clasificacion ao 2007

J Orthop Trauma • Volume 21, Number 10 Supplement, November/December 2007 S1

Summary: The purpose of this new classification compendium is torepublish the Orthopaedic Trauma Association’s (OTA) classification.The OTA classification was originally published in a compendium ofthe Journal of Orthopaedic Trauma in 1996. It adopted TheComprehensive Classification of the Long Bones developed by Müllerand colleagues and classified the remaining bones. In this com-pendium, the introductory chapter reviews new scientific informationabout classifying fractures that has been published in the last 11 years.The classification is presented in a revised format that is easier to fol-low. The OTA and AO classification will now have a unified alpha-numeric code eliminating the differences that have existed betweenthe 2 codes. The code was significantly revised for the clavicle andscapula, foot and hand, and patella. Dislocations have been expandedon an anatomic basis and for most joints will be coded separately. Thispublication should stimulate new developments and interest in a uni-fied language to code and classify fractures. Further improvements inclassification 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 ofOrthopaedic Trauma (JOT) in 1996.1 It adopted TheComprehensive Classification of Fractures of the Long Bones developed by Müller and collaborators,2 classified bonesthat had not been previously classified and revised the alpha-

numeric code developed by the Müller group. In their introduc-tion to the 1996 compendium, the Coding and ClassificationCommittee noted that the goal of the comprehensive classifica-tion was to classify fractures in a uniform and consistent fash-ion to allow standardization of research and communication.1

The committee observed that the current state of fracture clas-sification was ineffective for these purposes with multiple di-verse systems used in different parts of the skeleton for variouspurposes, thwarting any possibility of a standardized languageand accumulation of uniform data. Their intent was for the newclassification to be a flexible, evolving classification system inwhich changes would be made based on comment, criticismand appropriate clinical research. In this way the classificationcould continue to optimally serve the needs of orthopedic trau-matologists for both clinical practice and research.

Since the compendium was published in 1996, the classi-fication has resided on the OTA website and has been regularlyused in trauma databases in North American Trauma Centers. Itis the official classification of the OTA and of the JOT. In theseways it has developed wide acceptance and has dramatically im-proved the way information about fractures is communicated,stored, and used to advance knowledge through clinical re-search. In some anatomic areas this classification has largelysupplanted all others, achieving one of the original intents.

Unfortunately, the OTA classification has not achievedsome of its originally stated goals. It has not been modifiedsince 1996 and therefore it has not been the flexible, evolv-ing classification envisioned when it was published. It alsohas not become a truly universal language of communicationbecause multiple other anatomically specific classificationsstill 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 hasbeen published about fracture classification in general and theOTA system in particular. Factors leading to poor reliabilityand reproducibility of fracture classifications have been inten-sively studied. These studies have led to important new infor-mation on how clinicians interpret images of fractures onradiographs and the process by which fractures are classified.Unfortunately, difficulties with classification reliability haveled to some loss of enthusiasm with the classification process.It is now widely recognized that, to ensure that any classifica-tion is suitably reliable, it must undergo an intense and rigor-ous scientific scrutiny. The effort required is considerable,and this difficult process has either been ignored or avoidedin favor of popular and widely used classifications.

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 Audigé, DVM, PhD‡‡

From the *Department of Orthopaedics and Rehabilitation, The University of IowaHospitals and Clinics, Iowa City, IA; †Department of Paediatric Surgery,Paediatric Trauma and Orthopaedics, University Children's Hospital, BernSwitzerland; ‡Department of Orthopaedics, Harborview Medical Center, Seattle,WA; §Greenville University Medical Center, Greenville, SC; �Department ofOrthopaedic Surgery, Boston University Medical Center, Boston, MA;¶Department of Orthopaedics and Rehabilitation, University of New Mexico,Albuquerque, NM; #University of Wisconsin, Madison, WI; **Department ofOrthopaedics, New Jersey Medical School, Newark, NJ; ††Orthopaedic Trauma,St. Elizabeth Health Center, Orthopaedic Surgery Northeast Ohio UniversitiesCollege of Medicine, Youngstown, OH; ‡‡AO Clinical Investigation andDocumentation, Dübendorf, Switzerland

Disclosure: Dr. Henley is a consultant for Zimmer. The remaining authors reportno conflicts of interest.

Material presented in this Compendium is based on the ComprehensiveClassification of Fractures of Long Bones, by M.E. Müller, J. Nazarian, P.Koch and J. Schatzker, Springer-Verlag, Berlin, 1990. The OrthopaedicTrauma Association is indebted to Professor Maurice Müller for allowing theAssociation 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: [email protected]).

Copyright © 2007 by Lippincott Williams & Wilkins

INTRODUCTION

The purpose of this new classification compendium is torepublish the OTA classification. There are many reasons to dothis. It will further a cohesive collaboration between the OTAClassification, Database and Outcomes Committee and theArbeitsgemeinschaft für Osteosynthesefragen ClassificationTask Force (AO/CTF) group and will publish the unified cod-ing agreed upon by the two groups (Fig. 1). This will furtherthe original goal of developing an internationally recognizeduniform means to communicate about and perform clinical re-search on fractures and dislocations. This introductory chap-ter discusses the advantages and disadvantages of the uniformclassification as it has existed for the past 10 years, reviewsnew scientific information on fracture classification, high-lights the successes that have been realized, summarizes thedrawbacks to systematic classification of fractures, and de-scribes the process the OTA Classification, Database andOutcomes Committee has gone through to modify the exist-ing classification and adopt a new uniform alpha-numericcode as proposed by the AO/CTF group.

FUNDAMENTALS OF FRACTURE CLASSIFICATION

Classification is the process by which related groups areorganized based on similarities and differences.3 It condensesthe language necessary to convey information among individ-uals with a similar understanding of the classification. Abroad and diverse topic such as fractures lends itself well tothe classification process. We all classify fractures as part ofour standard description of an injury. In describing a fracture,we identify a bone, define a region in the bone, and routinelydescribe displacement and comminution and location of frac-ture lines with respect to relevant anatomy. In these ways weare verbally classifying the fracture as we describe it. Formalclassification of fractures systematizes this descriptiveprocess and replaces words with categories and numbers orletters that convey the same information. Fracture classifica-tion allows information about fractures to be stored in a waythat facilitates comparisons among different groups or amongsimilar groups treated differently.

A good fracture classification fulfills some fundamentalobjectives. It should provide a reliable and reproduciblemeans of communication. Different observers (reliability) orthe same observer on repeated viewings (reproducibility) pre-sented with the same material (for example, a radiograph)must agree on the classification of a fracture a high percent-age of the time. If this is not the case, the classification hasfailed in its fundamental goal—a means to communicate in-formation based on agreed similarities and differences.

There should be clear clinical relevance for the groupswithin the classification that relate either to treatment guide-lines, to prognosis, or to risk for complications. Without clini-cal relevance there is no good reason to define and separatedifferent groups. To ensure that this relevance is present,prospective clinical research is necessary. Generally speaking,the hierarchy of a classification should proceed from less se-vere (as defined by energy of injury, difficulty of treatment, orpatient outcome) to more severe, because classification is thefundamental way to convey information about injury severity.Another type of hierarchy used in both the OTA and the AOclassification organizes fractures within a class from less to

more detailed injury descriptions. This enables a rater to uti-lize the appropriate complexity to suit his or her purposes.This characteristic is relatively unique to this classification butits utility has not been widely employed in the past 11 years.Most good fracture classifications are organized with these hi-erarchies. Ideally, a classification should be all-inclusive (allfractures within reason in a given region should be included)and mutually exclusive (a given fracture should fit in only onecategory). Finally, a classification should be logical, compre-hensible, and should not contain an unmanageable number ofcategories, a problem that ensures poor reliability.4

Many different characteristics of fractures have beenused as the basis of fracture classification systems. Most clas-sifications, such as the OTA classification, are based on theanatomic location and the morphology of the fracture.1 Thesefeatures can simply be observed or formal measurements maybe necessary. Most commonly the observations and measure-ments are made on radiographs but in some circumstances in-formation obtained on physical exam, history orintra-operative findings is considered as part of the classifica-tion process. Other features of a fracture, such as the mecha-nism of injury or associated injuries, may be used indetermining how the fracture should be classified.5 Unless theinformation necessary to classify a fracture and how this infor-mation is assessed are precisely defined, observers will use theclassification in different ways and reliability will suffer.

To serve the purposes of populating large trauma data-bases, such as those used at many major trauma centers, and toprovide a space efficient shorthand across languages, a stan-dardized alpha-numeric code for all fractures is necessary andhas always been a part of this system, another relativelyunique feature. Site-specific classifications must be replacedwith a systematic, orderly classification system that encom-passes fractures of the entire skeleton. This is absolutely nec-essary for multi center collaboration, retrospective comparisonof results, international communication and for ease of accom-plishing the task of recording information about all fractures ina trauma database. Although site-specific research is possiblewithout a comprehensive classification, the more one systemis used consistently for all purposes, the closer we come to auniform universal language for fracture care. We believe thatthis is a goal that continues to be worth pursuing and is one ofthe fundamental advances of the comprehensive classifica-tions of Müller at al2 and the OTA classification.1

ADVANTAGES OF A COMPREHENSIVECLASSIFICATION OF FRACTURES

The publication of the English edition of The Compre-hensive Classification of Fractures of Long Bones by Müller atal in 1990 and the subsequent publication of the OTA classifi-cation in the 1996 JOT compendium were landmark advancesin fracture classification compared to the state of the art thatwas current at that time.1,2 Before these publications, a system-atic classification of fractures throughout the skeleton was notavailable. Eponyms were rampant—Colles fracture is an exam-ple used to designate diverse patterns of distal radius fracturesvariably including intra-articular and extra-articular patterns,partial and total articular comminution, and variable amountsof angulation and displacement. Trauma databases were essen-tially not possible. Classifications were developed by individ-

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

S2 © 2007 Lippincott Williams & Wilkins

ual investigators to suit their own purposes and were widelydisseminated not only in publications but in book chapters andother non scientific works. There was no uniform language thatrelated to injury severity. Some of the terminology of theseclassifications has now become commonplace, such as partialand total articular fractures.

The vision of Müller and colleagues and the collabora-tion of the OTA dramatically changed the field of fractureclassification.1,2 These widely adopted classifications are nowused internationally and have partially achieved a universallanguage for fracture communication. They are all-inclusivewith all bones and all fractures included, and each category,with only a very few exceptions, is mutually exclusive. Theyinclude common criteria (extra-articular, partial articular,total articular) throughout the skeleton, which makes it possi-ble for even relatively inexperienced practitioners to achievethe basics of using the classification at the type and grouplevel. However, experience has shown that this should not bepushed to an extreme because certain areas of the skeleton areamenable and others are not. For this reason, in someanatomic areas in this revision we have used criteria that areanatomically specific and clinically relevant.

Another advantage of the comprehensive classificationsis that there are clear definitions of the various groups and sub-groups. For example, the localization within a long bone is de-fined by the rule of squares to define the three areas in the bone(proximal, shaft, distal).2 This may appear simplistic, but mostother commonly used classifications do not adequately definethe fracture types or groups or even what fractures belong in theclassification. For example, the Schatzker classification is ofproximal tibia fractures but fails to define how a proximal tibiafracture should be distinguished from a shaft fracture.6

Therefore, not only is there uncertainty within the groups butexactly which fractures are chosen to be classified and whichones are not is not clearly communicated. Investigators are freeto use the classification in whatever way suits their purpose.

There have also been criticisms of the comprehensiveclassification systems and areas in which the original goalshave not been achieved. With 27 subgroups in each of theareas, it is easy to conclude that it is too complex and over-whelming for the average user. As the complexity increasesobserver reliability decreases. Although these concerns arevalid, one of the advantages of the design of this classificationis that it lends itself to use of as much or as little of the in-creasing complexity of the types, groups, and subgroups as isneeded for a given purpose or a given user. For example, re-search projects may require more detail, whereas routinedatabase entries may have less detail. Another problem is thatmany of the criteria that distinguish among groups and sub-groups may be of unknown or little clinical significance, ren-dering the complexity of the classification of minimal value.Further clinical research is necessary to refine groups intothose that have maximal clinical significance for either treat-ment techniques, risks of complications, or clinical outcomes.

FRACTURE CLASSIFICATION: ISSUES WITH OBSERVER RELIABILITY

The importance of careful scrutiny of the observer reli-ability of fracture classifications became increasingly appar-ent in the early 1990s and remains a major issue for fracture

classification. The language and assumptions we use to groupfractures was seriously questioned, and the lessons learnedcontinue to be of utmost importance today. In a 1993 publica-tion in the Journal of Bone and Joint Surgery, Siebenrock andGerber assessed the observer reliability of the Neer classifica-tion of proximal humerus fractures.7 This important classifi-cation was and still is one of the most commonly usedclassifications in fracture care. It fulfills many of the goals ofa good classification because it provides a way to communi-cate critically important information about proximal humerusfractures. Decisions on treatment and determinants of out-come are based on categories determined by defining the re-lationships between four typical fracture parts of the proximalhumerus. Unfortunately this important work demonstratedthat the observer reliability of this classification was muchpoorer than expected. This data created a wave of contro-versy, with many surgeons criticizing the data and the meth-ods. However, further publications on the Neer and manyother fracture classifications have demonstrated that the useof categorical classifications is generally not highly reliable,and that these problems must be acknowledged and the issuesthat lead to them carefully studied.8–12 The fact that reliabil-ity is far less than perfect in many common fracture classifi-cations is no longer a disputed issue.

The reasons for poor reliability have been extensively in-vestigated, and together these investigations constitute a signif-icant body of work produced over the past 10-14 years.Investigators have studied the effect on classification reliabilityof clinician experience,8–11 complex imaging studies,8,12–15

traced lines on radiographs,16 multiple radiographic views,10,17

number of categories,8,18–22 binary decision making,23 abilityto measure displacements,24,25 and to determine basic fractureassessments (comminuted or not; displaced or not).24 These in-vestigations have demonstrated that even under the most idealconditions with experienced clinicians, clear group definitions,and excellent imaging studies, observer disagreement still oc-curs. It can be decreased but not eliminated.

There are many reasons for observer disagreement inclassifying fractures. Some of them can be improved throughvalidated development of a classification and determining cate-gories but others present limitations to the degree that observerreliability can be achieved with categorical classifications.Observers have inherent biases based on their personal experi-ences that lead them to different conclusions on the basis of thesame information. Even without this bias they make errors suchas failing to see a fracture line that others agree is present.26

These problems are inevitable and cannot be overcome. Anotherfundamental issue is that fracture classification is in many waysan assessment of injury severity. Classifying a fracture andtherefore its severity places it within a specific category whereasin reality fracture severity occurs on a continuous spec-trum.21,27,28 Some injuries are on the border between one cate-gory and another, making observer disagreement inevitable.

Despite these issues, observer reliability is better in somecircumstances than in others and for some classifications thanfor others. Not surprisingly most studies have shown that expe-rienced clinicians usually classify fractures more reliably thanless experienced clinicians, although the effect is variable in dif-ferent studies.9–11 Reliability can be improved by modificationsof existing classifications or during the development of newclassifications by a systematic methodological approach.29

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

© 2007 Lippincott Williams & Wilkins S3

Through these methods, problems that are now known to in-crease observer error and disagreement can be readily identifiedand minimized as much as possible. Categories within a classi-fication should be as discrete as possible because less discretecategories lead to wide gray zones and thus increase observerdisagreement. For example, if a category is defined by asking ifa fracture line enters the articular surface, a clear judgment canbe made. However, if the category is defined by the presence orabsence of fracture comminution, this less clear assessment(how is comminuted defined?) increases the chances for dis-agreement.24 Similarly, subjective assessments perform poorly,such as a category defined by a high energy mechanism espe-cially without definition of what this phrase means.24 To the ex-tent possible, categories should be uniquely defined. As anexample, assessing whether the physis is either involved with afracture or is not is a more uniquely defined assessment thanwhether the fracture is angulated or not. The latter leaves roomfor various interpretations of angulation. If measurements areused to define categories the degree of error in measuring mustbe considered and minimized. For example, the degree of dis-placement of the articular surface in millimeters has been shownto have high observer error, which means that this commonlyused assessment is a poor way to define categories.24,30 Somemeasurements are impossible to make. A category defined asgreater or less than 1 centimeter of displacement between frag-ments (eg, the greater tuberosity from the rest of the humerus)requests an observer to measure something on radiographs thatare often exposed in a plane that makes this measurement im-possible, relegating the assignment of a fracture category to aguess unless multiple, carefully exposed radiographs in variousdegrees of rotation are evaluated.17 Moreover, categories aresometimes defined according to a pre-defined cut-off regardinga continuous diagnostic parameter. For example, the obliquityof 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 theyare reliably measured and clinically important, but this may notbe the case.

The Comprehensive Classification developed by Müllerat al and modified and adopted by the OTA has not been im-mune to these problems with observer reliability.1,2 Studies inthe distal radius, distal tibia, proximal tibia, proximalfemur8,18–22 and elsewhere have demonstrated that the observerreliability of the system falls off significantly between the typeand group level and again at the group to subgroup level. It hasgenerally been conceded that for the purposes of clinical re-search 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 de-signed to improve classification rather than merely to defineproblems.25 The rank order method has been used in studies inother clinical areas where categorical classification has provedto be difficult.27 To avoid problems with classification,Buckwalter et al assessed residents’ clinical performance byhaving faculty rank them in relation to each other and then cor-related the rankings with in-training exam scores.31 They foundhigh levels of faculty agreement for relative ranks of residentperformance indicating that the rank order method was an excel-

lent substitute for classification. As problems with categoricalclassification of fractures became apparent, rank order methodshave been applied to fractures. This method avoids the problemwith reliability that occurs when a continuous variable, such asfracture severity, is arbitrarily assigned to categories. Instead, anumber of fractures are ranked in relation to each other by ex-perienced clinicians for severity or for any variable of interest.DeCoster et al and Williams et al have demonstrated that therank order method to assess fracture severity leads to high lev-els of observer agreement in the relative rank betweencases.27,28 This indicates that observers agree on the relativeorder of injury severity but when asked to assign categories theyhave much greater disagreement. In both of these studies, therank order method was used to predict clinical outcomes.27,28

Unfortunately, this method is only amenable to use within a de-fined series of patients because the results cannot be transposedout of the series. It therefore has applicability only for researchpurposes where it can be used as a more reliable way to assignrelative severity than classification. Nork et al have recentlyused this method to assess injury severity in a series of bicondy-lar tibial plateau fractures and have applied the results to deter-mine factors that predict outcome after treatment.32

Considering the problems with previous classificationsanother new initiative in fracture classification has been devel-oped by the AO/CTF group, which has been working on sev-eral site-specific projects to develop new classifications using asystematic methodology in three phases.33 The first develop-ment phase involves clinical experts developing proposals forthe classification system, as well as defining the classificationprocess. This phase is related solely to diagnostics and definesa common language with which surgeons should be able toidentify and classify fractures similarly. Successive pilot agree-ment studies are conducted to ensure that clinical experts cando this, and if they cannot, the proposed system and classifica-tion process is appropriately changed and reevaluated. Such asystematic process has been applied for the development of apediatric long bone classification with very encouraging re-sults.34 An innovative approach using latent class modeling forthe analysis of classification data has been proposed, particu-larly when an acceptable reference standard classificationprocess is lacking.35 The second phase involves a multicenteragreement study to ensure that future users with less clinicalexperience can also classify fractures similarly. Depending onthe results, some modifications toward improvement of the sys-tem may still be proposed.36,37 This creates the basis for a reli-able classification tool to be used in the context of prospectiveclinical studies for evaluation of fracture treatment options andoutcomes in a third validation phase.

The AO/CTF group and the OTA’s Classification, Data-base and Outcomes Committee are collaborating in the devel-opment, validation, and promotion of clinically relevant andwidely accepted classification systems. Internationally recog-nized classification review groups for different body sites arebeing created as an important step forward. Modifications ofnew and existing systems should be evidence-based, ie, pro-posed and supported on the basis of solid validation data.

