bones, S75 fractures, S76S77 Cephalotubercular fracture, S7, S10 Cervical spine dislocation, S111 Childhood fractures. See Pediatric comprehensive classification of long bone fractures (PCCF), AO Clavicle dislocations, S104, S106S107 fractures, S72S74 medial end, diaphysis groups, S72 subgroups and qualifications, S73 medial end, lateral end groups, S72 subgroups and qualifications, S74 medial end, metaphysis, groups, S72 Corocoid. See Scapula Coronoid process. See Radius/ulna Cuboid bones, S94 fractures, S94 Cuneiforms bones, S94 fractures, S94 D Dislocations, S103S128 elbow, S108S110 foot and ankle, S125S128 general principles, S103 hand and wrist, S120S124 hip, S112
knee, S113S117 pelvic, S118S119 shoulder, S104S107 spine, S111 Distal interphalangeal joint dislocations, S124 E Elbow dislocations, S108S110 Epicondylar. See Humerus fractures and dislocations, distal Epiphyseal fractures. See Humerus fractures and dislocations, distal F Femur fractures, S31S42 diaphyseal, S35S38 complex groups, S35 subgroups and qualifications, S38 pediatric, S152 simple groups, S35 subgroups and qualifications, S36 wedge groups, S35 subgroups and qualifications, S37 distal, S39S42 complete articular groups, S39 subgroups and qualifications, S42 extra-articular groups, S39 subgroups and qualifications, S40 partial articular groups, S39 subgroups and qualifications, S41 proximal, S31S34 epiphyseal, pediatric, S150 head fracture groups, S31 subgroups and qualifications, S34 metaphyseal/femoral neck, pediatric, S140 neck fracture groups, S31 subgroups and qualifications, S33 trochanteric groups, S31 subgroups and qualifications, S32 Fibula. See Tibia/fibula Foot bones, S89 dislocations, S125S128
fractures, S90S94 (See also specific bones) multiple crush fractures, S94 Forefoot dislocations, S125, S127S128 G Galeazzi fracture-dislocations, S24S26 Glenohumeral dislocations, S7S10, S104S105 Goyrand-Smith fracture, S28 H Hamate bones, S75 fractures, S77 Hand and carpus. See also specific bones bones, S75 fractures, S75S77 Hand dislocations, S120S124 Hip dislocations, S112 Holdsworth slice rotation fracture, S132 Humerus fractures, S7S18 diaphyseal, S11S14 complex groups, S11 subgroups and qualifications, S14 pediatric, S142 simple groups, S11 subgroups and qualifications, S12 wedge groups, S11 subgroups and qualifications, S13 distal, S15S18 complete articular groups, S15 subgroups and qualifications, S18 epiphyseal, pediatric, S142 extra-articular groups, S15 subgroups and qualifications, S16 metaphyseal, pediatric, S142 partial articular groups, S15 subgroups and qualifications, S17 proximal, S7S10 articular groups, S7 subgroups and qualifications, S10 epiphyseal, pediatric, S141 extra-articular bifocal groups, S7 subgroups and qualifications, S9
S161
Index
Humerus fractures, proximal extra-articular unifocal groups, S7 subgroups and qualifications, S8 metaphyseal, pediatric, S141 I Intercarpal dislocations, S120S121 K Knee dislocations, S113S117 Kocher I fracture, S16 Kocher II fracture, S16 L Lumbar spine dislocation, S111 Lunate bones, S75 fractures, S76 M Metacarpal bones, S75 Metacarpal dislocations, S120, S122 Metacarpal fractures, S78S81 base articular, S80 articular/extra-articular, S81 extra-articular, S79 groups, S78 diaphysis, S78 head articular, S80 articular/extra-articular, S81 extra-articular, S80 groups, S78 Metacarpal phalangeal joint dislocations, S123 Metatarsal bones, S95 Metatarsal fractures, S95S98 diaphysis comminuted, S98 groups, S95 noncomminuted, S96 wedge, S97 distal articular, S98 extra-articular, S96 groups, S95 partial articular, S97 proximal articular, S98 extra-articular, S96 groups, S95 partial articular, S97 Metatarsal-phalangeal joint dislocations, S128 Milch I fracture, S17 Monteggia fracture-dislocations, S24S26 N Navicular bones, S89 fractures, S94
O Olecranon. See Radius/ulna P Patella fractures, S86S88 complete articular groups, S86 subgroups and qualifications, S88 extra-articular, S86 partial articular groups, S86 subgroups and qualifications, S87 Patellofemoral dislocations, S113, S115 Pediatric comprehensive classification of long bone fractures (PCCF), AO, S135S160 definitions, S136 femur diaphyseal, S151 proximal epiphyseal, S150 proximal metaphyseal/femoral neck, S140 humerus diaphyseal, S141 distal epiphyseal, S142 distal metaphyseal, S142 proximal epiphyseal, S141 proximal metaphyseal, S141 injury pattern and growth, S135 locations bone, S136 child code, S137S138 exceptions and additional code, S139S140 fracture severity code, S138 fracture type, S137 segments, S136S137 radius/ulna combinations, S159S160 diaphyseal, S145S146 distal epiphyseal, S148S149 distal metaphyseal, S147 proximal epiphyseal/radial head and neck, S140, S143 proximal metaphyseal, S144 supracondylar, additional code, S139S140 tibia/fibula combinations, S159 proximal epiphyseal, S153 Pelvis classification systems, S59 definitions, S59 dislocations, S118S119 fractures, S59S67 acetabulum, S64S67 complete articular, both columns groups, S64 subgroups and qualifications, S67