The AO/CTF group has also integrated approved clas-sification systems into a software named AO COIAC (AOComprehensive Injury Automatic Classifier) to support teach-ing and to facilitate diagnosis and coding of injuries. A skele-ton interface provides access to one of several area-specific



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


A Müller-AO classification system B OTA classification system

Figure 2: Proposal for a unified numbering AO/OTA system

FIGURE 1. Designation of bone location

C New unified classification system

classification modules. Drawing fracture lines or clickingwith the mouse on standard bone drawings aids the classifica-tion process for the user, with successive drop-down menusand classification options. Data can be saved in a relationaldatabase and exported for further analyses and presentations,or printed for the patient’s files. For each injury the classifi-cation data can be collected by several different surgeonsand/or at different times, hence supporting research and vali-dation efforts.33 The group’s initial publications have been ona pediatric long bone classification.34

THE PROCESS OF REVISING THE COMPENDIUM

At the time of the original publication of the OTA classi-fication the committee classified additional bones that were not

included in the original Comprehensive Classification proposedby Müller et al.1,2 This led the committee to make some changesin the overall numeric code which over the past 10 years re-sulted in two somewhat different codes, one used by the AO andone by the OTA. For example, in the original AO system clavi-cle was 91.2 and in the OTA system it was 06, patella 91.1 AOand 34 OTA, and the wrist and hand were 7 in AO and 24, 25and 26 for OTA. In early 2006 the AO/CTF group proposed anew unified numbering scheme to replace both of the previousversions. This proposal was considered and then accepted by theClassification, 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 agreementthere is now one universal alpha-numeric code that promotes theconcept of a universal language for fractures. The original AO

and OTA numbering schemes and the new unified numberingscheme are reproduced in Figure 1 A-C. The body of this com-pendium uses the new unified alpha-numeric code. There are nochanges to the long bone sections (humerus, radius and ulna,femur, and tibia) originally published by Müller et al,2 whichfurther promotes a unified fracture code accepted universally byboth groups.

In addition to accepting and incorporating the unifiednumbering format, other revisions of the OTA classificationwere produced with the help of member volunteers from theorganization. Members participating were asked to independ-ently review assigned sections of the classification and tomake suggestions for improvement in language, descriptions,style and format. All suggestions were collated anatomicallyand then reviewed by the Classification, Database andOutcomes Committee at a full day meeting. Committee mem-bers submitted additional suggestions. All suggestions fromthe member volunteers and committee members were individ-ually considered. Extra consideration was given to sugges-tions that were received from multiple individuals.

After discussion, if the committee unanimously agreedthat suggested revisions were improvements, they wereadopted and included in this volume. The major change that isimmediately apparent relates to format, where many memberssuggested and the committee agreed that all groups (A,B,C)should be presented on the same page rather than split as in the1996 publication. The long bone sections 1–4 were notchanged. The advantages of addressing difficulties with lan-guage and categories identified in these areas by OTA mem-bers and the committee were offset by the important goal offurthering a unified international fracture language. The sec-tions other than long bone (14, 15, 5–8) were updated. Wehave made extensive revisions to the foot and carpus.Metacarpal and metatarsal and phalanges are now exactlyaligned in both the foot and the hand. Dislocations were ex-panded 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 sectionhas been completely revised.

A new part of the classification, the pediatric long boneclassification, has been incorporated directly from the workof the AO/CTF group and is the result of their meticulous sci-entific effort. We sincerely hope that future republications ofthe OTA classification will be able to incorporate additionalchanges resulting from this type of rigorous scientific methodand will therefore need to depend less on committee review.

SUMMARY

Since the original publication of the OTA FractureClassification in the 1996 JOT Compendium, there has beenimportant progress in fracture classification. We are fartheralong toward the goal of a universally accepted fracture lan-guage, but more progress remains to be made. New knowl-edge has helped us to understand how classifications work, orsometimes do not work. Much of this new knowledge hasbeen enlightening; some of it has highlighted areas in whichadditional work is necessary. Advances in fracture care arepossible only through an organized grouping of the pathologypresented by the myriad of fracture patterns and associated in-juries. Republication of the OTA classification in this com-pendium combined with advances in fracture classificationsoftware and scientific methodology by the AO/CTF group,will serve to further this goal. We hope to reinvigorate inter-est in the language we use to communicate and record infor-mation about fractures and dislocations, because it is onlythrough this language that we can collectively learn from ourexperiences to provide better care for future fracture patients.We encourage those interested in fracture care to utilize thisclassification and to participate in further classification im-provements that will lead to the publishing of yet another im-proved version 10 years from now.



Listing of references can be found on page S133.

The AO Classification Supervisory Committee welcomes theopportunity to participate with the Orthopaedic TraumaAssociation (OTA) in the revision of the Compendium onFracture Classification. The original cooperative effort on thisCompendium was started to standardize the classification sys-tem for fractures based upon the work of Maurice Müllerthrough the Comprehensive Classification of Fractures. Thecollaboration of AO with the OTA ensured that this system hasa basic worldwide readership and distribution. This opportunityto attempt to standardize the terminology for fractures and clas-sifications has now led to a revision of the Compendium to dealwith any potential change. Two major events have occurred.First, a truly validated classification for pediatric fractures isnow available. This classification has gone through two criticalstages of internal validation and evaluation and has now beenpublished in pediatric peer-reviewed journals. This is a majorlandmark in the classification literature and development, inthat a classification system has now been validated by accepted

methodology. The OTA and the AO Classification SupervisoryCommittee are continuing this work by developing a validatedscapular fracture classification. This has just begun its firststages of validation. Consequently, it will not appear in this edi-tion of the Compendium but when it has been completed, prob-ably within the next year or year and a half, it will be availableas a supplement. The OTA and AO are firm in their convictionthat all new classifications must be developed on the basis ofbroad, internationally recognized expertise and that appropriatevalidation and verification by the accepted methodology shouldbe carried out before publication and use. It is also hoped thatover the next year or two, there will be an attempt to validatethe comprehensive classification.

Dr. Theddy F. Slongo Chairman of the AO Classification Supervisory Committee Inselspital3010 Bern, Switzerland

Introductory Message from the AO Classification Supervisory Committee

BONE: HUMERUS (1) Location: Proximal segment (11)

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

Groups:Humerus proximal segment, extra-articular unifocal(11-A)1. Avulsion of tuberosity(11-A1)

2. Impactedmetaphysis(11-A2)

3. Non-impactedmetaphysisfracture(11-A3)

B. Extra-articular, bifocal fracture (11-B) C. Articular fractures (11-C)

2. Withoutmetaphysealimpaction(11-B2)

2. Articularfracture im-pacted withmarked dis-placement(11-C2)

Humerus, proximal segment, extra-articular bifocal(11-B)1. With meta-physeal impaction (11-B1)

Humerus, proximal segment, articular fractures(11-C)1. Articular fracture with slight displace-ment impacted valgus fracture(11-C1)

3. Withglenohumeraldislocation(11-B3)

These fractures represent three part fractures, or frac-ture dislocations by the Neer classification.

3. Articularfracture withgleno-humeral dis-location(11-C3)

HUMERUS



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


Subgroups and Qualifications: Humerus, proximal, extra-articular, unifocal tuberosity (11-A1)1. Greater tuberosity not displaced(11-A1.1)

2. Greater tuberosity displaced(11-A1.2)(1) superior, (2) posterior

3. With glenohumeral dislocation(11-A1.3)(1) anterior and medial plus posteriorcephalic notch(2) anterior and medial plus greatertuberosity(3) erecta and greater tuberosity(4) posterior and lesser tuberosity

Humerus, proximal, extra-articular, unifocal, impacted metaphyseal (11-A2)1. Without frontal malalignment (11-A2.1)(1) without sagittal malalignment(2) posterior impaction(3) anterior impaction

2. With varus malalignment (11-A2.2)(1) pure medial impaction(2) posterior and medial impaction(3) anterior and medial impaction

3. With valgus malalignment(11-A2.3)(1) pure lateral impaction(2) posterior and lateral impaction(3) anterior and lateral impaction

Humerus, proximal, extra-articular, unifocal, non-impacted metaphyseal (11-A3)1. Simple with angulation (11-A3.1) 2. Simple with translation (11-A3.2)

(1) lateral(2) medial(3) with glenohumeral dislocation

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

A1

A2

A3

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


Humerus, proximal, extra-articular, bifocal, with metaphyseal impaction (11-B1)1. Lateral plus greater tuberosity (11-B1.1)(1) pure lateral impaction(2) posterior and lateral impaction(3) anterior and lateral impaction

2. Medial plus lesser tuberosity(11-B1.2)(1) pure lateral impaction(2) posterior and lateral impaction(3) anterior and lateral impaction

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

Humerus, proximal, extra-articular, bifocal, without metaphyseal impaction (11-B2)1. Without rotatory displacement of the epiphyseal fracture fragment (11-B2.1)

2. With rotatory displacement of theepiphyseal fragment (11-B2.2)(1) greater tuberosity separated(2) lesser tuberosity separated

3. Multifragmentary metaphysis plusone of the tuberosities (11-B2.3)(1) lesser tuberosity(2) greater tuberosity

Humerus, proximal, extra-articular, bifocal with glenohumeral dislocation (11-B3)1. “Vertical” cervical line plus greater tuberosity intact plus anterior medial dislocation (11-B3.1)

2. “Vertical” cervical line plus greatertuberosity fracture plus anterior me-dial dislocation (11-B3.2)

3. Lesser tuberosity fracture plus pos-terior dislocation (11-B3.3)(1) without anterior cephalic notch(2) with anterior cephalic notch

B1

B2

B3


S10 © 2007 Lippincott Williams & WilkinsS10 © 2007 Lippincott Williams & Wilkins

2. Anatomical neck and tuberosities(11-C3.2)(1) head impacted(2) head not impacted

Humerus, proximal, articular fracture dislocated (11-C3)1. Anatomical neck (11-C3.1)(1) anterior(2) posterior

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

Humerus, proximal, articular fracture with slight displacement (11-C1)1. Cephalotubercular with valgus malalignment (11-C1.1)

2. Cephalotubercular with varusmalalignment (11-C1.2)

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

Humerus, proximal, articular fracture impacted with marked displacement (11-C2)1. Cephalotubercular with valgus malalignment (11-C2.1)

2. Cephalotubercular with varusmalalignment (11-C2.2)

3. Transcephalic (double profile imageon x-ray) and tubercular, with varusmalalignment (11-C2.3)

C1

C2

C3



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 (12-A1)

2. Oblique(��30°) (12-A2)

3. Transverse(��30°) (12-A3)

Humerus diaphyseal, wedge (12-B)1. Spiral wedge (12-B1)

2. Bendingwedge (12-B2)

3. Frag-mentedwedge (12-B3)

Humerus diaphyseal, complex (12-C)1. Spiral (12-C1)

2. Segmental(12-C2)

3. Irregular(12-C3)



Subgroups and Qualifications: Humerus diaphyseal, simple, spiral (12-A1)1. Proximal zone (12-A1.1) 2. Middle zone (12-A1.2) 3. Distal zone (12-A1.3)

Humerus diaphyseal, simple, oblique (��30°) (12-A2)1. Proximal zone (12-A2.1) 2. Middle zone (12-A2.2) 3. Distal zone (12-A2.3)

Humerus diaphyseal, simple, transverse (��30°) (12-A3)1. Proximal zone (12-A3.1) 2. Middle zone (12-A3.2) 3. Distal zone (12-A3.3)

A1

A2

A3



2. Middle zone (12-B2.2) 3. Distal zone (12-B2.3)Humerus diaphyseal, wedge, bending (12-B2)1. Proximal zone (12-B2.1)

Humerus diaphyseal, wedge, spiral (12-B1)1. Proximal zone (12-B1.1) 2. Middle zone (12-B1.2) 3. Distal zone (12-B1.3)

Humerus diaphyseal, wedge, fragmented (12-B3)1. Proximal zone (12-B3.1) 2. Middle zone (12-B3.2) 3. Distal zone (12-B3.3)

B1

B2

B3



Humerus, diaphyseal, complex irregular (12-C3)1. With 2 or 3 intermediate fragments (12-C3.1)(1) 2 main intermediate fragments(2) 3 main intermediate fragments

2. With limited shattering (��4cm)(12-C3.2)(1) proximal zone(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

Humerus diaphyseal, complex, spiral (12-C1)(1) pure diaphyseal(2) proximal diaphysio-metaphyseal(3) distal diaphysio-metaphyseal1. With 2 intermediate fragments (12-C1.1)

2. With 3 intermediate fragments (12-C1.2)

3. With more than 3 intermediatefragments (12-C1.3)

Humerus, diaphyseal, complex segmental (12-C2)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

2. With 1 intermediate segmental andadditional 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 segmentalfragments (12-C2.3)(1) pure diaphyseal(2) proximal diaphysio-metaphyseal(3) distal diaphysio-metaphyseal

C1

C2

C3



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)

2. Meta-physealsimple (13-A2)

3. Meta-physeal multi-fragmentary(13-A3)

Groups:Humerus distal segment, extra-articular (13-A)1. Apophyseal avulsion (13-A1)

Humerus distal segment, partial articular (13-B)1. Lateral sagittal (13-B1)

2. Medialsagittal (13-B2)

3. Frontal (13-B3)Humerus distal segment, complete articular (13-C)1. Articular simple, metaphyseal simple (13-C1)

2. Articularsimple, meta-physeal multi-fragmentary(13-C2)

3. Articular,metaphysealmultifragmen-tary (13-C3)



Subgroups and Qualifications: Humerus, distal, extra-articular apophyseal avulsion (13-A1)1. Lateral epicondyle (13-A1.1) 2. Medial epicondyle, non-incarcerated

(13-A1.2)(1) non-displaced(2) displaced(3) fragmented

3. Medial epicondyle, incarcerated(13-A1.3)

Humerus, distal, extra-articular metaphyseal simple (13-A2)1. Oblique downwards and inwards (13-A2.1)

2. Oblique down-wards and outwards(13-A2.2)

3. Transverse (13-A2.3)(1) transmetaphyseal (2) juxta-epiphyseal

with posterior displace-ment (Kocher I)

(3) juxta-epiphysealwith anterior displace-ment (Kocher II)

Humerus, distal, extra-articular metaphyseal multifragmentary (13-A3)1. With intact wedge (13-A3.1)(1) lateral(2) medial

2. With fragmented wedge (13-A3.2)(1) lateral(2) medial

3. Complex (13-A3.3)

A1

A2

A3



Humerus, distal, partial articular lateral sagittal (13-B1)1. Capitellum (13-B1.1)(1) through the capitellum (Milch I)(2) between capitellum and trochlea

2. Transtrochlear simple (13-B1.2)(1) medial collateral ligament intact(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

Humerus, distal, partial articular, medial sagittal (13-B2)1. Transtrochlear simple, through medial side (Milch I) (13-B2.1)

2. Transtrochlear simple, through thegroove (13-B2.2)

3. Transtrochlear multifragmentary(13-B2.3)(1) epiphysio-metaphyseal(2) epiphysio-metaphyseal-diaphyseal

Humerus, distal, partial articular, frontal (13-B3)1. Capitellum (13-B3.1)(1) incomplete (Kocher-Lorenz)(2) complete (Hahn-Steinthal 1)(3) with trochlear component (Hahn-Steinthal 2)(4) fragmented

2. Trochlea (13-B3.2)(1) simple(2) fragmented

3. Capitellum and trochlea (13-B3.3)

B1

B2

B3



Humerus, distal, complete multifragmentary (13-C3)1. Metaphyseal simple (13-C3.1) 2. Metaphyseal wedge (13-C3.2)

(1) intact(2) fragmented

3. Metaphyseal complex (13-C3.3)(1) localized(2) extending into diaphysis

Humerus, distal complete, articular simple, metaphyseal simple (13-C1)1. With slight displacement (13-C1.1)(1) Y-shaped(2) T-shaped(3) V-shaped

2. With marked displacement(13-C1.2)(1) Y-shaped(2) T-shaped(3) V-shaped

3. T-shaped epiphyseal (13-C1.3)

Humerus, distal, complete articular simple metaphyseal multifragmentary (13-C2)1. With intact wedge (13-C2.1)(1) metaphyseal lateral(2) metaphyseal medial(3) metaphysio-diaphyseal-lateral(4) metaphysio-diaphyseal-medial

2. With a fragmented wedge (13-C2.2)(1) metaphyseal lateral(2) metaphyseal medial(3) metaphysio-diaphyseal-lateral(4) metaphysio-diaphyseal-medial

3. Complex (13-C2.3)

C1

C2

C3

BONE: RADIUS/ULNA (2) Location: Proximal segment (21)

Types:A. Extra-articular (21-A)

Groups:Radius/ulna, proximal, extra-articular (21-A)

1. Ulna only(21-A1)

2. Radius only(21-A2)

3. Radius andulna (21-A3)

B. Articular fracture involving articularsurface of only 1 of the 2 bones (21-B)

C. Articular fracture involving artic-ular surface of 2 bones (21-C)

2. Radius frac-tured, ulna in-tact (21-B2)

2. Simple of1, multifrag-mentary ofother (21-C2)

Radius/ulna, proximal, articular surface one bone(21-B)1. Ulna fractured, radius intact(21-B1)

Radius/ulna, proximal, articular both bones (21-C)

1. Simple of both bones (21-C1)

3. Articular of1 bone, extra-articular ofother (21-B3)

3. Multifrag-mentary ofboth (21-C3)

RADIUS/ULNA



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


Subgroups and Qualifications:Radius/ulna, proximal, extra-articular ulna fractured (21-A1)1. Avulsion of triceps insertion from olecranon (21-A1.1)

2. Metaphyseal simple (21-A1.2) 3. Metaphyseal multifragmentary(21-A1.3)

Radius/ulna, proximal, extra-articular radius fractured (21-A2)1. Avulsion of bicipital tuberosity of radius (21-A2.1)

2. Neck simple (21-A2.2) 3. Neck multifragmentary (21-A2.3)

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)

A1

A2

A3

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


Radius/ulna, proximal, articular, radial fracture (21-B2)1. Simple (21-B2.1)(1) nondisplaced(2) displaced

2. Multifragmentary without depres-sion (21-B2.2)

3. Multifragmentary with depression(21-B2.3)

Radius/ulna, proximal, articular fracture ulna (21-B1)1. UnifocaI (21-B1.1)(1) olecranon 1 line(2) olecranon 2 lines(3) olecranon multifragmentary(4) coronoid process alone

2. Bifocal (21-B1.2) 3. Bifocal multifragmentary (21-B1.3)(1) multifragmentary olecranon(2) multifragmentary coronoid process(3) multifragmentary of both

Radius/ulna, proximal, articular of 1, extra-articular of other (21-B3)1. Ulna articular simple (21-B3.1)(1) radius extra-articular simple(2) radius extra-articular multifragmentary

2. Radius articular simple (21-B3.2)(1) ulna extra-articular simple(2) ulna extra-articular multifragmentary

3. Articular multifragmentary(21-B3.3)(1) ulna, radius extra-articular simple(2) ulna, radius extra-articular multifrag-mentary(3) radius, ulna extra-articular simple(4) radius, ulna extra-articular multifrag-mentary

B1

B2

B3



2. Ulna, more than 3 fragments(21-C3.2)(1) radius, 3 fragments(2) radius, more than 3 fragments

Radius/ulna, proximal, articular multifragmentary both bones (21-C3)1. 3 fragments both bones (21-C3.1) 3. Radius, more than 3 fragments

(21-C3.3)(1) ulna, 3 fragments(2) ulna, epiphysio-diaphyseal

Radius/ulna, proximal, articular both simple (21-C1)1. Olecranon and radial head(21-C1.1)

2. Coronoid process and radial head(21-C1.2)

Radius/ulna, proximal, articular, both bones, 1 simple the other multifragmentary (21-C2)1. Olecranon multifragmentary, radial head, simple (21-C2.1)

2. Olecranon simple, radial head multi-fragmentary (21-C2.2)

3. Coronoid process simple, radialhead multifragmentary (21-C2.3)

C1

C2

C3



BONE: RADIUS/ULNA (2) 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, radius intact(22-A1)

2. Radius sim-ple, ulna intact(22-A2)

3. Simple frac-ture bothbones (22-A3)

Radius/ulna, diaphyseal, wedge fracture (22-B)1. Ulna fracture, radius intact(22-B1)

2. Radius frac-ture, ulna in-tact (22-B2)

3. Wedgefracture, sim-ple or wedgeof other bone(22-B3)

Radius/ulna, diaphyseal, complex (22-C)1. Complex of ulna (22-C1)

2. Complex ofradius (22-C2)

3. Complex ofboth bones(22-C3)



Subgroups and Qualifications:Radius/ulna, diaphyseal, simple fracture of ulna (22-A1) 1. Oblique (22-A1.1) 2. Transverse (22-A1.2) 3. With dislocation of radial head

(Monteggia) (22-A1.3)

Radius/ulna, diaphyseal, simple fracture of radius (22-A2)1. Oblique (22-A2.1) 2. Transverse (22-A2.2) 3. With dislocation of distal radio-

ulnar joint (Galeazzi) (22-A2.3)

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)

A1

A2

A3



Radius/ulna, diaphyseal, wedge fracture of ulna (22-B1)1. Intact wedge (22-B1.1) 2. Fragmented wedge (22-B1.2) 3. With dislocation of radial head

(Monteggia) (22-B1.3)

2. Fragmented wedge (22-B2.2) 3. With dislocation of distal radio-ulnar joint (Galeazzi) (22-B2.3)

Radius/ulna, diaphyseal, wedge fracture of radius (22-B2)1. Intact wedge (22-B2.1)

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(22-B3.1)

2. Radial wedge, simple fracture ofulna (22-B3.2)

3. Radial and ulnar wedge (22-B3.3)

B1

B2

B3



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)

Radius/ulna, diaphyseal, complex fracture of ulna (22-C1)1. Bifocal, radius intact (22-C1.1)(1) without dislocation(2) with radial head dislocated (Monteggia)

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

Radius/ulna, diaphyseal, complex fracture of radius (22-C2)1. Bifocal, ulna intact (22-C2.1)(1) without dislocation(2) with dislocation of distal radioulnar joint (Galeazzi)

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

C1

C2

C3



BONE: RADIUS/ULNA (2) Location: Distal segment (23)

Types:A. Extra-articular (23-A) B. Partial articular fracture of radius (23-B) C. Complete articular fracture of ra-

dius (23-C)

2. Extra-artic-ular simpleradius frac-ture, ulnaintact (23-A2)

3. Extra-articu-lar, multifrag-mentaryradius fracture(23-A3)

Groups:Radius/ulna, distal, extra-articular (23-A)1. Extra-articular ulna fracture, radius intact(23-A1)

Radius/ulna, distal, partial articular radius (23-B)1. Partial articular radius, sagittal (23-B1)

2. Partial artic-ular radius,dorsal rim(Barton)(23-B2)

3. Partial articularradius, volar rim(reverse Barton,Goyrand SmithII) (23-B3)

Radius/ulna, distal, complete articular (23-C)1. Complete articular radius, simple articular and metaphysis(23-C1)

2. Completearticular ra-dius, simplearticular,metaphysealmultifragmen-tary (23-C2)

3. Completearticular ra-dius, multi-fragmentary(23-C3)



Subgroups and Qualifications:Radius/ulna, distal, extra-articular fracture of ulna (23-A1)1. Ulna styloid process (23-A1.1) 2. Metaphyseal simple (23-A1.2) 3. Metaphyseal multifragmentary

(23-A1.3)(1) wedge(2) complex

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 neck1. Transverse, no tilt, but may be axially shortened (23-A2.1)

2. With dorsal tilt, oblique fracture up-ward and back (Pouteau-Colles)(23-A2.2)

3. Volar tilt, oblique upwards and for-ward (Goyrand-Smith) (23-A2.3)

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 neck1. Impacted with axial shortening(23-A3.1)

2. With a wedge (23-A3.2) 3. Complex (23-A3.3)

A1

A2

A3



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 neck1. Lateral simple (23-B1.1) 2. Lateral multifragmentary (23-B1.2) 3. Medial (23-B1.3)

Radius/ulna, distal, partial articular fracture of radius, dorsal rim (Barton’s) (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 neck1. Simple (23-B2.1) 2. With lateral sagittal fracture

(23-B2.2)3. With dorsal dislocation of carpus(23-B2.3)

Radius/ulna, distal, partial articular fracture of radius, volar rim (reverse Barton’s, 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 neck1. Simple with small fragment(23-B3.1)

2. Simple with larger fragment(23-B3.2)

3. Multifragmentary (23-B3.3)

B1

B2

B3



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 neck1. Metaphyseal simple (23-C3.1) 2. Metaphyseal multifragmentary

(23-C3.2)3. Extending into diaphysis (23-C3.3)

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 neck1. Sagittal articular fracture line(23-C2.1)

2. Frontal articular fracture line(23-C2.2)

3. Extending into diaphysis (23-C2.3)

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 neck1. Posteromedial articular fragment(23-C1.1)

2. Sagittal articular fracture line(23-C1.2)

3. Frontal articular fracture line(23-C1.3)

C1

C2

C3

BONE: FEMUR (3) Location: Proximal segment (31)

Types:A. Trochanteric area (31-A)

Groups:Femur, proximal trochanteric (31-A)1. Pertro-chanteric simple(31-A1)

2. Pertro-chantericmultifrag-mentary(31-A2)

3. Intertro-chanteric(31-A3)

B. Neck fractures (31-B) C. Head fractures (31-C)

2. Transcer-vical (31-B2)

2. With de-pression(31-C2)

Femur, proximal, neck fracture (31-B)1. Subcapital with slight displacement(31-B1)

Femur, proximal, head fracture (31-C)1. Split (31-Cl)3. Subcapital

with markeddisplacement(31-B3)

3. With neckfracture(31-C3)

FEMUR



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


Subgroups and Qualifications:Femur, proximal, pertrochanteric simple (only 2 fragments) (31-A1) 1. Along intertrochanteric line(31-A1.1)

2. Through the greater trochanter (31-A1.2)(1) nonimpacted(2) impacted

3. Below lesser trochanter (31-A1.3)(1) high variety, medial fracture line atlower limit of lesser trochanter(2) low variety, medial fracture line in di-aphysis below lesser trochanter

Femur proximal, trochanteric fracture, pertrochanteric multifragmentary (always have posteromedial fragment with lessertrochanter and adjacent medial cortex) (31-A2)1. With 1 intermediate fragment(31-A2.1)

2. With several intermediate frag-ments (31-A2.2)

3. Extending more than 1 cm belowlesser trochanter (31-A2.3)

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

A1

A2

A3

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


Femur, proximal, neck fracture, transcervical (31-B2)1. Basicervical (31-B2.1) 2. Midcervical adduction (31-B2.2) 3. Midcervical shear (31-B2.3)

Femur, proximal, neck fracture, slight displacement (31-B1)1. Impacted in valgus ��15°(31-B1.1) (Garden 1)(1) posterior tilt �15°(2) posterior tilt �15°

2. Impacted in valgus ��15°(31-B1.2) (Garden 1/2)(1) posterior tilt �15°(2) posterior tilt �15°

3. Nonimpacted (31-B1.3) (Garden 2)

Femur, proximal, neck fracture, sub-capital, nonimpacted displaced (31-B3)1. Moderate displacement in varus and external rotation (31-B3.1) (Garden 3)

2. Moderate displacement with verti-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

B1

B2

B3



2. Split and subcapital neck fracture(31-C3.2)

Femur, proximal, head fracture with neck fracture (31-C3) 1. Split and transcervical neck fracture(31-C3.1)

3. Depression and neck fracture (31-C3.3)

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)

Femur, proximal, head fracture, split (31-C1)1. Avulsion of ligamentum teres (31-C1.1)

2. With rupture of ligamentum teres(31-C1.2)

3. Large fragment (31-C1.3)

C1

C2

C3



BONE: FEMUR (3) Location: Diaphyseal segment (32)


Groups:Femur, diaphyseal, simple fracture (32-A)1. Spiral (32-A1) 2. Oblique

(��30°) (32-A2)3. Transverse(��30°) (32-A3)

Femur, diaphyseal, wedge fracture (32-B)1. Spiral wedge(32-B1)


3. Fragmentedwedge (32-B3)

Femur, diaphyseal, complex (32-C)1. Spiral (32-C1) 2. Segmental

(32-C2)3. Irregular(32-C3)



Subgroups and Qualifications:Femur, diaphyseal, simple spiral (32-A1)1. Subtrochanteric zone (32-A1.1) 2. Middle zone (32-A1.2) 3. Distal zone (32-A1.3)

Femur, diaphyseal, simple oblique (��30°) (32-A2)1. Subtrochanteric zone (32-A2.1) 2. Middle zone (32-A2.2) 3. Distal zone (32-A2.3)

Femur, diaphyseal, transverse (��30°) (32-A3)1. Subtrochanteric zone (32-A3.1) 2. Middle zone (32-A3.2) 3. Distal zone (32-A3.3)

A1

A2

A3



Femur, diaphyseal, wedge spiral (32-B1)1. Subtrochanteric zone (32-B1.1) 2. Middle zone (32-B1.2) 3. Distal zone (32-B1.3)

2. Middle zone (32-B2.2) 3. Distal zone (32-B2.3)Femur, diaphyseal, wedge, bending (32-B2)1. Subtrochanteric zone (32-B2.1)

Femur, diaphyseal, wedge fragmented (32-B3)1. Subtrochanteric zone (32-B3.1) 2. Middle zone (32-B3.2) 3. Distal zone (32-B3.3)

B1

B2

B3



Femur, diaphyseal, complex irregular (32-C3)1. With 2 or 3 intermediate fragments(32-C3.1)(1) 2 main intermediate fragments(2) 3 main intermediate fragments

2. With limited shattering (��5cm)(32-C3.2)(1) proximal zone(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

Femur, diaphyseal, complex spiral (32-C1)(1) pure diaphyseal(2) proximal diaphysio-metaphyseal(3) distal diaphysio-metaphyseal1. With 2 intermediate fragments(32-C1.1)

2. With 3 intermediate fragments(32-C1.2)


Femur, diaphyseal, complex segmental (32-C2)1. With 1 intermediate segmental fracture (32-C2.1)(1) pure diaphyseal(2) proximal diaphysio-metaphyseal(3) distal diaphysio-metaphyseal(4) oblique lines(5) transverse and oblique lines

2. With 1 intermediate segmental andadditional wedge fragments (32-C2.2)(1) pure diaphyseal(2) proximal diaphysio-metaphyseal(3) distal diaphysio-metaphyseal(4) distal wedge(5) 2 wedges, proximal and distal


C1

C2

C3



BONE: FEMUR (3) Location: Distal segment (33)

Types:A. Extra-articular (33-A) B. Partial articular (33-B) C. Complete articular (33-C)

Groups:Femur, distal, extra-articular (33-A)1. Simple (33-A1)

2. Meta-physealwedge (33-A2)

3. Metaphyseal complex (33-A3)

2. Medialcondyle,sagittal(33-B2)


Femur, distal, partial articular (33-B)1. Lateral condyle, sagittal (33-B1)

Femur, distal, complete articular (33-C)1. Articular simple, meta-physeal simple (33-C1)

3. Frontal(33-B3)

3. Multifrag-mentaryarticular fracture(33-C3)



Subgroups and Qualifications:Femur, distal, extra-articular simple (33-A1)1. Apophyseal (33-A1.1)(1) avulsion lateral epicondyle(2) avulsion medial epicondyle

2. Metaphyseal oblique or spiral(33-A1.2)

3. Metaphyseal transverse (33-A1.3)

Femur, distal, extra-articular, metaphyseal wedge (33-A2)1. Intact wedge (33-A2.1)(1) lateral(2) medial

2. Fragmented lateral (33-A2.2) 3. Fragmented medial (33-A2.3)

Femur, distal, extra-articular, metaphyseal complex (33-A3)1. With an intermediate split segment(33-A3.1)

2. Irregular limited to metaphysis(33-A3.2)

3. Irregular extending to diaphysis(33-A3.3)

A1

A2

A3



Femur, distal, partial articular, lateral condyle, sagittal (33-B1)1. Simple through the notch (33-B1.1) 2. Simple through load bearing sur-

face (33-B1.2)3. Multifragmentary (33-B1.3)

Femur, distal, partial articular, medial condyle, sagittal (33-B2)1. Simple through notch (33-B2.1) 2. Simple through load bearing sur-

face (33-B2.2)3. Multifragmentary (33-B2.3)

Femur, distal, partial articular, frontal (33-B3)1. Anterior and lateral flake fracture(33-B3.1)

2. Unicondylar posterior (Hoffa)(33-B3.2)(1) lateral(2) medial

3. Bicondylar posterior (33-B3.3)

B1

B2

B3



Femur, distal, complete articular, articular multifragmentary (33-C3)1. Metaphyseal simple (33-C3.1) 2. Metaphyseal multifragmentary

(33-C3.2)3. Metaphysio-diaphyseal multifrag-mentary (33-C3.3)

Femur, distal, complete articular, articular simple, metaphyseal simple (33-C1)1. T- or Y-shaped with slight displace-ment (33-C1.1)

2. T- or Y-shaped with marked dis-placement (33-C1.2)

3. T-shaped epiphyseal (33-C1.3)

Femur, distal, complete articular, articular simple, metaphyseal multifragmentary (33-C2)1. With intact wedge (33-C2.1)(1) lateral(2) medial

2. With fragmented wedge (33-C2.2)(1) lateral(2) medial


C1

C2

C3

BONE: TIBIA/FIBULA (4) Location: Proximal segment (41)

Types:A. Extra-articular (41-A)

Groups:Tibia/fibula, proximal, extra-articular (41-A)1. Avulsion(41-A1)

2. Metaphy-seal simple(41-A2)

3. Metaphysealmultifragmen-tary (41-A3)

B. Partial articular (41-B) C. Complete articular (41-C)

2. Pure de-pression(41-B2)


Tibia/fibula, proximal, partial articular (41-B)1. Pure split(41-B1)

Tibia/fibula, proximal, complete articular (41-C)1. Articular simple, meta-physeal simple(41-C1)

3. Split de-pression(41-B3)

3. Articularmultifrag-mentary(41-C3)

TIBIA/FIBULA



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


Subgroups and Qualifications:Tibia/fibula, proximal, extra-articular, avulsion (41-A1)1. Of fibular head (41-A1.1) 2. Of tibial tuberosity (41-A1.2) 3. Of cruciate insertion (41-A1.3)

(1) anterior(2) posterior

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)

Tibia/fibula, proximal, extra-articular, multifragmentary metaphysis (41-A3)1. Intact wedge (41-A3.1)(1) lateral(2) medial

2. Fragmented wedge (41-A3.2)(1) lateral(2) medial

3. Complex (41-A3.3)(1) slightly displaced(2) significantly displaced

A1

A2

A3

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


Tibia/fibula, proximal, partial articular, depression (41-B2)1. Lateral total (41-B2.1)(1) 1 piece(2) mosaic-like

2. Lateral limited (41-B2.2)(1) peripheral(2) central(3) anterior(4) posterior

3. Medial (41-B2.3)(1) central(2) anterior(3) posterior(4) total

Tibia/fibula, proximal, partial articular, split (41-B1)1. Of lateral surface (41-B1.1)(1) marginal(2) sagittal(3) frontal anterior(4) frontal posterior

2. Of medial surface (41-B1.2)(1) marginal(2) sagittal(3) frontal anterior(4) frontal posterior

3. Oblique, involving the tibial spinesand 1 of the surfaces (41-B1.3)(1) lateral(2) medial

Tibia/fibula, proximal, partial articular, split depression (41-B3)1. Lateral (41-B3.1)(1) antero-lateral depression(2) postero-lateral depression(3) antero-medial depression(4) postero-medial depression

2. Medial (41-B3.2)(1) antero-lateral depression(2) postero-lateral depression(3) antero-medial depression(4) postero-medial depression

3. Oblique involving the tibial spinesand 1 of the surfaces (41-B3.3)(1) lateral(2) medial

B1

B2

B3



2. Medial (41-C3.2)

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 complex1. Lateral (41-C3.1) 3. Lateral and medial (41-C3.3)

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 involved1. Slight displacement (41-C1.1) 2. 1 condyle displaced (41-C1.2) 3. Both condyles displaced (41-C1.3)

Tibia/fibula, proximal, complete articular, articular simple, metaphysis multifragmentary (41-C2)1. Intact wedge (41-C2.1)(1) lateral(2) medial

2. Fragmented wedge (41-C2.2)(1) lateral(2) medial


C1

C2

C3



BONE: TIBIA/FIBULA (4) Location: Diaphyseal segment (42)


Groups:Tibia/fibula, diaphyseal, simple (42-A)1. Spiral (42-A1) 2. Oblique

(��30°) (42-A2)3. Transverse(��30°)(42-A3)

Tibia/fibula, diaphyseal, wedge (42-B)1. Spiral wedge(42-B1)


3. Frag-mentedwedge (42-B3)

Tibia/fibula, diaphyseal, complex (42-C)1. Spiral(42-C1)

2. Segmented(42-C2)

3. Irregular(42-C3)



Subgroups and Qualifications:Tibia/fibula, diaphyseal, simple, spiral (42-A1)(1) proximal zone(2) middle zone(3) distal zone1. Fibula intact (42-A1.1) 2. Fibula fracture at different level

(42-A1.2)3. Fibula fracture at same level(42-A1.3)

Tibia/fibula, diaphyseal, simple, oblique (�30°) (42-A2)(1) proximal zone(2) middle zone(3) distal zone1. Fibula intact (42-A2.1) 2. Fibula fracture at different level


Tibia/fibula, diaphyseal, simple, transverse (<30°) (42-A3)(1) proximal zone(2) middle zone(3) distal zone1. Fibula intact (42-A3.1) 2. Fibula fracture at different level


A1

A2

A3



Tibia/fibula, diaphyseal, wedge, spiral (42-B1)(1) proximal zone(2) middle zone(3) distal zone1. Fibula intact (42-B1.1) 2. Fibula fracture at different level

(42-B1.2)3. Fibula fracture at same level(42-B1.3)

2. Fibula fracture at different level(42-B2.2)

3. Fibula fracture at same level(42-B2.3)

Tibia/fibula, diaphyseal, wedge, bending (42-B2)(1) proximal zone(2) middle zone(3) distal zone1. Fibula intact (42-B2.1)

Tibia/fibula, diaphyseal, wedge fragmented (42-B3)(1) proximal zone(2) middle zone(3) distal zone1. Fibula intact (42-B3.1) 2. Fibula fracture at different level

(42-B3.2)3. Fibula fracture at same level(42-B3.3)

B1

B2

B3



Tibia/fibula, diaphyseal, complex, irregular (42-C3)1. With 2 or 3 intermediate fragments(42-C3.1)(1) 2 intermediate fragments(2) 3 intermediate fragments

2. Limited shattering (��4cm)(42-C3.2)

3. Extensive shattering (��4cm)(42-C3.3)(1) pure diaphyseal(2) proximal diaphysio-metaphyseal(3) distal diaphysio-metaphyseal

Tibia/fibula, diaphyseal, complex, spiral (42-C1)(1) pure diaphyseal(2) proximal diaphysio-metaphysis(3) distal diaphysio-metaphysis1. With 2 intermediate fragments(42-C1.1)

2. With 3 intermediate fragments(42-C1.2)


Tibia/fibula, diaphyseal, complex segmental (42-C2)1. With an intermediate segmental fragment (42-C2.1)(1) pure diaphyseal(2) proximal diaphysio-metaphyseal(3) distal diaphysio-metaphyseal(4) oblique lines(5) transverse and oblique lines

2. With an intermediate segmentaland additional wedge fragment(s)(42-C2.2)(1) pure diaphyseal(2) proximal diaphysio-metaphyseal(3) distal diaphysio-metaphyseal(4) distal wedge(5) 3 wedges, proximal and distal


C1

C2

C3



BONE: TIBIA/FIBULA (4) Location: Distal segment (43)

Types:A. Extra-articular (43-A) B. Partial articular (43-B) C. Complete articular (43-C)

2. Metaphy-seal wedge(43-A2)

3. Metaphy-seal complex(43-A3)

Groups:Tibia/fibula, distal, extra-articular (43-A)1. Metaphyseal simple (43-A1)

Tibia/fibula, distal, partial articular (43-B)1. Pure split(43-B1)