partial articular, one column groups, S64 subgroups and qualifications, S65 partial articular, transverse groups, S64 subgroups and qualifications, S66 pelvic ring, S59S63 complete disruption of posterior arch groups, S59S60 subgroups and qualifications, S63 partially stable groups, S60 subgroups and qualifications, S62 stable groups, S60 subgroups and qualifications, S61 types, S59 unstable groups, S60 subgroups and qualifications, S63 Phalanges, foot, S89 Phalanx, foot, fractures, S99S102 diaphysis complex, S102 groups, S99 simple, S100 wedge, S101 distal articular, S102 extra-articular, S100 groups, S99 partial articular, S101 proximal articular, S102 extra-articular, S100 groups, S99 partial articular, S101 Phalanges, hand, S75 dislocations, S123S124 Phalanx, hand, fractures, S82S85 articular, S82 complete articular groups, S82 subgroups and qualifications, S85 diaphyseal, S82S83 extra-articular distal, S83 groups, S82 proximal, S83 partial articular groups, S82 subgroups and qualifications, S84 Pisiform fractures, S77 Pouteau-Colles fracture, S28
S162
Index
Proximal interphalangeal joint dislocations foot, S128 hand, S123 R Radial carpal bone bones, S75 fractures, S76S77 Radiocarpal dislocations, S120S121 Radiohumeral dislocation, S108S109 Radioulnar dislocation, distal, S108, S110 Radius/ulna fractures, S19S30 diaphyseal, S23S26 complex groups, S23 subgroups and qualifications, S26 pediatric, S143S149 simple groups, S23 subgroups and qualifications, S24 wedge groups, S23 subgroups and qualifications, S25 distal, S27S30 complete articular groups, S27 subgroups and qualifications, S30 extra-articular groups, S27 subgroups and qualifications, S28 partial articular groups, S27 subgroups and qualifications, S29 pediatric epiphyseal, S149S150 metaphyseal, S148 pediatric combinations, S159S160 proximal, S19S22 articular, surface of one bone groups, S19 subgroups and qualifications, S21 articular, surface of two bones groups, S19 subgroups and qualifications, S22 extra-articular groups, S19 subgroups and qualifications, S20 pediatric epiphyseal/radial head and neck, S140, S143 metaphyseal, S144, S147
S Sacroiliac dislocations, S118 Scaphoid bones, S75 fractures, S76 Scapula dislocations, S104, S107 Scapula fractures, S68S71 extra-articular groups, S68 subgroups, S69 partial articular groups, S68 subgroups, S70 total articular groups, S68 subgroups, S71 Shoulder dislocations, S104S107 Spine dislocations, S111 Spine fractures, S129132 anterior or posterior element injury with distraction, S129, S131 anterior or posterior element injury with rotations, S129, S132 vertebral body compression, S129S130 Sternoclavicular dislocation, S104, S107 Styloid process. See Radius/ulna fractures and dislocations, distal Supracondylar fractures, pediatric, S139S140 Symphysis pubic dislocation, S118S119 T Talus avulsions, process and head fractures, S90S91 body fractures, S90S91 bones, S89 neck fractures, S90S91 Tarsal metatarsal dislocations, S126S127 Thoracic spine dislocation, S111 Tibia/fibula fractures and dislocations, combinations, pediatric, S159 Tibia/fibula fractures, S43S58 diaphyseal, S47S50 complex groups, S47 subgroups and qualifications, S50 simple groups, S47 subgroups and qualifications, S48 wedge groups, S47 subgroups and qualifications, S49 distal, S51S54 complete articular groups, S53
subgroups and qualifications, S54 extra-articular groups, S51 subgroups and qualifications, S52 partial articular groups, S53 subgroups and qualifications, S53 malleolar, S55S58 infrasyndesmotic groups, S55 subgroups and qualifications, S56 suprasyndesmotic groups, S55 subgroups and qualifications, S58 transsyndesmotic groups, S55 subgroups and qualifications, S57 proximal, S43S46 complete articular groups, S43 subgroups and qualifications, S46 epiphyseal, pediatric, S153 extra-articular groups, S43 subgroups and qualifications, S44 partial articular groups, S43 subgroups and qualifications, S45 Tibiofemoral dislocations, S113S114 Tibiofibular dislocations, S113, S116S117 Trapezium fractures, S77 Trapezoid fractures, S77 Triquetrum fractures, S77 Trochlear fractures, S15, S17 Tuberosity, avulsion of, S7S8 U Ulna. See Radius/ulna Ulnar carpal bone bones, S75 fractures, S76 Ulnohumeral dislocation, S108S109 V Vertebral body compression fractures, S129S130 W Wrist dislocations, S120S121 Y Young-Burgess classification, S59
S163