2. Split de-pression(43-B2)

3. Multifragmen-tary depression(43-B3)

Tibia/fibula, distal, complete articular (43-C)1. Articular simple, meta-physis simple(43-C1)

2. Articularsimple, meta-physis multi-fragmentary(43-C2)

3. Articularmultifragmen-tary (43-C3)



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 fibula1. Spiral (43-A1.1) 2. Oblique (43-A1.2) 3. Transverse (43-A1.3)

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 fibula1. Posterolateral impaction (43-A2.1) 2. Anteromedial wedge (43-A2.2) 3. Extending into diaphysis (43-A2.3)

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 fibula1. With 3 intermediate fragments(43-A3.1)

2. More than 3 intermediate frag-ments (43-A3.2)

3. Extending into diaphysis (43-A3.3)

A1

A2

A3



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 fibula1. Frontal (43-B1.1)(5) anterior(6) posterior (Volkmann)

2. Sagittal (43-B1.2)(5) lateral(6) medial (medial malleolus)

3. Metaphyseal multifragmentary(43-B1.3)

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 fibula1. Frontal (43-B2.1)(5) anterior(6) posterior

2. Sagittal (43-B2.2)(5) lateral(6) medial

3. Of the central fragment (43-B2.3)

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 fibula1. Frontal (43-B3.1)(5) anterior(6) posterior

2. Sagittal (43-B3.2)(5) lateral(6) medial

3. Metaphyseal, multifragmentary(43-B3.3)

B1

B2

B3



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 fibula1. Epiphyseal (43-C3.1) 2. Epiphysio-metaphyseal (43-C3.2) 3. Epiphysio-metaphysio-diaphyseal

(43-C3.3)

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 fibula1. Without impaction (43-C1.1)(5) frontal plane(6) sagittal plane

2. With epiphyseal depression(43-C1.2)


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 fibula1. With asymmetric impaction(43-C2.1)(5) frontal plane split(6) sagittal plane split

2. Without asymmetric impaction(43-C2.2)


C1

C2

C3



BONE: TIBIA/FIBULA (4) Location: Malleolar segment (44)

Types:A. Infrasyndesmotic lesion (44-A)

Groups:Tibia/fibula, malleolar, infrasyndesmotic lesions (44-A)1. Isolated(44-A1)

2. With me-dial malleolarfracture(44-A2)

3. With postero-medialfracture(44-A3)

B. Transsyndesmotic fibula fracture (44-B) C. Suprasyndesmotic lesion (44-C)

2. With me-dial lesion(44-B2)

2. Multifrag-mentary frac-ture of fibulardiaphysis(44-C2)

Tibia/fibula, malleolar, transsyndesmotic fibula frac-ture (44-B)1. Isolated(44-B1)

Tibia/fibula, malleolar, suprasyndesmotic (44-C)

1. Simple dia-physeal fibular fracture (44-C1)

3. With me-dial lesionandVolkmann(fracture ofthe postero-lateral rim)(44-B3)

3. Proximalfibula (44-C3)



Subgroups and Qualifications:Tibia/fibula, malleolar, infrasyndesmotic, isolated (44-A1)1. Rupture of lateral collateral ligament (44-A1.1)

2. Avulsion of tip of lateral malleolus(44-A1.2)

3. Transverse fracture of lateral malle-olus (44-A1.3)

Tibia/fibula, malleolar, infrasyndesmotic lesion with medial malleolar fracture (44-A2)(1) transverse(2) oblique(3) vertical1. Rupture of lateral collateral ligament (44-A2.1)



Tibia/fibula, malleolar, infrasyndesmotic lesion with postero-medial fracture (44-A3)1. Rupture of lateral collateral ligament (44-A3.1)



A1

A2

A3



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)

3. Multifragmentary (44-B1.3)

Tibia/fibula, malleolar, transsyndesmotic fracture with medial lesion (44-B2)1. Simple, rupture of medial collateral and anterior syndesmosis (44-B2.1)(1) in substance(2) Chaput(3) Lefort

2. Simple with fracture of medialmalleolus and rupture of anterior syn-desmosis (44-B2.2)(1) in substance(2) Chaput(3) Lefort

3. Multifragmentary (44-B2.3)(1) rupture of medial collateral ligament(2) fracture of medial malleolus

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 fracture1. Fibula simple with medial collateral ligament rupture (44-B3.1)

2. Simple fibula fracture with fractureof medial malleolus (44-B3.2)

3. Multifragmentary with fracture ofmedial malleolus (44-B3.3)

B1

B2

B3



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 fragment1. Without shortening, without Volkmann (44-C3.1)

2. With shortening, withoutVolkmann (44-C3.2)

3. Medial lesion and a Volkmann(44-C3.3)

Tibia/fibula, malleolar, suprasyndesmotic, multifragmentary fibular diaphyseal fracture (44-C2)1. With rupture of medial collateral ligament (44-C2.1)

2. With fracture of medial malleolus(44-C2.2)

3. With fracture of medial malleolusand a Volkmann (Dupuytren)(44-C2.3)(1) extra-articular avulsion(2) peripheral articular fragment(3) significant articular fragment

Tibia/fibula, malleolar, susprasyndesmotic, simple diaphyseal fracture of fibula (44-C1)1. Rupture of medial collateral ligament (44-C1.1)

2. With fracture of medial malleolus(44-C1.2)

3. With fracture of medial malleolusand a Volkmann (Dupuytren)(44-C1.3)(1) extra-articular avulsion(2) peripheral articular fragment(3) significant articular fragment

C1

C2

C3


PELVIS


The classification of pelvic ring and acetabular fractures isbased on the work of Pennal and Tile and Judet and Letournel.This classification was developed to accommodate the alpha-numeric system of The Comprehensive Long Bone System.

DEFINITIONS

Pelvic ring has two arches: (a) posterior arch is behind ac-etabular surface and includes sacrum, sacroiliac joints andtheir ligaments and posterior ilium, and (b) anterior arch is infront of acetabular surface and includes pubic rami bone andsymphyseal joint.

Anterior column of acetabulum extends from the anterior halfof the iliac crest to the pubis (iliopubic).

Posterior column of acetabulum extends from the greater sci-atic 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 withoutdisplacement.

Partially stable: posterior osteoligamentous integrity partiallymaintained and pelvic floor intact.

Unstable: complete loss of posterior osteoligamentous in-tegrity; pelvic floor disrupted.

Where appropriate, the Young-Burgess classification hasbeen 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 easilycode into the alpha-numeric system for documentation. Thefollowing are the definitions of the Young-Burgess System:

APC: anterior-posterior compression; LC: lateral compression;SI: sacroiliac; VS: vertical shear; CMI: combined mechanical in-stability.

ACKNOWLEDGEMENTS

The O.T.A. Coding and Classification Committee gratefullyacknowledges the following individuals for their significantcontributions to the development of systematic universalpelvic and acetabular classifications:

Emile Letournel, MD; Marvin Tile, MD; Balz Isler, MD; DavidHelfet, MD; Serge Nazarian, MD

Location: Pelvic ring (61)BONE: PELVIS (6)

Types:A. Lesion sparing (or with no displacement of)posterior arch (61-A)

B. Incomplete disruption of posterior arch, par-tially stable (61-B)

C. Complete disruption of posterior arch, unsta-ble (61-C)


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


Groups:Pelvis, ring, stable (61-A)1. Fracture of innominate bone, avulsion (61-A1)

2. Fracture of innominate bone, directblow (61-A2)

3. Transverse fracture of sacrum andcoccyx (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 ofposterior arch, internal rotation (lat-eral compression injury) (61-B2)

3. Bilateral, partial lesion of posteriorarch (61-B3)

Pelvis, ring, complete disruption of posterior arch unstable (61-C)1. Unilateral, complete disruption of posterior arch (61-C1)

2. Bilateral, ipsilateral complete, con-tralateral incomplete (61-C2)

3. Bilateral, complete disruption(61-C3)

A

B

C

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


Subgroups and Qualifications:Pelvis, ring, stable, avulsion of innominate bone (61-A1)1. Iliac spine (61-A1.1)(1) anterior superior(2) anterior inferior(3) pubic spine

2. Iliac crest (61-A1.2) 3. Ischial tuberosity (61-A1.3)

Pelvis, ring, stable, innominate bone, direct blow (61-A2)1. Iliac wing (61-A2.1)(1) 1 fragment(2) more than 1 fragment

2. Unilateral fracture of anterior arch(61-A2.2)(1) through pubic bone/rami(2) through pubic bone involving sym-physis pubis

3. Bifocal fracture of anterior arch(61-A2.3)(1) bilateral pubic rami(2) pubic rami on 1 side and symphysispubis

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)

A1

A2

A3



Pelvis, ring, partially stable, unilateral, internal rotation (lateral compression) (61-B2)1. Anterior compression fracture of sacrum (LC-I) (61-B2.1)(1) anterior lesion ipsilateral(2) anterior lesion contralateral (bucket handle)

2. Partial sacroiliac joint fracture/sub-luxation (LC-II) (61-B2.2)(1) anterior lesion ipsilateral(2) anterior lesion contralateral (buckethandle)

3. Incomplete posterior iliac fracture(LC-II) (61-B2.3)(1) anterior lesion ipsilateral(2) anterior lesion contralateral (buckethandle)

Pelvis, ring, partially stable, bilateral (61-B3)1. Bilateral B1 (open book, external rotation) (APC-II) (61-B3.1)(1) bilateral sacroiliac joint anterior disruption(2) bilateral sacral fracture(3) unilateral partial SI joint disruption/contralateral sacral fracture (c*)

2. B1 and B2 (LC-III) (61-B3.2, a*, b**,c*)

3. Bilateral B2 (61-B3.3, a*, b**, c*)

Pelvis, ring, partially stable, unilateral, external rotation (open book, APC-II) (61-B1)(1) ipsilateral(2) contralateral(3) anterior lesion1. Sacroiliac joint anterior disruption(61-B1.1)

2. Sacral fracture (61-B1.2, c*)

B1

B2

B3



2. Complete through sacroiliac joint(61-C2.2, b*, c*)(a1) transiliac fracture dislocation(a2) pure dislocation(a3) transsacral fracture dislocation

Pelvis, ring, unstable, bilateral, ipsilateral complete, contralateral incomplete (LC-III) (61-C2)1. Complete through ilium(61-C2.1, b*, c*)

3. Complete through the sacrum(61-C2.3, b*, c*)(a1) lateral (ala)(a2) foraminal(a3) medial to foramen

Pelvis, ring, unstable, bilateral (APC-III) (61-C3, b***, c*)1. Extrasacral on both sides (61-C3.1)(a1) ilium; (a2) SI joint, transiliac fracture/dislocation; (a3) SI joint, transsacral fracture/dislocation; (a4) SI joint dislocation

2. Sacral one side, extra sacral otherside (61-C3.2, b***, c*)(a1) sacral ala; (a2) sacral foraminal;(a3) sacral medial to foramen

3. Sacral both sides (61-C3.3, c*)(a) a1) lateral alar; a2) foraminal; a3) me-dial(b) b1) lateral alar; a2) foraminal; a3) me-dial

Pelvis, ring, complete disruption, unilateral (APC-III) (61-C1)1. Through ilium (61-C1.1, c*) 2. Through sacroiliac joint (61-C1.2, c*)

(a1) transiliac fracture dislocation(a2) pure dislocation(a3) transsacral fracture dislocation

3. Through the sacrum (61-C1.3, c*)(a1) lateral (ala)(a2) foraminal(a3) medial to foramen

Footnotes:

*a: Ipsilateral posterior pelvic lesion:a1) sacroiliac joint anterior disruption; a2) sacral

fracture; a3) anterior compression fracturesacrum; a4) partial sacroiliac joint fracture/sublux-ation; a5) incomplete posterior iliac fracture.

*b: Contralateral pelvic lesion:b1) external rotation, “open book” partial disrup-

tion: .1) sacroiliac joint anterior disruption; .2)sacral fracture

b2) internal rotation, “lateral compression” partialdisruption: .1) anterior compression fracture of

the sacrum; .2) partial sacroiliac jointfracture/subluxation; .3) incomplete posterioriliac fracture

**b: Contralateral posterior pelvic lesion:bl) sacroiliac joint anterior disruption; b2) sacral

fracture; b3) anterior compression fracturesacrum; b4) partial sacroiliac joint fracture/sublux-ation; b5) incomplete posterior iliac fracture.

***b: Contralateral pelvic lesion:b1) ilium; b2) sacroiliac joint, transiliac fracture dis-

location; b3) sacroiliac joint, transsacral fracturedislocation; b4) sacroiliac joint, pure dislocation.

*c: Anterior pelvic lesion:cl) unilateral pubis/rami fracture, ipsilateral: c2) uni-

lateral pubis/rami fracture, contralateral; c3) bilat-eral pubis/rami fracture; c4) symphysis pubisdisruption, pure < 2.5 cm; c5) symphysis pubisdisruption, pure > 2.5 cm; c6) symphysis pubisdisruption, pure, locked; c7) symphysis and ipsi-lateral pubis/rami fracture (tilt); c8) symphysisand contralateral pubis/rami fracture; c9) symph-ysis and bilateral pubis/rami fracture; c10) no an-terior lesion.

C1

C2

C3



BONE: PELVIS (6)Modifiers to describe articular surfaces:�1) femoral head subluxation, anterior; �2)

femoral head subluxation, medial; �3) femoralhead subluxation, posterior.

§1) femoral head dislocation, anterior; §2)femoral head dislocation, medial; §3) femoralhead dislocation, posterior.

�1) acetabular surface, chondral lesion; �2) ac-etabular surface, impacted.

�1) femoral head, chondral lesion; �2) femoralhead, impacted; �3) femoral head, osteochondralfracture.

�1) intraarticular fragment requiring surgical re-moval.

ø1) nondisplaced fracture of the acetabulum.

Location: Acetabulum (62)

Types:A. Partial articular, 1 column (62-A)

Groups:Pelvis, acetabulum, partial articular, one column (62-A)1. Posterior wall(62-A1)

2. Posteriorcolumn(62-A2)

3. Anterior(62-A3)

B. Partial articular, transverse (62-B) C. Complete articular, bothcolumns (62-C)

2. T-shaped(62-B2)

2. Low(62-C2)

Pelvis, acetabulum, partial articular, transverse (62-B)1. Transverse(62-B1)

Pelvis, acetabulum, complete articular, bothcolumns (62-C)1. High (62-C1)3. Anterior

column, pos-terior hemi-transverse(62-B3)

3. Involvingsacroiliacjoint (62-C3)



Subgroups and Qualifications:Pelvis, acetabulum, partial articular, 1 column posterior wall (62-A1)1. Pure fracture dislocation, 1 fragment (62-A1.1)(1) posterior(2) posterior superior(3) posterior inferior

2. Pure fracture dislocation, multifrag-mentary (62-A1.2, a*)(1) posterior(2) posterior superior(3) posterior inferior

3. Fracture dislocation with marginalimpaction (62-A1.3, a*)(1) posterior(2) posterior superior(3) posterior inferior

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)

Pelvis, acetabulum, partial articular, 1 column posterior column (62-A2)1. Through ischium (62-A2.1) 2. Through obturator ring (62-A2.2)

(1) preserving tear drop(2) involving tear drop

3. Associated with posterior wall(62-A2.3, a*)(1) pure fracture dislocation: .1) poste-rior; .2) posterior superior; .3) posteriorinferior(2) with marginal impaction: .1) poste-rior; .2) posterior superior; .3) posteriorinferior

*a: a1) 1 fragment; a2) 2 fragments; a3) more than2 fragments.

**a: a1) anterior column in 1 fragment; a2) anteriorcolumn in 2 fragments; a3) anterior column inmore than 2 fragments.

A1

A2

A3



Pelvis, acetabulum, partial articular, transverse posterior hemitransverse, anterior column (62-B3)1. Anterior wall (62-B3.1) 2. Anterior column high (62-B3.2, a**) 3. Anterior column low (62-B3.3, a**)

Pelvis, acetabulum, partial articular, transverse T-type (62-B2)1. Infratectal (62-B2.1, a*)(1) stem posterior(2) stem through obturator foramen(3) stem anterior

2. Juxtatectal (62-B2.2, a*)(1) stem posterior(2) stem through obturator foramen(3) stem anterior

3. Transtectal (62-B2.3, a*)(1) stem posterior(2) stem through obturator foramen(3) stem anterior

*a: a1) pure transverse; a2) and posterior wall, singlefragments; a3) and posterior wall, multifragmen-tary; a4) and posterior wall, multifragmentarywith marginal impaction.

**a: a1) anterior column in 1 fragment; a2) anteriorcolumn in 2 fragments; a3) anterior column inmore than 2 fragments.

Pelvis, acetabulum, partial articular, transverse (62-B1)1. Infratectal (62-B1.1, a*) 2. Juxtatectal (62-B1.2, a*) 3. Transtectal (62-B1.3, a*)

B1

B2

B3



**a: a1) anterior column in 1 fragment; a2) anteriorcolumn in 2 fragments; a3) anterior column inmore man 2 fragments.

***a: a1) anterior column simple; a2) anterior col-umn multifragmentary.

*b: b1) posterior wall, single fragment; b2) posteriorwall, multifragmentary without impaction; b3)posterior wall, multifragmentary with marginalimpaction.

**b: b1) pure separation; b2) and posterior wall, sin-gle fragment; b3) and posterior wall, multifrag-mentary without impaction; b4) and posteriorwall, multifragmentary with marginal impaction.

Pelvis, acetabulum, complete articular, both columns involving sacroiliac joint (62-C3)1. Anterior wall (62-C3.1)(a1) anterior column simple, high(a2) anterior column simple, low(a3) anterior column multifragmentary, high(a4) anterior column multifragmentary, low

2. Posterior column multifragmen-tary, anterior column high(62-C3.2, a***, b**)

3. Posterior column multifragmen-tary, anterior column low (62-C3.3,a***, b**)

Pelvis, acetabulum, complete articular, both columns low (62-C2)1. Each column simple (62-C2.1) 2. Posterior column simple, anterior

column multifragmentary (62-C2.2)3. Posterior column and posteriorwall (62-C2.3, a**, b*)

2. Posterior column simple, anteriorcolumn multifragmentary (62-C1.2)

Pelvis, acetabulum, complete, both columns high (62-C1)1. Each column simple (62-C1.1) 3. Posterior column and posterior wall

(62-C1.3, a**, b*)

C1

C2

C3


BONE: SCAPULA (14)

Types:A. Extra-articular (not glenoid) (14-A)

Groups:Scapula, extra-articular (not glenoid) (14-A)1. Acromion (14-A1)

2. Coracoid(14-A2)

3. Body(14-A3)

B. Partial articular (glenoid) (14-B) C. Total articular (glenoid) (14-C)

2. Posteriorrim (14-B2)

2. Intra-artic-ular with neck(14-C2)

3. Intra-artic-ular withbody (14-C3)

Scapula, partial articular (glenoid) (14-B)1. Anterior rim (14-B1)

Scapula, total articular (glenoid) (14-C)1. Extra-articular glenoid neck(14-C1)

3. Inferior rim(14-B3)

SCAPULA

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


Subgroups:Scapula extra-articular (not glenoid) (14-A)Acromion (14-A1)1. Acromion, noncomminuted (14-A1.1)

2. Acromion, comminuted (14-A1.2)

Coracoid (14-A2)1. Coracoid, noncomminuted (14-A2.1) 2. Coracoid, comminuted (14-A2.2)

Body (14-A3)1. Body, noncomminuted (14-A3.1) 2. Body, comminuted (14-A3.2)

A1

A2

A3

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


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)

Posterior rim (14-B2)1. Posterior rim, noncomminuted (14-B2.1)

2. Posterior rim, comminuted (14-B2.2)

Inferior rim (14-B3)1. Inferior rim, noncomminuted(14-B3.1)

2. Inferior rim, comminuted (14-B3.2)

B1

B2

B3

J Orthop Trauma • Volume 21, Number 10, November/December 2007 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, com-minuted (14-C1.2)

Intra-articular with neck (14-C2)1. Intra-articular with neck, articular noncomminuted, neck noncomminuted(14-C2.1)

2. Intra-articular with neck, commin-uted, articular noncomminuted(14-C2.2)

3. Intra-articular with glenoid neck,articular comminuted (14-C2.3)

C1

C2

Intra-articular with body (14-C3)

C3


BONE: CLAVICLE (15)

Location: Medial end (15-A)

Type:A. Clavicle, medial end (15-A)

Group:Clavicle, medial end (15-A)1. Extra-articular (15-A1)

2. Intra-articular (15-A2)

Clavicle, diaphysis (15-B)1. Simple (15-B1)

2. Wedge (15-B2)

3. Complex (15-B3)

Clavicle, lateral end (15-C)1. Extra-articular (15-C1)

2. Intra-articular (15-C2)

3. Comminuted (15-A3)

CLAVICLE

Location: Diaphysis (15-B) Location: Lateral end (15-C)

Type:B. Clavicle, diaphysis (15-B)

Type:C. Clavicle, lateral end (15-C)

Note for clavicle:

• There are no subgroups of A.

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


Groups:Clavicle, diaphysis, noncomminuted (15-B1)Subgroups:1. Spiral (15-B1.1)

2. Oblique (15-B1.2)

3. Transverse (15-B1.3)

Clavicle, diaphysis, wedge (15-B2)1. Spiral wedge (15-B2.1)

2. Bending wedge (15-B2.2)

3. Comminuted (15-B2.3)

Clavicle, diaphysis, segmental (15-B3)1. Spiral (15-B3.1)

2. 2 transverse (15-B3.2)

3. Complex comminuted (15-B3.3)

Location: Diaphysis (15-B)BONE: CLAVICLE

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


Clavicle, lateral end, intra-articular (15-C2)

2. Noncomminuted (C-C ligament dis-rupted) (15-C2.2)

3. Comminuted (C-C ligament dis-rupted) (15-C2.3)

Groups:Clavicle, lateral end, extra-articular (15-C1)

2. Noncomminuted (C-C ligament dis-rupted) (15-C1.2)

1. With slight displacement (C-C liga-ment intact) (15-C2.1)

Subgroups:1. Impacted (C-C ligament intact)(15-C1.1)

3. Comminuted (C-C ligament dis-rupted) (15-C1.3)

Location: Lateral end (15-C)BONE: CLAVICLE


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)

HAND AND CARPUS

Multiple hand and carpal fractures (79)A. Carpal (79-A)B. Metacarpal (79-B)C. Phalanges (79-C)


Hand and Carpus J Orthop Trauma • Volume 21, Number 10 Supplement, November/December 2007


Location: Carpus (71-76)Types: A. Noncomminuted B. Comminuted

Scaphoid (72)A. Noncomminuted (72-A)1. Proximal Pole (72-A1)

2. Waist (72-A2)

3. Distal pole (72-A3)

B. Comminuted (72-B)1. Proximal Pole (72-B1)

2. Waist (72-B2)

3. Distal Pole (72-B3)

Lunate (71)A. Noncomminuted (71-A) B. Comminuted (71-B)

Capitate (73)A. Noncomminuted (73-A) B. Comminuted (73-B)

J Orthop Trauma • Volume 21, Number 10 Supplement, November/December 2007 Hand and Carpus


Hamate (74)A. Noncomminuted (74-A) B. Comminuted (74-B)

Ulnar carpal bones (75)A. Noncomminuted (75-A) B. Comminuted (75-B)1. Pisiform (75-A1) 1. Pisiform (75-B1)2. Triquetrum (75-A2) 2. Triquetrum (75-B2)

Radial carpal bones (76)A. Noncomminuted (76-A) B. Comminuted (76-B)1. Trapezium (76-A1) 1. Trapezium (76-B1)2. Trapezoid (76-A2) 2. Trapezoid (76-B2)


BONE: METACARPALS (77)Modifiers for metacarpals:T, thumb; I, index; M, middle; R, ring; L, little.

Location: Metacarpals (77)

Types:A. Metacarpal proximal and distalnonarticular and diaphysis non-comminuted (77-A)

Groups:1. Metacarpal, proximal extra-articular (77-A1)

2. Meta-carpal, diaph-ysis non-comminuted(77-A2)

3. Metacarpal,distal extra-articular(77-A3)

B. Metacarpal proximal and dis-tal partial articular diaphysiswedge comminution (77-B)

C. Metacarpal proximaland distal complete articu-lar diaphysis comminuted(77-C)

2. Metacarpal,diaphysiswedge(77-B2)

2. Meta-carpal, diaph-ysis com-minuted (77-C2)

1. Metacarpal, proximal partial articular (77-B1)

1. Metacarpal, proximal complete articular (77-C1)

3. Meta-carpal, distalpartial articu-lar (77-B3)

3. Meta-carpal, distalcompletearticular(77-C3)

METACARPALS

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


Subgroups and Qualifications:Metacarpal, proximal extra-articular (77-A1)1. Noncomminuted (77-A1.1) 2. Comminuted (77-A1.2)

(1) wedge(2) complex

Metacarpal, diaphysis noncomminuted (77-A2)1. Spiral (77-A2.1) 2. Oblique (77-A2.2) 3. Transverse (77-A2.3)

Metacarpal, distal extra-articular (77-A3)1. Noncomminuted (77-A3.1) 2. Comminuted (77-A3.2)

A1

A2

A3

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


Metacarpal, proximal partial articular (77-B1)1. Avulsion OR Split (77-B1.1)(1) unicondyle medial(2) unicondyle lateral(3) coronal split volar fragment(4) coronal split dorsal fragment

2. Depression (77-B1.2) 3. Split/depression (77-B1.3)(1) unicondyle medial(2) unicondyle lateral(3) coronal split volar fragment(4) coronal split dorsal fragment

Metacarpal, diaphysis wedge (77-B2)1. Spiral (77-B2.1) 2. Bending (77-B2.2) 3. Comminuted (77-B2.3)

Metacarpal, distal partial articular (77-B3)1. Avulsion OR Split (77-B3.1)(1) unicondyle medial(2) unicondyle lateral(3) coronal split volar fragment(4) coronal split dorsal fragment


B1

B2

B3

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


Metacarpal, distal articular (77-C3)1. Simple articular/metaphysis(77-C3.1)

2. Simple articular/comminuted meta-physis (77-C3.2)

3. Comminuted articular (77-C3.3)

Metacarpal, proximal articular (77-C1)1. Noncomminuted articular andmetaphysis (77-C1.1)

2. Noncomminuted articular, commin-uted metaphysis (77-C1.2)


Metacarpal, diaphysis comminuted (77-C2)1. Segmental (77-C2.1) 2. Complex comminuted (77-C2.2)

C1

C2

C3


BONE: PATELLA (34) Location: Patella (34)

Types:A. Patella extra-articular (34-A)

Groups:Patella, extra-articular (34-A)1. Patella, extra-articular, avulsion (34-A1)

2. Patella,extra-articu-lar isolatedbody (34-A2)

3. Patella, ar-ticular, com-minuted(34-C3)

B. Partial articular, vertical (34-B) C. Complete articular, non-vertical(34-C)

2. Patella, partialarticular, vertical,medial (34-B2)

2. Patella, ar-ticular, trans-verse plussecond frag-ment (34-C2)

Patella, partial articular, vertical (34-B)1. Patella, partial articular, vertical, lateral (34-B1)

Patella, complete articular, non-vertical (34-C)1. Patella, articular, transverse(34-C1)

PATELLA

Note for patella:

• There are no subgroups of A.

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


Patella, partial articular, vertical, lateral (34-B1)1. Noncomminuted (34-B1.1) 2. Comminuted (34-B1.2)

Patella, partial articular, vertical, medial (34-B2)1. Noncomminuted (34-B2.1) 2. Comminuted (34-B2.2)

B1

B2

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


Patella, articular, transverse plus second fragment (34-C2)1. Middle (34-C2.1) 2. Proximal (34-C2.2) 3. Distal (34-C2.3)

Patella, complete articular, transverse (34-C1)1. Middle (34-C1.1) 2. Proximal (34-C1.2) 3. Distal (34-C1.3)

Patella, articular, complex (34-C3)1. With 3 fragments (34-C3.1) 2. More than 3 fragments (34-C3.2)

C1

C2

C3


BONE: PHALANX (78)Modifiers for phalanx:T1 and T2, thumb 1/2;N1, N2 and N3, index1/2/3; M1, M2 and M3,middle 1/2/3; R1, R2and R3, ring 1/2/3; L1,L2 and L3, little 1/2/3.

Location: Phalanx (78)

Types:A. Phalanx proximal and distal extra-artic-ular and diaphysis noncomminuted (78-A)

Groups:1. Phalanx, proximal extra-articular (78-A1)

2. Phalanx di-aphysis, non-comminuted(78-A2)

3. Phalanx, dis-tal extra-artic-ular (78-A3)

B. Phalanx proximal and distal partialarticular and diaphysis wedge com-minution (78-B)

C. Phalanx proximal and distalcomplete articular and diaphysiscomminuted (78-C)

2. Phalanx, diaphysiswedge (78-B2)

2. Phalanx, diaphysiscomminuted(78-C2)

1. Phalanx, proximal partial articular (78-B1)

1. Phalanx, proximal complete articular (78-C1)

3. Phalanx,distal partialarticular (78-B3)

3. Phalanx,distal com-plete articu-lar (78-C3)

PHALANX - HAND

J Orthop Trauma • Volume 21, Number 10 Supplement, November/December 2007 Phalanx - Hand


Subgroups and Qualifications:Phalanx, proximal extra-articular (78-A1)1. Noncomminuted (78-A1.1) 2. Comminuted (78-A1.2)

2. Oblique (78-A2.2)Phalanx diaphyseal noncomminuted (78-A2)1. Spiral (78-A2.1) 3. Transverse (78-A2.3)

Phalanx, distal extra-articular (78-A3)1. Spiral noncomminuted (78-A3.1) 2. Comminuted (78-A3.2)

A1

A2

A3

Phalanx - Hand J Orthop Trauma • Volume 21, Number 10 Supplement, November/December 2007


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

Phalanx, diaphysis wedge (78-B2)1. Spiral (78-B2.1) 2. Bending (78-B2.2) 3. Fragmented (78-B2.3)

B2

B1

B3

Phalanx, proximal partial articular (78-B1)1. Avulsion OR Split (78-B1.1)(1) unicondyle medial(2) unicondyle lateral(3) coronal split volar fragment(4) coronal split dorsal fragment


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


J Orthop Trauma • Volume 21, Number 10 Supplement, November/December 2007 Phalanx - Hand


Phalanx, proximal complete articular (78-C1)1. Noncomminuted articular/metaphysis (78-C1.1)

2. Noncomminuted articular/commin-uted metaphysis (78-C1.2)

Phalanx, distal articular (78-C3)1. Noncomminuted articular/meta-physis (78-C3.1)



3. Comminuted articular and metaph-ysis (78-C1.3)

Phalanx, diaphysis comminuted (78-C2)1. Segmental (78-C2.1) 2. Complex comminuted (78-C2.2)

C1

C2

C3


AREA: FOOT (81-89)

Bones:Talus (81) Calcaneus (82) Navicular (83) Cuboid (84)

Cuneiforms (85) Metatarsals (87) Phalanges (88)

FOOT

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 becoded with the same last digit.

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


BONE: TALUS (81)Location: Foot (81-85)

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)1. Avulsions(81-A1)

2. Process(81-A2)

3. Head frac-tures (withoutneck fracture)(81-A3)

2. Displacedwith subluxa-tion of subta-lar joint(81-B2)

2. Subtalarjoint involve-ment (81-C2)

Neck fractures (81-B)1. Nondisplaced(81-B1)

Body fractures (81-C)1. Ankle joint involvment, dome fractures (81-C1)

3. Displacedwith subluxa-tion of subta-lar and anklejoints (81-B3)

3. Ankle andsubtalar jointinvolvement(81-C3)

2. Displaced with subluxation of subtalar joint(81-B2)

1. Noncomminuted (81-B2.1)


3. Involves talar head (81-B2.3)

3. Displaced with subluxation of subtalar andankle joints (81-B3)

1. Noncomminuted (81-B3.1)


3. Involves talar head (81-B3.3)

3. Head fractures (without neck fracture) (81-A3)1. Noncomminuted (81-A3.1)

2. Comminuted (81-A3.2)

2. Process (81-A2)1. Lateral (81-A2.1)

2. Posterior (81-A2.2)

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


Groups:Talus avulsions, process or head fractures (81-A)1. Avulsions (81-A1)

1. Anterior (81-A1.1)

2. Other (81-A1.2)

Groups:Neck fractures (81-B)1. Nondisplaced (81-B1)

3. Ankle and subtalar joint involvement (81-C3)1. Noncomminuted (81-C3.1)

2. Comminuted (81-C3.2)

Groups:Body fractures (81-C)1. Ankle joint involvement, dome fractures (81-C1)

1. Noncomminuted (81-C1.1)


2. Subtalar joint involvement (81-C2)1. Noncomminuted (81-C2.1)


A

B

C



BONE: CALCANEUS (82)Location: Foot (81-85)

Types: A. Avulsion or process or tuberosity (82-A) B. Nonarticular body fractures (82-B) C. Articular fractures involving pos-

terior facet (82-C)

Groups:Avulsion or process or tuberosity (82-A)1. Anterior process (82-A1) 2. Medial, sustentaculum (82-A2) 3. Tuberosity (82-A3)1. Noncomminuted (82-A1.1) 1. Noncomminuted (82-A2.1) 1. Noncomminuted (82-A3.1)

2. Comminuted (82-A1.2) 2. Comminuted (82-A2.2) 2. Comminuted (82-A3.2)




2. 2-part fractures (82-C2) 3. 3-part fractures (82-C3) 4. 4 or more parts (82-C4)

Groups:Articular fractures involving posteriorfacet (82-C)1. Nondisplaced (82-C1)

Groups:Nonarticular body fractures (82-B)1. Noncomminuted (82-B1) 2. Comminuted (82-B2)

A

B

C



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)


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 distalnonarticular and diaphysis non-comminuted (87-A)

Groups:1. Metatarsal, proximal extra-articular (87-A1)

2. Metatarsal,diaphysisnoncommin-uted (87-A2)

3. Metatarsal,distal extra-articular(87-A3)

2. Metatarsal proximal and dis-tal partial articular diaphysiswedge comminution (87-B)

3. Metatarsal proximal anddistal complete articulardiaphysis comminuted (87-C)

2. Metatarsal,diaphysiswedge(87-B2)

2. Metatarsal,diaphysiscomminuted(87-C2)

1. Metatarsal, proximal partial articular (87-B1)

1. Metatarsal, proximal complete articular (87-C1)

3. Metatarsal,distal partialarticular(87-B3)

3. Metatarsal,distal com-plete articu-lar (87-C3)

METATARSALS

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


Subgroups and Qualifications:Metatarsal, proximal extra-articular (87-A1)1. Noncomminuted (87-A1.1) 2. Comminuted (87-A1.2)

(1) wedge(2) complex

Metatarsal, diaphysis noncomminuted (87-A2)1. Spiral (87-A2.1) 2. Oblique (87-A2.2) 3. Transverse (87-A2.3)

Metatarsal, distal extra-articular (87-A3)1. Noncomminuted (87-A3.1) 2. Comminuted (87-A3.2)

A1

A2

A3

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


Metatarsal, proximal partial articular (87-B1)1. Avulsion OR Split (87-B1.1)(1) unicondyle medial(2) unicondyle lateral(3) coronal split volar fragment(4) coronal split dorsal fragment


Metatarsal, diaphysis wedge (87-B2)1. Spiral (87-B2.1) 2. Bending (87-B2.2) 3. Comminuted wedge (87-B2.3)

Metatarsal, distal partial articular (87-B3)1. Avulsion OR Split (87-B3.1)(1) unicondyle medial(2) unicondyle lateral(3) coronal split volar fragment(4) coronal split dorsal fragment


B1

B2

B3

Metatarsal, distal articular (87-C3)1. Simple articular/metaphysis(87-C3.1)

2. Simple articular/comminuted meta-physis (87-C3.2)


Metatarsal, proximal articular (87-C1)1. Noncomminuted articular andmetaphysis (87-C1.1)

2. Noncomminuted articular, commin-uted metaphysis (87-C1.2)


Metatarsal, diaphysis Comminuted (87-C2)1. Segmental (87-C2.1) 2. Complex comminuted (87-C2.2)

C1

C2

C3


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


Location: Phalanx (88)BONE: PHALANX (88)Modifiers for phalanx:T1 and T2, thumb toe1/2; N1, N2 and N3,index toe 1/2/3; M1,M2 and M3, middle toe1/2/3; R1, R2 and R3,ring toe 1/2/3; L1, L2and L3, little toe 1/2/3.

Types:A. Phalanx proximal and distal extra-articular and diaphysis noncomminuted (88-A)

Groups:1. Phalanx, proximal extra-articular (88-A1)

2. Phalanx di-aphysis, non-comminuted(88-A2)

3. Phalanx, dis-tal extra-artic-ular (88-A3)

B. Phalanx proximal and distal partialarticular and diaphysis wedge com-minution (88-B)

C. Phalanx proximal and distalcomplete articular and diaphysiscomminuted (88-C)

2. Phalanx, diaphysiswedge (88-B2)

2. Phalanx, diaphysiscomminuted(88-C2)

1. Phalanx, proximal partial articular (88-B1)

1. Phalanx, proximal complete articular (88-C1)

3. Phalanx,distal partialarticular (88-B3)

3. Phalanx,distal com-plete articu-lar (88-C3)

PHALANX - FOOT

Phalanx - Foot J Orthop Trauma • Volume 21, Number 10 Supplement, November/December 2007


Subgroups and Qualifications:Phalanx, proximal extra-articular (88-A1)1. Noncomminuted (88-A1.1) 2. Comminuted (88-A1.2)

2. Oblique (88-A2.2)Phalanx, diaphyseal noncomminuted (88-A2)1. Spiral (88-A2.1) 3. Transverse (88-A2.3)

Phalanx, distal extra-articular (88-A3)1. Noncomminuted (88-A3.1) 2. Comminuted (88-A3.2)

A1

A2

A3

J Orthop Trauma • Volume 21, Number 10 Supplement, November/December 2007 Phalanx - Foot


Phalanx, diaphysis wedge (88-B2)1. Spiral (88-B2.1) 2. Bending (88-B2.2) 3. Fragmented (88-B2.3)

B1

B2

B3

Phalanx, proximal partial articular (88-B1)1. Avulsion OR Split (88-B1.1)(1) unicondyle medial(2) unicondyle lateral(3) coronal split volar fragment(4) coronal split dorsal fragment


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



Phalanx - Foot J Orthop Trauma • Volume 21, Number 10 Supplement, November/December 2007

Phalanx, proximal complete articular (88-C1)1. Noncomminuted articular/metaphysis (88-C1.1)


Phalanx, distal articular (88-C3)1. Noncomminuted articular/meta-physis (88-C3.1)

2. Noncomminuted articular commin-uted metaphysis (88-C3.2)


3. Comminuted articular and metaph-ysis (88-C1.3)

Phalanx, diaphysis comminuted (88-C2)1. Segmental (88-C2.1) 2. Complex comminuted (88-C2.2)

C1

C2

C3


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 sys-tem is based primarily upon the basic tenets of identification of the exact joint involved and the direction of the dis-tal bone relative to the proximal bone. These two basic principles of classification are applicable throughout theskeletal system. The ligaments that are disrupted in each dislocation can be inferred from the classification but is nota specific component of the classification process. “Fracture-dislocations” are generally assigned 2 separate codes, 1for the fracture (bone) and 1 for the dislocation (joint). In general, the first digit of the numerical code represents thebody part and the second digit of the numerical code is 0 for dislocation. For example, 30 represents a hip disloca-tion 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 2bone joint is assigned a third place designation (eg, knee joint 40-A is tibiofemoral and 40-B is patellofemoral). Ingeneral, the dislocations are subclassified by the direction the distal bone is positioned relative to the proximal boneat 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 dislo-cation of the knee joint (with the tibia anterior to the femur). The designation of “other” is used for various situa-tions including spontaneous reduction of a presumed dislocation where the direction is not known (eg, a knee injurywith disruption of the ACL and PCL but with the presentation radiographs demonstrating a reduced knee joint is 40-A5). This “other” or “5” category is also used when direction of the dislocation does not meet the standard 4anatomic directions (eg, 10-A5 for inferior dislocation of the shoulder or “luxatio erecta”). Some dislocations wereincluded in the long bone fracture classification (eg, forearm), and there is the potential for more than 1 code to beappropriate for a given injury.