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INTRODUCTION

Fracture and Dislocation Classification Compendium - 2007

THE RATIONALE FOR REPUBLISHING

J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007

Journal of Orthopaedic Trauma Volume 21, Number 10 Supplement, November/December 2007

FUNDAMENTALS OF FRACTURE CLASSIFICATION

ADVANTAGES OF A COMPREHENSIVE CLASSIFICATION OF FRACTURES

Journal of Orthopaedic Trauma Volume 21, Number 10 Supplement, November/December 2007

FRACTURE CLASSIFICATION: ISSUES WITH OBSERVER RELIABILITY

Journal of Orthopaedic Trauma Volume 21, Number 10 Supplement, November/December 2007

NEW INITIATIVES IN CLASSIFICATION OVER 10 YEARS

Journal of Orthopaedic Trauma Volume 21, Number 10 Supplement, November/December 2007

A Mller-AO classification system

B OTA classification system

FIGURE 1. Designation of bone location

THE PROCESS OF REVISING THE COMPENDIUM

Journal of Orthopaedic Trauma Volume 21, Number 10 Supplement, November/December 2007

Introductory Message from the AO Classification Supervisory Committee

2007 Lippincott Williams & Wilkins

BONE: HUMERUS (1)

Location: Proximal segment (11)

Types: A. Extra-articular, unifocal fracture (11-A)

B. Extra-articular, bifocal fracture (11-B)

C. Articular fractures (11-C)

2007 Lippincott Williams & Wilkins

J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007

3. Multifragmentary (11-A3.3) (1) wedge (2) complex (3) glenohumeral dislocation

2007 Lippincott Williams & Wilkins

3. Posterior plus greater tuberosity (11-B1.3)

2007 Lippincott Williams & Wilkins

J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007

3. Anatomical neck (11-C1.3) (1) nondisplaced (2) displaced

3. Cephalotubercular fragmentation (11-C3.3) (1) head intact (2) head fragmented

2007 Lippincott Williams & Wilkins

J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007

BONE: HUMERUS (1)

Location: Diaphyseal segment (12)

Types: A. Simple fracture (12-A)

B. Wedge fracture (12-B)

C. Complex fracture (12-C)

3. Transverse (30) (12-A3)

3. Fragmented wedge (12-B3)

2007 Lippincott Williams & Wilkins

J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007

3. Distal zone (12-A1.3)

3. Distal zone (12-A2.3)

3. Distal zone (12-A3.3)

2007 Lippincott Williams & Wilkins

3. Distal zone (12-B1.3)

3. Distal zone (12-B2.3)

3. Distal zone (12-B3.3)

2007 Lippincott Williams & Wilkins

J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007

3. With more than 3 intermediate fragments (12-C1.3)

2007 Lippincott Williams & Wilkins

J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007

BONE: HUMERUS (1)

Location: Distal segment (13)

Types: A. Extra-articular fracture (13-A)

B. Partial articular fracture (13-B)

C. Complete articular fracture (13-C)

articular (13-C) 3. Articular, metaphyseal multifragmentary (13-C3)

2007 Lippincott Williams & Wilkins