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


DISLOCATION REGION: Shoulder (10)

Types by joint involved:

A. Glenohumeral (10-A) B. Acromioclavicular (10-B) C. Sternoclavicular (10-C) D. Scapulothoracic (10-D)

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


A. Glenohumeral (10-A)

3. Lateral (theoretical)(10-A3)

4. Medial (theoretical)(10-A4)

5. Other (inferior-luxatio erecta) (10-A5)

Groups by direction:

1. Anterior (10-A1) 2. Posterior (10-A2)



B. Acromioclavicular (10-B)

3. Superior (10-B3) 4. Inferior (10-B4) 5. Other (10-B5)


1. Anterior (theoreti-cal) (10-B1)

2. Posterior (10-B2)

3. Grade 3, ��100% dis-placement (10-B3.3)

4. Grade 4, grade 3 plusdeltoid origin detachedfrom clavicle (10-B3.4)

Subgroups of 10-B3 by severity of displacement:

1. Grade 1 sprain (10-B3.1) 2. Grade 2, partial displace-ment (10-B3.2)



3. Lateral (theoretical)(10-C3)

4. Medial (theoretical)(10-C4)

5. Other (10-C5)

C. Sternoclavicular (10-C)

D. Scapulothoracic (10-D)


1. Anterior (10-C1) 2. Posterior (10-C2)



DISLOCATION REGION: Elbow (20):

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 withthe radius going in the same direction as the ulna for types 20-A1—20-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 theclassification system we generally recommend that fractures and dislocations be separately coded.


A. Ulnohumeral with radiohumeral*(20-A)

B. Isolated radiohumeral (20-B) C. Distal radioulnar dislocation (20-C) D. Other (20-D)



3. Medial (20-A3) 4. Lateral (20-A4) 5. Divergent (20-A5)

A. Ulnohumeral (20-A)


1. Anterior (20-A1) 2. Posterior (20-A2)

3. Medial (20-B3) 4. Lateral (20-B4)

B. Radiohumeral (20-B)


1. Anterior (20-B1) 2. Posterior (20-B2)



3. Other (20-C3)

C. Distal radioulnar dislocations (20-C)


1. Anterior (volar) (20-C1) 2. Posterior (dorsal) (20-C2)

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)





DISLOCATION REGION: Hip (30):

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 frac-

ture of the central acetabulum. Although commonly referred to as a medial or central dislocation of the hip, the 30-A3 injuryis a particular pattern of fracture displacement rather than a true dislocation. It is left to the discretion of the coder to decidewhen, if ever, to utilize 30-A3 in addition to the fracture code (62).

• There are no current injury patterns appropriate for 30-B designation.


Hip joint (30-A)


1. Anterior (30-A1)



DISLOCATION REGION: Knee (40)

B. Patellofemoral (40-B) C. Tibiofibular (proximal) (40-C)

D. Tibiofibular (distal)(40-D)


A. Tibiofemoral (40-A)

Notes for classification of knee dislocations:

• The classification committee recognizes that distal tibiofibular dislocations are NOT knee dislocations but they fit well here andARE dislocations associated with the leg bone segment 4. Distal tibiofibular dislocations (as well as DRUJ) could reasonably bemoved to 80 foot and ankle dislocations (and DRUJ to 70 wrist and hand dislocations). However, those segments already havemany codes because there are so many joints in these body parts with small bones. Therefore for practical and consistencyreasons 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.



3. Medial (40-A3) 4. Lateral (40-A4)

A. Tibiofemoral (40-A)


1. Anterior (40-A1) 2. Posterior (40-A2) 5. Other (40-A5)



3. Medial patellofemoral dislocation(40-B3)

4. Lateral patellofemoral dislocation(40-B4)

Groups by direction of the patella:

1. Distal (quadriceps tendon disruption) (40-B1) 2. Proximal (patellar tendon disruption) (40-B2)

5. Other (40-B5)

B. Patellofemoral (40-B)



C. Proximal tibiofibular dislocation (40-C)

3. Lateral (40-C3) 4. Medial (40-C4)


1. Anterior (40-C1) 2. Posterior (40-C2) 5. Other (40-C5)

Subgroups of 40-C5:

1. Superior (40-C5.1) 2. Inferior (40-C5.2)



D. Distal tibiofibular dislocation(40-D)

3. Lateral (40-D3) 4. Other (40-D5)

Groups by the direction of the fibula:

1. Anterior (40-D1) 2. Posterior (40-D2)

Subgroups of 40-D5:

1. Superior (40-D5.1) 2. Inferior (40-D5.2)



DISLOCATION REGION: Pelvic dislocation (60)


A. Sacroiliac right (60-A)

1. Anterior (60-A1) 2. Posterior (60-A2) 3. Lateral (60-A3) 4. Other (eg proximal) (60-A4)


A. Sacroiliac right (60-A) B. Sacroiliac left (60-B) C. Symphysis pubis (60-C)

Notes for classification of pelvic dislocations:

• Because pubic diastasis and sacroiliac (SI) joint dislocations and fracture dislocations are such an integral component of “pelvicring disruption,” pelvic fracture codes (61), the 60 codes are restricted to “pure dislocations” without fracture. 61 codes areto be used for fracture dislocations or pelvic ring injuries that include fractures AND SI or symphysis disruptions. Therefore thefollowing:

• 60 codes are for pure dislocations. Pelvic ring disruptions with fractures (with or without SI and symphysis joint injuries) shouldbe 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 thepubic symphysis would be coded 60-B2 (left SI posterior dislocation), 60-A1 (right SI dislocation with ilium anteriorly dis-placed) and 60-C3 (pubic symphysis dislocation with the right side displaced proximal to the left).



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)



DISLOCATION REGION: Hand and Wrist (70)

Types by area or joints involved:

A. Radiocarpal B. Intercarpal C. Carpal-metacarpal D. Phalanx (70-D)(70-A) (70-B) (70-C)

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, thenindividual 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.



A. Radiocarpal (wrist joint) (70-A)

3. Radial (70-A3) 4. Ulnar (70-A4) 5. Other (70-A5)

Groups by direction of the distal fragment:

1. Anterior (volar) (70-A1)

2. Posterior (dorsal)(70-A2)

B. Intercarpal dislocations (70-B)

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)



C. Carpal-metacarpal joints (70-C)



D. Phalangeal dislocations (70-D)

Groups by level involved:

1. Metacarpal phalangeal 2. Proximal interphalangeal 3. Distal interphalangeal (70-D1) (70-D2) (70-D3)

4. Sesamoid dislocation (70-D4) 5. Multiple finger dislocations (70-D9)



1. Metacarpal phalangeal joint (70-D1)

Subgroups by joint involved radial to ulnar:

1. 1st metacarpal 2. 2nd metacarpal 3. 3rd metacarpal 4. 4th metacarpal 5. 5th metacarpal phalangeal joint phalangeal joint phalangeal joint phalangeal joint phalangeal joint(70-D1.1) (70-D1.2) (70-D1.3) (70-D1.4) (70-D1.5)

3. Distal interphalangeal joint (70-D3)


1. None 2. Index (2nd) 3. Long (3rd) 4. Ring (4th) 5. Small (5th)(70-D3.2) (70-D3.3) (70-D3.4) (70-D3.5)

2. Proximal interphalangeal joint (70-D2)


1. Thumb (1st) 2. Index (2nd) 3. Long (3rd) 4. Ring (4th) 5. Small (5th) (70-D2.1) (70-D2.2) (70-D2.3) (70-D2.4) (70-D2.5)



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)

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).


1. Anterior (80-A1) 2. Posterior (80-A2) 3. Medial (80-A3) 4. Lateral (80-A4) 5. Other (80-A5)



B. Subtalar (80-B)


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)



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)



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. 1st metatarsal phalangeal joint (80-D1.1)2. 2nd metatarsal phalangeal joint (80-D1.2)3. 3rd metatarsal phalangeal joint (80-D1.3) 4. 4th metatarsal phalangeal joint (80-D1.4)5. 5th metatarsal phalangeal joint (80-D1.5)

2. Proximal interpahalangeal joint (80-D2)


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)


1. No code as there is no DIP in big toe 2. 2nd toe (80-D3.2)3. 3rd toe (80-D3.3)4. 4th toe (80-D3.4)5. 5th toe (80-D3.5)


B. Distraction injuries of the anteriorand posterior elements (tensile forces)(5_-B)

BONE: SPINE (5) Location: Cervical (51)

Types:A. Compression injuries of the body(compressive forces) (5_-A)

SPINE

Location: Thoracic (52) Location: Lumbar (53)

C. Multidirectional injurieswith translation affecting theanterior and posterior ele-ments (axial torque causingrotation injuries) (5_-C)

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


BONE: SPINE (5)

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)

Types:A. Compression injuries of the body(compressive forces) (5_-A)

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


B. Distraction injuries of the anteriorand posterior elements (tensile forces)(5_-B)

2. Posterior disruption pre-dominantly osseous (flexion-distraction injury) (5_-B2)

Groups:Anterior or posterior element injury with distraction (5_-B)1. Posterior disruption predominantlyligamentous (flexion-distraction injury) (5_-Bl)

3. Anterior disruptionthrough the disc (hyperex-tension-shear injury) (5_-B3)

BONE: SPINE (5)

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)

BONE: SPINE (5) C. Multidirectional injurieswith translation affecting theanterior and posterior ele-ments (axial torque causingrotation injuries) (5_-C)

2. Flexion subluxation withrotation (5_-C2)

Groups:Anterior or posterior element injury with rotation (5_-C)1. Rotational wedge, split, and burst fractures (5_-C1)

3. Rotational shear injuries(Holdsworth slice rotationfracture) (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)


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


REFERENCES1. Fracture and dislocation compendium. Orthopaedic Trauma Association

Committee for Coding and Classification. J Orthop Trauma. 1996:10(Suppl 1):v-ix, 1–154.

2. Müller ME, Nazarian S, Koch P, et al. The Comprehensive Classificationof Fractures of Long Bones. Berlin, Germany: Springer-Verlag;1990.

3. Webster’s New Riverside University Dictionary. Boston, MA: RiversidePublishing; 1984:268.

4. Martin JS, Marsh JL. Current classification of fractures. Rationale andutility. Radiol Clin North Am. 1997;35:491–506.

5. Brumback RJ, Jones AL. Interobserver agreement in the classificationof open fractures of the tibia. The results of a survey of two hundred andforty-five orthopaedic surgeons. J Bone Joint Surg Am. 1994;76:1162–1166.

6. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. TheToronto experience 1968—1975. Clin Orthop Relat Res. 1979;138:94–104.

7. Siebenrock KA. Gerber C. The reproducibility of classification of frac-tures of the proximal end of the humerus. J Bone Joint Surg Am.1993;75:1751–1755.

8. Martin JS, Marsh JL, Bonar SK, et al. Assessment of the AO/ASIF fracture classification for the distal tibia. J Orthop Trauma. 1997;11:477–483.

9. Sidor ML, Zuckerman JD, Lyon T, et al. The Neer classification systemfor proximal humeral fractures. An assessment of interobserver reliabil-ity and intraobserver reproducibility. J Bone Joint Surg Am. 1993;75:1745–1750.

10. Petrisor BA, Bhandari M, Orr RD, et al. Improving reliability in theclassification of fractures of the acetabulum. Arch Orthop Trauma Surg.2003;123:228–233.

11. Kristiansen B, Andersen UL, Olsen CA, et al. The Neer classification offractures of the proximal humerus. An assessment of interobserver vari-ation. Skeletal Radiol. 1988;17:420–422.

12. Bernstein J, Adler LM, Blank JE, et al. Evaluation of the Neer systemof classification of proximal humeral fractures with computerized tomo-graphic scans and plain radiographs. J Bone Joint Surg Am. 1996;78:1371–1375.

13. Flikkilä T, Nikkola-Sihto A, Kaarela O, et al. Poor interobserver relia-bility of AO classification of fractures of the distal radius. Additionalcomputed tomography is of minor value. J Bone Joint Surg Br. 1998;80:670–672.

14. Humphrey CA, Dirschl DR, Ellis TJ. Interobserver reliability of a CT-based fracture classification system. J Orthop Trauma. 2005;19:616–622.

15. Barker L, Anderson J, Chesnut R, et al. Reliability and reproducibility ofdens fracture classification with use of plain radiography and reformattedcomputer-aided tomography. J Bone Joint Surg Am. 2006;88: 106–112.

16. Dirschl DR, Adams GL. A critical assessment of factors influencing re-liability in the classification of fractures, using fractures of the tibial pla-fond as a model. J Orthop Trauma. 1997;11:471–476.

17. Parsons BO, Klepps SJ, Miller S, et al. Reliability and reproducibility ofradiographs of greater tuberosity displacement. A cadaveric study. J BoneJoint Surg Am. 2005;87:58–65.

18. Schipper IB, Steyerberg EW, Castelein RM, et al. Reliability of theAO/ASIF classification for pertrochanteric femoral fractures. Acta OrthopScand. 2001;72:36–41.

19. Walton NP, Harish S, Roberts C, et al. AO or Schatzker? How reliableis classification of tibial plateau fractures? Arch Orthop Trauma Surg.2003;123:396–398.

20. Andersen DJ, Blair WF, Steyers CM, et al. Classification of distal radiusfractures: an analysis of interobserver reliability and intraobserver re-producibility. J Hand Surg [Am]. 1996:21:574–582.

21. Swiontkowski MF, Sands AK, Agel J, et al. Interobserver variation inthe AO/OTA fracture classification system for pilon fractures: is there aproblem? J Orthop Trauma. 1997;11:467–470.

22. Kreder HJ, Hanel DP, McKee M, et al. Consistency of AO fracture clas-sification for the distal radius. J Bone Joint Surg Br. 1996;78:726–731.

23. Craig WL 3rd, Dirschl DR. Effects of binary decision making on theclassification of fractures of the ankle. J Orthop Trauma. 1998;12:280–283.

24. Kreder HJ, Hanel DP, McKee M, et al. Radiographic fracture assess-ments: which ones can we reliably make? J Orthop Trauma. 2000;14:379–385.

25. Follmann D, Wittes J, Cutler JA. The use of subjective rankings in clin-ical trials with an application to cardiovascular disease. Stat Med.1992;11:427–437; discussion 439–454.

26. Oskam J, Kingma J, Klasen HJ. Interrater reliability for the basic cate-gories of the AO/ASIF’s system as a frame of reference for classifyingdistal radial fractures. Percept Mot Skills. 2001;92:589–594.

27. Williams TM, Nepola JV, DeCoster TA, et al. Factors affecting outcomein tibial plafond fractures. Clin Orthop Relat Res. 2004;423:93–98.

28. DeCoster TA, Willis MC, Marsh JL, et al. Rank order analysis of tibialplafond fractures: does injury or reduction predict outcome? Foot AnkleInt. 1999;20:44–49.

29. Audigé L, Bhandari M, Kellam J. How reliable are reliability studies offracture classifications? A systematic review of their methodologies.Acta Orthop Scand. 2004;75:184–194.

30. Kreder HJ, Hanel DP, McKee M, et al. X-ray film measurements forhealed distal radius fractures. J Hand Surg [Am]. 1996;21:31–39.

31. Buckwalter JA, Schumacher R, Albright JP, et al. The validity of or-thopaedic in-training examination scores. J Bone Joint Surg Am. 1981;63:1001–1006.

32. Barei DP, Nork SE, Mills WJ, et al. Functional outcomes of severe bi-condylar tibial plateau fractures treated with dual incisions and medialand lateral plates. J Bone Joint Surg Am. 2006;88:1713–21.

33. Audigé L, Bhandari M, Hanson B, et al. A concept for the validation offracture classifications. J Orthop Trauma. 2005;19:401–406.

34. Slongo T, Audigé L, Schlickewei W, et al. Development and validation ofthe AO pediatric comprehensive classification of long bone fractures bythe Pediatric Expert Group of the AO Foundation in collaboration with AOClinical Investigation and Documentation and the InternationalAssociation for Pediatric Traumatology. J Pediatr Orthop. 2006;26:43–49.

35. Audigé L, Hunter J, Weinberg AM, et al. Development and evaluationprocess of a pediatric long-bone fracture classification proposal. Eur JTrauma. 2004;30:248–254.

36. Slongo T, Audigé L, Clavert JM, et al. The AO comprehensive classifi-cation of pediatric long-bone fractures: a web-based multicenter agree-ment study. J Pediatr Orthop. 2007;27:171–180

37. Slongo T, Audigé L, Lutz N, et al. Documentation of fracture severitywith the AO classification of pediatric long-bone fractures. Acta Orthop.2007;78:247–253.

J Orthop Trauma • Volume 21, Number 10 Supplement, November/December 2007 S135

Summary: The AO Pediatric Expert Group and the AOPediatric Classification Group, in cooperation with the AOInvestigation and Documentation Group introduce and pres-ent the first comprehensive classification of pediatric longbone fractures. The anatomy is related to the 4 long bones andtheir 3 segments defined as proximal (1), shaft (2) and distal(3). It is further described by the fracture subsegmentrecorded as epiphyseal (E), metaphyseal (M) and diaphyseal(D), whereby proximal and distal fractures are classified as Eor M and shaft fractures are always D. The distinction be-tween metaphyseal and diaphyseal fractures is achieved bylocalizing the center of fracture lines with regard to a squaredrawn over the respective growth plates. The morphology ofthe fracture is documented by a subsegment-specific childpattern code, a severity code as well as an additional code fordisplacement of specific fractures such as supracondylar frac-tures and radial heads. The classification process requirestrained observers to read standard radiographic images.

J Orthop Trauma 2007;21(Suppl.): S135-S160

INTRODUCTIONThe need to compile a classification of pediatric frac-

tures arises, on the one hand, from an obligation to performquality control and, on the other hand, from a desire to pursuebasic research in the form of prospective and retrospectivestudies.

In contrast to adult fractures, the primary difficulty withregard to pediatric fractures is not their complexity or sever-ity, but rather the phenomenon of growth. This is driven bymechanisms, still not fully understood, that may alter thecourse of healing depending on the fracture pattern and theage of the patient. Among these mechanisms, the epiphysealcartilage is considered most distinctive.

Any classification or documentation must do justice tothe two phenomena of injury pattern and growth. The well-known classifications of children’s fractures in the literaturetake into account only particular aspects of the bones, eg, theSalter–Harris classification for epiphyseal fractures,1

Baumann,2 Gartland3 and L.v. Laer4 for supracondylar frac-tures or Judet’s classification for radial neck/head fractures,5

while other classifications have attempted to include all frac-ture patterns by simplifications.6 However, none of these clas-sifications have been scientifically validated.7 In addition, noclassification system is available for diaphyseal long bonefractures.

To perform appropriate clinical data auditing (qualitycontrol) and well-documented studies, there is an inescapableneed for a comprehensive classification of pediatric fractures.A documentation system for fractures in childhood based onthe AO classification for adults,8 has been implemented dur-ing the past decade.9 This experience has shown that an adap-tation of the classification of pediatric fractures including allwell-known and currently applied systems, is necessary.

Fracture and Dislocation Classification Compendium for Children

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)1

Theddy F. Slongo, MD* and Laurent Audigé, 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 comprehen-sive documentation as the basis for treatment and research.”

Th. Slongo, 20071 Original publications

Audigé L, Hunter J, Weinberg A, Magidson J, Slongo T. Development and Evaluation Process of a Paediatric Long-Bone Fracture Classification Proposal. European Journal ofTrauma. 2004;30:248–254.

Slongo T, Audigé L, Schlickewei W, Clavert J-M, Hunter J. Development and Validation of the AO Pediatric Comprehensive Classification of Long Bone Fractures by the PediatricExpert Group of the AO Foundation in Collaboration With AO Clinical Investigation and Documentation and the International Association for Pediatric Traumatology. Journal ofPediatric Orthopaedics. 2006;26:43–49.

Slongo T, Audigé 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;27:171–180.

Slongo T, Audigé 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;78:247–253.

PEDIATRIC LONG BONE FRACTURES

From the *Department of Paediatric Surgery, Paediatric Trauma andOrthopaedics, University Children’s Hospital, Bern, Switzerland; and †AOClinical Investigation and Documentation, Dübendorf, Switzerland. ‡Membersof the AO Pediatric Classification Group are listed in the Appendix on pageS160.

Disclosure: The authors report no conflicts of interest.Correspondence: Theddy F. Slongo, MD, Paediatric Trauma and Orthopaedics,

University Children’s Hospital, Department of Paediatric Surgery, CH-3010Bern, Switzerland (e-mail: [email protected]).

Copyright © 2007 by Lippincott Williams & Wilkins

Pediatric Long Bone Fractures J Orthop Trauma • Volume 21, Number 10 Supplement, November/December 2007


The need for clinical relevance dictates that a systemdifferent from those for adults must be developed, and that al-ready known pediatric classifications must be considered.1,4-6

However, the structures of both adult and pediatric classifica-tions of similar bones should remain similar to facilitate theirapplication in the clinical setting. In addition, the classifica-tion process (ie, the fracture diagnosis) should be reliable andvalid,7,10,11 underscoring the need to start early with suchevaluation in the development process.12 Audigé et al11 haverecommended that 3 research phases should be completed be-fore a classification can be considered as validated. The firstdevelopment phase involves clinical experts who develop afirst proposal for the classification system and define the clas-sification process. This phase has delineated a common lan-guage with which surgeons should be able to view anddescribe fractures similarly. Successive pilot studies are con-ducted to ensure agreement among clinical experts. The sec-ond phase involves a multicenter study to ensure agreementamong future users. This phase establishes the basis for aclassification tool to be used for documentation and evalua-tion of treatment options. Only after these first two phases arecompleted can recommendations for patient care based on theclassification be developed in a third phase, after the imple-mentation of a prospective clinical study.

To meet these needs, the AO Pediatric Expert Group(PAEG) and the AO Pediatric Classification Group, in coop-eration with the AO Investigation and Documentation(AOCID) Group introduce and present the first comprehen-sive classification of pediatric long bone fractures.13–15

PEDIATRIC LONG BONE CLASSIFICATION

GlossaryThe terms and definitions in the glossary of the classifi-

cation of pediatric fractures follow the meanings that havebeen established by Müllers’s Long Bone ComprehensiveClassification of Fractures. The glossary therefore comprisesan extension of this internationally accepted classification ofadult fractures, which has proven its worth over a period ofmore than 30 years.

Description of the Classification DefinitionThe current classification proposal is based on the

Müller AO classification for adults8 and considers child-spe-cific relevant fracture features. The original unifying principleof the CCF, valid for all fractures, is an anatomic and morpho-logic organization divided mostly into triads. The anatomy isrelated to the four long bones and their three segments. It isfurther described by the fracture subsegment recorded as E, M,or D (see below). The morphology of the fracture is docu-mented by a location-specific child code, a severity code, andan additional code for displacement of specific fractures.

LocationBone

Following the Müller AO classification for adults, thebones are similarly coded: 1 = Humerus, 2 = Radius/Ulna, 3= Femur, 4 = Tibia/Fibula (Figure 1). Except for the knownMonteggia and Galeazzi lesions, when the paired bonesRadius/Ulna or Tibia/Fibula are fractured with the same pedi-atric pattern (see below), a single classification code should

be used, with the severity code referring to the more badlyfractured of the two bones. When a single bone is fractured, asmall 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 arefractured with different pediatric patterns (eg, a complete frac-ture of the radius and a bowing fracture of the ulna), each bonemust be coded separately including the corresponding small let-ter (Figure 2). This will allow a detailed documentation of com-bined fractures of the radius and ulna, or those of the tibia andfibula, in clinical studies so that their relative influence on treat-ment outcomes can be properly evaluated. A list of the mostcommon combinations of paired fractures is presented at the endof this article.

SegmentsThe segments within the bones also follow a similar

coding scheme, ie, 1 = proximal, 2 = diaphyseal, 3 = distal, buttheir identification differs from that in adults. For the latter, theproximal and distal metaphyseal fragments are identified via asquare “whose sides are the same length as the widest part ofthe epiphysis”.8 However, we know that the metaphysis in pe-diatric fractures extends much further into the shaft, as can beobserved with the typical pediatric metaphyseal fractures (eg,

Code Fracture

23r – E/2.1 Salter-Harris II fracture of the dis-tal radius

23u – E/2.1 Salter-Harris II fracture of the dis-tal ulna

FIGURE 2. Coding of same fracture but different bone inpaired bones.

FIGURE 1. Designation of bone location

buckle and torus fractures). Furthermore, the width of thegrowth plate is almost visible in younger children, whereas theepiphysis itself cannot be used because of the different age-dependent ossification stages. This makes the same use ofsquares in children clinically inappropriate. For pediatric longbone fractures, the metaphysis is identified by a square whoseside has the same length as the widest part of the physis inquestion (Figure 3). For the pairs of bones radius/ulna andtibia/ fibula, both bones must be included in the square. Conse-quently, the three segments can be defined as follows:

Segment 1: Proximal, including subsegments epiphysis(E) and metaphysis (M)

Segment 2: Shaft/Diaphysis (D)Segment 3: Distal, including subsegments metaphysis

(M) and epiphysis (E)

Malleolar fractures in adults are classified with a spe-cific code 44 because they have a very special pattern.8

However, such fractures are not so common in children andtheir characteristics do not justify a specific coding. Therefore,they are simply coded as distal tibia fractures (for example thefracture of the medial malleolus is a typical Salter-Harris III orIV fracture of the distal tibia coded, as 43).

SubsegmentThe original severity coding A-B-C used in adults is re-

placed by a classification of fractures according to diaphysis(D), metaphysis (M) and epiphysis (E) (Figure 3). This termi-nology is known and accepted worldwide and is relevant topediatric fractures. The most common fracture subsegmentsin children are the shaft fractures (segment 2), and the epi-metaphyseal subsegment (segments 1 and 3). Use of the E-M-D coding identifies intra-articular and extra-articular fractureswithout ambiguity because epiphyseal fractures are intra-ar-ticular fractures by definition. The metaphyseal fractures areidentified through the position of the square (the center of thefracture lines must be located in the square) with one sideover the physis (Figures 3 and 4). For easier and more accu-rate application of the squares and, consequently, more reli-able classification, a series of pre-drawn squares are copied

on a transparency and applied to the anteroposterior (AP) ra-diographic view (Figure 4). For the pairs of bones radius/ulnaand tibia/fibula, both bones must be included in the square.This square definition is not applicable to the proximal femurwhere metaphyseal fractures are located between the physisof the head and the intertrochanteric line (see below).

In applying the square definition, surgeons should beaware that if this view is not strictly on the AP plane, eg, if theplane is slightly rotated the applied square will be smaller thanexpected, leading to risk of misclassification. In such cases, theclassification process should be checked after fracture reduc-tion. When a metaphyseal fragment is severely angulated in thefrontal plane, the square will be correctly chosen, but the lengthof the fragment will appear smaller than it really is. In this situ-ation, the same square should be used on the lateral radiographicview to assess the length of the metaphyseal fragment.

MorphologyChild 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 theentire classification code (Figure 5). Relevant child patternsare specific to one of the fracture subsegments E, M, or D andhence are grouped accordingly. Regardless of fracture type,

J Orthop Trauma • Volume 21, Number 10 Supplement, November/December 2007 Pediatric Long Bone Fractures


FIGURE 3. Definition of bone segments and subsegments; Forchildren, the square must be placed over the larger part of thephysis.

FIGURE 4. Use of the square patterns to classify a fracture asepiphyseal (E), metaphyseal (M) or diaphyseal (D).

child patterns having a similar morphology are given thesame child code for simplification and consistency.

Internationally known and accepted child patterns areconsidered. Patterns of epiphyseal fractures include theknown epiphyseal injuries I to IV according to Salter andHarris1 using the child codes E/1 to E/4. These codes resultedfrom intensive discussion within the AO Pediatric ExpertGroup and among other surgeons about whether Salter-HarrisI and II fractures should be classified as metaphyseal fractures(M), since they have very similar characteristics to these frac-tures.6 However, surgeons worldwide traditionally recognizethese fractures as epiphyseal fractures (E) (Figure 6). Otherchild 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 frac-tures, ie, the buckle or torus greenstick fractures (M/2), com-plete fracture (M/3) and osteo-ligamentous, musculo-ligamentous 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 identi-fied when the angle between the fracture line and the linetransverse to the bone axis is above 30º. A 30º angle shouldbe drawn on the transparency sheet mentioned above andshould be applied to the radiographs for more reliable classi-fication. The angle should be measured according to the lon-gitudinal axis of the main fragment and on the radiographicview showing the most severe angle (lateral or AP view)

(Figure 9). Similarly the code /9 should be used for fracturesthat may not belong to well-defined categories.

Severity CodeA grade of fracture severity is considered, not so much

because of its influence on healing, as in adults, but becauseof the need to investigate the indications for various methodsof osteosynthesis.

This code distinguishes between simple (.1), wedge(partially unstable fracture with 3 fragments including a fullyseparated fragment) and complex (totally unstable fracturewith more than 3 fragments) (.2), as shown in Figure 10.

Exceptions and Additional CodesAs for adult fractures, not all pediatric fractures can

simply be classified according to the above scheme, and a fewmore definitions and rules were agreed on:

• Fractures of the apophysis are recognized as metaphysealinjuries.

• Transitional fractures with or without metaphyseal wedgeare classified as epiphyseal fractures.

• Intra- and extra-articular ligament avulsions are epiphysealand metaphyseal injuries, respectively.



FIGURE 6. Definition of child patterns for epiphyseal fractures.

FIGURE 7. Definition of child patterns for metaphyseal frac-tures.

FIGURE 8. Definition of child patterns for diaphyseal fractures.

FIGURE 5. Overall structure of the paediatric fracture classifi-cation.



• Supracondylar humerus fractures (code 13 – M/3) are givenan additional code regarding the grade of displacement at 4levels (I to IV) (see supracondylar fractures).

• Radial head (21-E/1 or /2) and neck fractures (21-M/2 orM/3) are given an additional code (I –III) regarding theaxial deviation and level of displacement (see radial neckfractures).

• Femoral neck fractures. Epiphysiolysis and epiphysiolysiswith a metaphyseal wedge are coded as normal Type E epi-physeal SH I and II fractures E/1 and E/2. Fractures of thefemoral neck are coded as normal type M metaphyseal frac-tures code I to III (see femoral neck fractures). The in-tertrochanteric line limits the metaphysis.

• The side of ligament avulsion fractures of the distalhumerus 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 frac-ture entities depending on the use of an exception code. Twotypical classification examples are presented in Figure 11.

Supracondylar FracturesSupracondylar humerus fractures (code 13 – M/3) are

given an additional code regarding the grade of displacementat 4 levels (I to IV) as defined below and presented in an al-gorithm (Figure 12).

Type IIncomplete fracture. In a strict lateral view, the Rogers’

line still intersects the capitellum. In the AP view there is nomore than a 2mm valgus/varus fracture gap.

Type IIIncomplete fracture: Antecurvation or recurvation with

continuity of the posterior (extension fracture) or anterior cor-tex (flexion fracture). The Rogers’ line does not intersect thecapitellum.

FIGURE 11. Example of a supracondylar fracture (a) and atibia shaft fracture (b).

FIGURE 10. Severity implies anticipated difficulties andmethod of treatment, not the prognosis.

FIGURE 9. Measurement of the fracture angle.

FIGURE 12. Algorithm for supracondylar fracture classifica-tion.



Type IIIComplete fracture: No bone continuity (broken cortex),

but still some contact between the fracture planes, independ-ent of the type of displacement.

Type IVComplete fracture: No bone continuity (broken cortex),

and no contact between the fracture planes, independent ofthe type of displacement.

Radial Neck (Head) FracturesRadial head (21-E/1 or /2) and neck fractures (21-M2 or

M/3) are given an additional code regarding the axial devia-tion and level of displacement: no angulation and no displace-ment (I), angulation with displacement up to half of the bonediameter (II) and angulation with displacement more than halfof the bone diameter (III) as shown in Figure 13.

Femoral Neck FracturesFemoral neck fractures. Epiphysiolysis and epiphysioly-

sis with a metaphyseal wedge are coded as subsegment E epi-physeal SH I and II fractures E/1 and E/2. Fractures of thefemoral neck are coded as subsegment M metaphyseal frac-tures: midcervical (I), basocervical (II), and transtrochanteric(III). The intertrochanteric line limits the methaphysis (Figure14).

Detailed Presentation and DefinitionsIn the following sections, only the most common pedi-

atric fractures are described, illustrated and coded.

FIGURE 13. Classification of radial neck (head) fractures.

FIGURE 14. Classification of femoral neck fractures.

HUMERUS (1)

Proximal epiphyseal fractures (11-E)

Simple fractures Wedge/complex fractures

Code Figure Description Code Figure Description

11 – E/1.1 Simple epiphysiolysis

11 – E/2.1 Simple epiphysiolysis 11 – E/2.2 Epiphysiolysis with with metaphyseal multifragmentary

wedge metaphyseal wedge

11 – E/3.1 Simple epiphyseal 11 – E/3.2 Multifragmentary fracture SH III epiphyseal fracture

SH III

11 – E/4.1 Simple epi- 11 – E/4.2 Multifragmentarymetaphyseal epimetaphyseal fracture SH IV fracture SH IV

11 – E/8.1 Single intraarticular 11 – E/8.2 Multipleflake fracture intraarticular flake

fracture

Proximal metaphyseal fractures (11-M)



11 – M/2.1 Metaphyseal torus / buckle fracture

11 – M/3.1 Complete, simple 11 – M/3.2 Complete, metaphyseal multifragmetary

metaphyseal

Diaphyseal fractures (12-D)



12 – D/4.1 Simple, transverse 12 – D/4.2 Multifragmentary, (>30°) diaphyseal transverse (>30°)

diaphyseal

12 – D/5.1 Simple, oblique or 12 – D/5.2 Multifragmentaryspiral (< 30°) oblique or spiral diaphyseal (<30°) diaphyseal



Distal metaphyseal fractures (13-M)



13 – M/2.1 Torus, buckle metaphyseal, supracondylar

fracture

13 – M/3.1 Incomplete 13 – M/3.2 Multifragmentarysupracondylar complete fracture

fracture

13u – M/7.1 Avulsion of the ulnar epicondyle

(extra-articular)

Distal epiphyseal fractures (13-E)




SH I


with metaphyseal wedge SH II

13 – E/3.1 Simple epiphyseal fracture SH III

13r – E/4.1 Simple epiphyseal 13 – E/4.2 Complex epi-fracture with metaphysealmetaphyseal ( Y or T fracture )wedge SH IV

13r – E/7.1 Avulsion of the radial collateral

ligament

13r – E/8.1 Simple flake fracture 13r – E/8.2 Multifragmentaryof the radial condyle flake fracture of

the radial condyle





Radius/Ulna (2)

Proximal epiphyseal fractures/radial head (21-E)

Simple fractures Wedge/multifragmentary fractures


21r – E/1.1 I Simple epiphysiolysis radial head

SH Ino displacement

21r – E/1.1 II Simple epiphysiolysis radial head SH I angulation and displacement

�1/2 shaft

21r – E/1.1 III Simple epiphysiolysis radial head SH I

displacement>1/2 shaft or complete

21r – E/2.1 I epiphysiolysis radial 21r – E/2.2 I epiphysiolysis radial head with simple head with

metaphyseal wedge multifragmentarySH II metaphyseal wedge

no displacement SH II no displacement

21r – E/2.1 II epiphysiolysis radial 21r – E/2.2 II epiphysiolysis radial head with simple head with


angulation and SH II displacement angulation and

�1/2 shaft displacement �1/2 shaft

21r – E/2.1 III epiphysiolysis radial 21r – E/2.2 III epiphysiolysis radial head with simple head with


displacement SH II >1/2 shaft or complete displacement

>1/2 shaft or complete

21r – E/3.1 Simple epiphyseal 21r – E/3.2 multifragmentaryradial head epiphyseal radial

fracture SH III head fracture SH III

21r – E/4.1 Simple epi- 21r – E/4.2 multifragmentarymetaphyseal radial epimetaphyseal head fracture SH IV radial head

fracture SH IV



Proximal metaphyseal fractures radius/ulna (21-M)



21r – M/2.1 Metaphyseal torus/buckle

fracture radial neck

21r – M/3.1 I Complete, simple 21r – M/3.2 I Complete, metaphyseal multifragmentaryradial neck metaphyseal radial

no displacement neck no displacement

21r – M/3.1 II Complete, simple 21r – M/3.2 II Complete, metaphyseal multifragmentaryradial neck metaphyseal

angulation and radial neck displacement angulation and

�1/2 shaft displacement �1/2 shaft

21r – M/3.1 III Complete, simple 21r – M/3.2 III Complete, metaphyseal multifragmentaryradial neck metaphyseal radial

displacement neck >1/2 shaft or complete displacement

>1/2 shaft or complete

21u – M/2.1 Metaphyseal torus / buckle olecranon

21u – M/3.1 Complete, simple 21u – M/3.2 Complete,metaphyseal multifragmentary

olecranon metaphyseal olecranon

21u – M/7.1 Avulsion of the olecranon apophysis



Diaphyseal fractures radius/ulna (22-D)



22 – D/1.1 Bowing diaphyseal

22 – D/2.1 Greenstick diaphyseal

22 – D/4.1 Complete simple 22 – D/4.2 Completeforearm transverse multifragmentary

forearm transverse

22 – D/5.1 Complete simple 22 – D/5.2 Completeforearm oblique multifragmentary

or spiral forearm oblique or spiral

22 – D/6.1 Monteggia lesion, 22 – D/6.2 Monteggiaulna simple lesion, ulna

multifragmentary

22 – D/7.1 Galeazzi lesion, 22 – D/7.2 Galeazzi lesion, radius simple radius

multifragmentary

22r – D/1.1 Bowing radius





22r – D/2.1 Greenstick radius

22r – D/4.1 Radius complete, 22r – D/4.2 Radius complete, single transverse multifragmentary,

transverse

22r – D/5.1 Radius complete, 22r – D/5.2 Radius complete, single oblique multifragmentary

or spiral oblique or spiral

22u – D/1.1 Bowing ulna

22u – D/2.1 Greenstick ulna

22u – D/4.1 Ulna complete, 22u – D/4.2 Ulna complete, single transverse multifragmentary

transverse

22u – D/5.1 Ulna complete, 22u – D/5.2 Ulna complete, single oblique multifragmentary

or spiral oblique or spiral



Distal metaphyseal fractures radius/ulna (23-M)



23 – M/2.1 Torus, buckle metaphyseal, distal

radius/ulna

23 – M/3.1 Complete simple 23 – M/3.2 Completedistal radius/ulna multifragmentary

distal radius/ulna

23r – M/2.1 Torus/buckle distal radius

23r – M/3.1 Complete simple 23r – M/3.2 Complete distal radius multifragmentary

distal radius

23u – M/2.1 Torus/buckle distal ulna

23u – M/3.1 Complete simple 23u – M/3.2 Complete distal ulna multifragmentary

distal ulna



Distal epiphyseal fractures radius/ulna (23-E)



23 – E/1.1 Simple epiphysiolysis SH I

23 – E/2.1 Simple epiphysiolysis 23 – E/2.2 Epiphysiolysis withwith metaphyseal multifragmentary

wedges SH II metaphyseal wedges SH II

23 – E/3.1 Simple epiphyseal fracture SH III

23 – E/4.1 Simple epimetaphyseal fracture SH IV

23 – E/7.1 Radioulnar ligament avulsion

23r – E/1.1 Simple epiphysiolysis SH I radius

23r – E/2.1 Simple epiphysiolysis 23r – E/2.2 Multifragmentary with metaphyseal epiphysiolysis

wedge SH II radiusradius SH II

23r – E/3.1 Simple epiphyseal fracture SH III

radius

23r – E/4.1 Simple epiphyseal 23r – E/4.2 Multifragmentaryfracture with epiphyseal fracture

metaphyseal wedge with metaphyseal SH IV radius wedge SH IV radius





23u – E/1.1 Simple epiphysiolysis SH I ulna

23u – E/2.1 Simple epiphysiolysis 23u – E/2.2 multifragmentarywith metaphyseal epiphysiolysis with wedge SH II ulna metaphyseal wedge

SH II ulna

23u – E/3.1 Simple epiphyseal fracture SH III

ulna

23u – E/4.1 Simple epi- 23u – E/4.2 multifragmentarymetaphyseal fracture epimetaphyseal

SH IV ulna fracture SH IV ulna

23u – E/7.1 Ligament avulsion ulnar styloid process



Exception femoral neck fractures Exception femoral neck fractures

Femur (3)

Proximal epiphyseal fractures (31-E)



31 – E/1.1 Epiphysiolysis (SUFE/SCFE)

SH I

31 – E/2.1 Epiphysiolysis (SUFE/SCFE) with

metaphyseal wedgeSH I

31 – E/7.1 Ligament avulsion (ligam. capitis femoris)

31 – E/8.1 Single flake fracture 31 – E/8.2 Multipleflake fracture

Proximal metaphyseal fracture/femoral neck (31-M)



31 – M/2.1 I Incompletemidcervical

31 – M/3.1 I Simple complete 31 – M/3.2 I Multifragmentarymidcervical midcervical

31 – M/2.1 II Incomplete basocervical





31 – M/3.1 II Simple complete 31 – M/3.2 II Multifragmentarybasocervical basocervical

31 – M/2.1 III Incomplete transtrochanteric

31 – M/3.1 III Simple complete 31 – M/3.2 III Multifragmentarytranstrochanteric transtrochanteric

31 – M/7.1 Ligament avulsion of greater

OR lesser trochanter

Diaphyseal fractures femur (32-D)



32 – D/4.1 Simple complete 32 –D/4.2 Multifragmentary transverse transverse

(≤30°) (≤30°)

32 – D/5.1 Simple complete 32 – D/5.2 Multifragmentary oblique or spiral oblique or spiral

(>30°) (>30°)

Exception femoral neck fractures



Distal metaphyseal fractures femur (33-M)



33 – M/2.1 Torus/buckle metaphysealdistal femur

33 – M/3.1 Simple 33 – M/3.2 Multifragmentarycomplete distal distal femur

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)




33 – E/2.1 Simple epiphysiolysis 33 – E/2.2 Epiphysiolysis with metaphyseal with multifrag-

wedge SH II menatry metaphysealwedge SH II

33 – E/3.1 Simple 33 – E/3.2 Multifragmentary epiphyseal epiphyseal

fracture SH III fracture SH III

33 – E/4/1 Simple 33 – E/4.2 Multifragmentaryepimetaphyseal epimetaphysealfracture SH IV fracture SH IV

33 – E/8.1 Single intraarticular 33 – E/8.2 Multiple intra-flake fracture articular flake

fracture



Tibia/Fibula (4)

Proximal epiphyseal fractures tibia/fibula (41-E)



41t – E/1.1 Simple epiphysiolysis tibia

SH I

41t – E/2.1 Simple tibial 41t – E/2.2 Tibial epiphysiolysis, epiphysiolysis, simple multifragmentary

metaphyseal metaphyseal wedges wedge SH II SH II

41t – E/3.1 Simple tibial 41t – E/3.2 Multifragmentary epiphyseal fracture tibial epiphyseal

SH III fracture SH III

41t – E/4.1 Simple tibial 41t - E/4.2 Multifragmentaryepi-metaphyseal tibial epimetaphyseal fracture SH IV fracture SH IV

41t – E/7.1 Tibial spine fracture

41t – E/8.1 Flake fracture tibial plateau

Only tibia



Proximal metaphyseal fractures tibia/fibula (41-M)



41 – M/2.1 Torus/bucklefracture tibia/

fibula

41 – M/3.1 Simple complete 41 – M/3.2 Multifragmentarytibia and fibula tibia and fibula

Only tibia

41t – M/2.1 Torus/bucklefracture tibia

41t – M/3.1 Tibia simple 41t – M/3.2 Tibiacomplete multifragmentary

41t – M/7.1 Fracture of the tibial apophysis

Only fibula

41f – M/2.1 Torus/bucklefibula

41f – M/3.1 Fibula simple 41f – M/3.2 Fibulacomplete multifragmentary

Only tibia

Only fibula



Disphyseal fractures tibia/fibula (42-D)



42 – D/1.1 Bowing tibiaand fibula

42 – D/2.1 Greensticktibia and fibula

42 – D/4.1 Transverse 42 – D/4.2 Transversesimple tibia multifragmentaryand fibula tibia and fibula

(�30°) (�30°)

42 – D/5.1 Simple oblique 42 – D/5.2 Multifragmentaryor spiral tibia oblique or spiral

and fibula tibia and fibula(�30°) (�30°)

Only tibia

42t – D/1.1 Bowing tibia

42t – D/2.1 Greensticktibia

42t – D/4.1 Transverse 42t – D/4.2 Transversesimple tibia multifragmentary

(�30°) tibia(�30°)

42t – D/5.1 Oblique or 42t – D/5.2 Oblique or spiral spiral tibia multifragmentary

(�30°) tibia(�30°)

Only tibia

Distal metaphyseal fractures tibia/fibula (43-M)



43 – M/2.1 Torus/buckletibia and fibula

43 – M/3.1 Complete simple 43 – M/3.2 Multifragmentarytibia and fibula tibia and fibula

Only tibia

43t – M/2.1 Torus/buckletibia

43t – M/3.1 Complete 43t – M/3.2 Multifragmentarysimple tibia tibia





42f – D/1.1 Bowing fibula

42f – D/2.1 Greenstickfibula

42f – D/4.1 Transverse 42f – D/4.2 Transversesimple fibula multifragmentary

(�30°) fibula(�30°)

42f – D/5.1 Oblique or 42f – D/5.2 Oblique or spiralspiral simple multifragmentary

fibula fibula(�30°) (�30°)

Only fibula

Only tibia



Distal epiphyseal fractures tibia/fibula (43-E)



43 – E/1.1 Simpleepiphysiolysis

tibia and fibula

Only tibia

43t – E/1.1 Simpleepiphysiolysis

tibia SH I

43t – E/2.1 Simple epi- 43t – E/2.2 Multifragmentarymetaphyseal epimetaphysealfracture tibia fracture tibia SH II

SH II

43t – E/3.1 Simplemetaphysealfracture tibia

SH III

43t – E/4.1 Simple epi- 43t – E/4.2 Multifragmentarymetaphyseal epimetaphysealfracture SH IV fracture SH IV

43t – E/5.1 Tillaux (twoplane) fracture

SH III

Only tibia



43f – M/2.1 Torus/bucklefibula

43f – M/3.1 43f – M/3.2 Multifragmentaryfibula

Only fibula





43t – E/6.1 Tri-planefractureSH IV

43t – E/8.1 Intra-articularflake tibia

43f – E/1.1 Simple epiphysiolysis

fibulaSH I

43f – E/2.1 Simpleepiphysiolysis

withmetaphysealwedge fibula

SH II

43f – E/3.1 Simple epiphyseal

fracture fibulaSH III

43f – E/4.1 Simple epi-metaphyseal

fractrue fibulaSH IV

43f – E/7.1 Osteoligamentavulsion fibula

43f – E/8.1 Intra-articularflake fibula

Only fibula



Frequent fracture combinations in paired bones

Codes Combinations Description

Tibia/fibula

41t – E/2.1 Proximal lower leg 41f – M/3.1 SH II tibia and complete

metaphyseal fibula

42t – D/4.1 Complete diaphyseal 42f – D/1.1 tibia and bowing

of the fibula

42t – D/5.2 Multifragmentary diaphyseal 42f – D/2.1 tibia and greenstick fibula

43t – E/4.1 Combined fracture: 43f – E/1.1 SH III tibia and

SH I fibula

43t – E/4.2 Multifragmentary43f – E/1.1 epiphyseal fracture tibia

SH III and SH I fibula

43t – E/2.1 Distal lower leg43f – M/3.1 SH II tibia and complete

metaphyseal fibula

Radius/Ulna

21r – M/3.1 III Complete radial neck Type III 21u – M/3.1 and olecranon fracture

22r – D/5.1 Simple oblique or spiral 22u – D/1.1 complete radius and

bowing of the ulna

23r – E/2.1 Radial SH II and fracture of23u – E/7.1 the ulnar styloid



APPENDIXThe AO Pediatric Classification Group consists of: T. Slongo,L. Audigé, P. Schmittenbecher, N. Lutz, J-M. Clavert, S.Frick, J. Hunter, and W. Schlickewei.

REFERENCES1. Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone

Joint Surg Am. 1963;45:587–622.2. Baumann E. Ellbogen. In: Nigst H, ed. Spezielle Frakturen- und

Luxationslehre. Stuttgart: Thieme, 1965.3. Gartland JJ. Management of supracondylar fractures of the humerus in

children. Surg Gynecol Obstet. 1959;109:145–154.4. von Laer, L., Frakturen und Luxationen im Wachstumsalter. 4. überar-

beitete und aktualisierte Auflage ed. 2001.5. Judet J, Judet R, Lefranc J. Fractures du col radial chez l’enfant. Ann

Chir. 1952;16:1377–1385.6. von Laer L, Gruber R, Dallek M, et al. Classification and documenta-

tion of children’s fractures. Eur J Trauma. 2000;26:02–14.7. Audigé L, Bhandari M, Kellam J. How reliable are reliability studies of

fracture classifications? A systematic review of their methodologies.Acta Orthop Scand. 2004;75:184–194.

8. Müller ME, Nazarian S, Koch P, et al. The Comprehensive Classi-fication of Fractures of Long Bones. Berlin, Germany: Springer-Verlag,1990.

9. Slongo T, Schaerli AF, Koch P, et al. Klassifikation und Dokumen-tation der Frakturen im Kindesalter—Pilotstudie der internationalenArbeitsgemeinschaft für Kindertraumatologie. Zentralbl Kinderchir.1995;157–163.

10. Garbuz DS, Masri BA, Esdaile J, et al. Classification systems in or-thopaedics. J Am Acad Orthop Surg. 2002;10:290–297.

11. Audigé L, Hunter J, Weinberg AM, et al. Development and evaluationprocess of a pediatric long-bone fracture classification proposal. Eur JTrauma. 2004;30:248–254.

12. Audigé L, Bhandari M, Hanson B, et al. A concept for the validation offracture classifications. J Orthop Trauma. 2005;19:401–406.

13. Slongo T, Audigé L, Lutz N, et al. Documentation of fracture severitywith the AO classification of pediatric long-bone fractures. ActaOrthop. 2007;78:247–253.

14. Slongo T, Audigé L, Clavert JM, et al. The AO comprehensive classi-fication of pediatric long-bone fractures: a web-based multicenteragreement study. J Pediatr Orthop. 2007;27:171–180.

15. Slongo T, Audigé L, Schlickewei W, et al. Development and validationof the AO pediatric comprehensive classification of long bone fracturesby the Pediatric Expert Group of the AO Foundation in collaborationwith AO Clinical Investigation and Documentation and theInternational Association for Pediatric Traumatology. J PediatrOrthop. 2006;26:43–49.

Codes Combinations Description

Radius/Ulna

23r – M/2.1 Torus/buckle of the radius and 23u – M/3.1 complete metaphyseal ulna

23r – M/2.1 Torus/buckle of the radius and23u – E/7.1 fracture of the ulnar styloid


AAcetabulum

anterior column, S59posterior column, S59

Acromioclavicular dislocation, S104,S106

Acromion. See ScapulaAnkle dislocations, S125AO pediatric comprehensive

classification of long bonefractures (PCCF). See Pediatriccomprehensive classification oflong bone fractures

Avulsion of tuberosity, S7–S8

CCalcaneus

articular fractures involvingposterior facet, S92–S93

avulsion, process or tuberosityfractures, S92–S93

bones, S92nonarticular body fractures, S92–S93

Capitatebones, S75fractures, S76

Capitellum fracture, S17Carpal-metacarpal dislocations, S120,

S122Carpus

bones, S75fractures, S76–S77

Cephalotubercular fracture, S7, S10Cervical spine dislocation, S111Childhood fractures. See Pediatric

comprehensive classification oflong bone fractures (PCCF), AO

Clavicle dislocations, S104, S106–S107fractures, S72–S74medial end, diaphysis

groups, S72subgroups and qualifications, S73

medial end, lateral endgroups, S72subgroups and qualifications, S74

medial end, metaphysis, groups, S72Corocoid. See ScapulaCoronoid process. See Radius/ulnaCuboid

bones, S94fractures, S94

Cuneiformsbones, S94fractures, S94

DDislocations, S103–S128

elbow, S108–S110foot and ankle, S125–S128general principles, S103hand and wrist, S120–S124hip, S112

knee, S113–S117pelvic, S118–S119shoulder, S104–S107spine, S111

Distal interphalangeal jointdislocations, S124

EElbow dislocations, S108–S110Epicondylar. See Humerus fractures

and dislocations, distalEpiphyseal fractures. See Humerus

fractures and dislocations, distal

FFemur fractures, S31–S42

diaphyseal, S35–S38complex

groups, S35subgroups and qualifications,

S38pediatric, S152simple


S36wedge


S37distal, S39–S42

complete articulargroups, S39subgroups and qualifications,

S42extra-articular


S40partial articular


S41proximal, S31–S34

epiphyseal, pediatric, S150head fracture


S34metaphyseal/femoral neck,

pediatric, S140neck fracture


S33trochanteric


S32Fibula. See Tibia/fibulaFoot

bones, S89dislocations, S125–S128

fractures, S90–S94 (See alsospecific bones)

multiple crush fractures, S94Forefoot dislocations, S125,

S127–S128

GGaleazzi fracture-dislocations, S24–S26Glenohumeral dislocations, S7–S10,

S104–S105Goyrand-Smith fracture, S28

HHamate


Hand and carpus. See also specific bonesbones, S75fractures, S75–S77

Hand dislocations, S120–S124Hip dislocations, S112Holdsworth slice rotation fracture,

S132Humerus fractures, S7–S18



S14pediatric, S142simple


S12wedge




S18epiphyseal, pediatric, S142extra-articular


S16metaphyseal, pediatric, S142partial articular



articulargroups, S7subgroups and qualifications,

S10epiphyseal, pediatric, S141extra-articular bifocal


S9

INDEX

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


extra-articular unifocalgroups, S7subgroups and qualifications, S8

metaphyseal, pediatric, S141

IIntercarpal dislocations, S120–S121

KKnee dislocations, S113–S117Kocher I fracture, S16Kocher II fracture, S16

LLumbar spine dislocation, S111Lunate


MMetacarpal bones, S75Metacarpal dislocations, S120, S122Metacarpal fractures, S78–S81

basearticular, S80articular/extra-articular, S81extra-articular, S79groups, S78

diaphysis, S78head

articular, S80articular/extra-articular, S81extra-articular, S80groups, S78

Metacarpal phalangeal jointdislocations, S123

Metatarsal bones, S95Metatarsal fractures, S95–S98

diaphysiscomminuted, S98groups, S95noncomminuted, S96wedge, S97

distalarticular, S98extra-articular, S96groups, S95partial articular, S97

proximalarticular, S98extra-articular, S96groups, S95partial articular, S97

Metatarsal-phalangeal jointdislocations, S128

Milch I fracture, S17Monteggia fracture-dislocations,

S24–S26

NNavicular


OOlecranon. See Radius/ulna

PPatella fractures, S86–S88


S88extra-articular, S86partial articular

groups, S86subgroups and qualifications, S87

Patellofemoral dislocations, S113,S115

Pediatric comprehensive classificationof long bone fractures (PCCF),AO, S135–S160

definitions, S136femur

diaphyseal, S151proximal epiphyseal, S150proximal metaphyseal/femoral

neck, S140humerus

diaphyseal, S141distal epiphyseal, S142distal metaphyseal, S142proximal epiphyseal, S141proximal metaphyseal, S141

injury pattern and growth, S135locations

bone, S136child code, S137–S138exceptions and additional code,

S139–S140fracture severity code, S138fracture type, S137segments, S136–S137

radius/ulnacombinations, S159–S160diaphyseal, S145–S146distal epiphyseal, S148–S149distal metaphyseal, S147proximal epiphyseal/radial head

and neck, S140, S143proximal metaphyseal, S144

supracondylar, additional code,S139–S140

tibia/fibulacombinations, S159proximal epiphyseal, S153

Pelvisclassification systems, S59definitions, S59dislocations, S118–S119fractures, S59–S67

acetabulum, S64–S67complete articular, both columns


S67

partial articular, one columngroups, S64subgroups and qualifications,

S65partial articular, transverse


S66pelvic ring, S59–S63

complete disruption of posteriorarch

groups, S59–S60subgroups and qualifications,

S63partially stable


S62stable


S61types, S59unstable


S63Phalanges, foot, S89Phalanx, foot, fractures, S99–S102

diaphysiscomplex, S102groups, S99simple, S100wedge, S101

distalarticular, S102extra-articular, S100groups, S99partial articular, S101

proximalarticular, S102extra-articular, S100groups, S99partial articular, S101

Phalanges, hand, S75dislocations, S123–S124

Phalanx, hand, fractures, S82–S85articular, S82complete articular


S85diaphyseal, S82–S83extra-articular

distal, S83groups, S82proximal, S83

partial articulargroups, S82subgroups and qualifications, S84

Pisiform fractures, S77Pouteau-Colles fracture, S28

Humerus fractures, proximal—

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


Proximal interphalangeal jointdislocations

foot, S128hand, S123

RRadial carpal bone

bones, S75fractures, S76–S77

Radiocarpal dislocations, S120–S121Radiohumeral dislocation, S108–S109Radioulnar dislocation, distal, S108,

S110Radius/ulna fractures, S19–S30



S26pediatric, S143–S149simple


S24wedge




S30extra-articular




S29pediatric

epiphyseal, S149–S150metaphyseal, S148

pediatric combinations, S159–S160proximal, S19–S22

articular, surface of one bonegroups, S19subgroups and qualifications,

S21articular, surface of two bones


S22extra-articulargroups, S19subgroups and qualifications,

S20pediatric

epiphyseal/radial head andneck, S140, S143

metaphyseal, S144, S147

SSacroiliac dislocations, S118Scaphoid


Scapula dislocations, S104, S107Scapula fractures, S68–S71

extra-articulargroups, S68subgroups, S69

partial articulargroups, S68subgroups, S70

total articulargroups, S68subgroups, S71

Shoulder dislocations, S104–S107Spine dislocations, S111Spine fractures, S129–132

anterior or posterior element injurywith distraction, S129, S131

anterior or posterior element injurywith rotations, S129, S132

vertebral body compression,S129–S130

Sternoclavicular dislocation, S104, S107Styloid process. See Radius/ulna

fractures and dislocations, distalSupracondylar fractures, pediatric,

S139–S140Symphysis pubic dislocation,

S118–S119

TTalus

avulsions, process and headfractures, S90–S91

body fractures, S90–S91bones, S89neck fractures, S90–S91

Tarsal metatarsal dislocations,S126–S127

Thoracic spine dislocation, S111Tibia/fibula fractures and dislocations,

combinations, pediatric, S159Tibia/fibula fractures, S43–S58



S50simple


S48wedge



complete articulargroups, S53

subgroups and qualifications,S54

extra-articulargroups, S51subgroups and qualifications,



S53malleolar, S55–S58

infrasyndesmoticgroups, S55subgroups and qualifications,

S56suprasyndesmotic


S58transsyndesmotic




S46epiphyseal, pediatric, S153extra-articular




S45Tibiofemoral dislocations, S113–S114Tibiofibular dislocations, S113,

S116–S117Trapezium fractures, S77Trapezoid fractures, S77Triquetrum fractures, S77Trochlear fractures, S15, S17Tuberosity, avulsion of, S7–S8

UUlna. See Radius/ulnaUlnar carpal bone


Ulnohumeral dislocation, S108–S109

VVertebral body compression fractures,

S129–S130

WWrist dislocations, S120–S121

YYoung-Burgess classification, S59

clasificacion ao 2007

Documents