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numeric code developed by the Mller group. In their introduction to the 1996 compendium, the Coding and Classification
Committee noted that the goal of the comprehensive classification was to classify fractures in a uniform and consistent fashion to allow standardization of research and communication.1
The committee observed that the current state of fracture classification was ineffective for these purposes with multiple diverse systems used in different parts of the skeleton for various
purposes, thwarting any possibility of a standardized language
and accumulation of uniform data. Their intent was for the new
classification to be a flexible, evolving classification system in
which changes would be made based on comment, criticism
and appropriate clinical research. In this way the classification
could continue to optimally serve the needs of orthopedic traumatologists for both clinical practice and research.
Since the compendium was published in 1996, the classification has resided on the OTA website and has been regularly
used in trauma databases in North American Trauma Centers. It
is the official classification of the OTA and of the JOT. In these
ways it has developed wide acceptance and has dramatically improved the way information about fractures is communicated,
stored, and used to advance knowledge through clinical research. In some anatomic areas this classification has largely
supplanted all others, achieving one of the original intents.
Unfortunately, the OTA classification has not achieved
some of its originally stated goals. It has not been modified
since 1996 and therefore it has not been the flexible, evolving classification envisioned when it was published. It also
has not become a truly universal language of communication
because multiple other anatomically specific classifications
still exist and are part of commonly used fracture language,
and for some areas of the skeleton they are still preferred.
Since 1996, considerable new scientific information has
been published about fracture classification in general and the
OTA system in particular. Factors leading to poor reliability
and reproducibility of fracture classifications have been intensively studied. These studies have led to important new information on how clinicians interpret images of fractures on
radiographs and the process by which fractures are classified.
Unfortunately, difficulties with classification reliability have
led to some loss of enthusiasm with the classification process.
It is now widely recognized that, to ensure that any classification is suitably reliable, it must undergo an intense and rigorous scientific scrutiny. The effort required is considerable,
and this difficult process has either been ignored or avoided
in favor of popular and widely used classifications.
S1
Introduction
FUNDAMENTALS OF FRACTURE
CLASSIFICATION
Classification is the process by which related groups are
organized based on similarities and differences.3 It condenses
the language necessary to convey information among individuals with a similar understanding of the classification. A
broad and diverse topic such as fractures lends itself well to
the classification process. We all classify fractures as part of
our standard description of an injury. In describing a fracture,
we identify a bone, define a region in the bone, and routinely
describe displacement and comminution and location of fracture lines with respect to relevant anatomy. In these ways we
are verbally classifying the fracture as we describe it. Formal
classification of fractures systematizes this descriptive
process and replaces words with categories and numbers or
letters that convey the same information. Fracture classification allows information about fractures to be stored in a way
that facilitates comparisons among different groups or among
similar groups treated differently.
A good fracture classification fulfills some fundamental
objectives. It should provide a reliable and reproducible
means of communication. Different observers (reliability) or
the same observer on repeated viewings (reproducibility) presented with the same material (for example, a radiograph)
must agree on the classification of a fracture a high percentage of the time. If this is not the case, the classification has
failed in its fundamental goala means to communicate information based on agreed similarities and differences.
There should be clear clinical relevance for the groups
within the classification that relate either to treatment guidelines, to prognosis, or to risk for complications. Without clinical relevance there is no good reason to define and separate
different groups. To ensure that this relevance is present,
prospective clinical research is necessary. Generally speaking,
the hierarchy of a classification should proceed from less severe (as defined by energy of injury, difficulty of treatment, or
patient outcome) to more severe, because classification is the
fundamental way to convey information about injury severity.
Another type of hierarchy used in both the OTA and the AO
classification organizes fractures within a class from less to
S2
more detailed injury descriptions. This enables a rater to utilize the appropriate complexity to suit his or her purposes.
This characteristic is relatively unique to this classification but
its utility has not been widely employed in the past 11 years.
Most good fracture classifications are organized with these hierarchies. Ideally, a classification should be all-inclusive (all
fractures within reason in a given region should be included)
and mutually exclusive (a given fracture should fit in only one
category). Finally, a classification should be logical, comprehensible, and should not contain an unmanageable number of
categories, a problem that ensures poor reliability.4
Many different characteristics of fractures have been
used as the basis of fracture classification systems. Most classifications, such as the OTA classification, are based on the
anatomic location and the morphology of the fracture.1 These
features can simply be observed or formal measurements may
be necessary. Most commonly the observations and measurements are made on radiographs but in some circumstances information obtained on physical exam, history or
intra-operative findings is considered as part of the classification process. Other features of a fracture, such as the mechanism of injury or associated injuries, may be used in
determining how the fracture should be classified.5 Unless the
information necessary to classify a fracture and how this information is assessed are precisely defined, observers will use the
classification in different ways and reliability will suffer.
To serve the purposes of populating large trauma databases, such as those used at many major trauma centers, and to
provide a space efficient shorthand across languages, a standardized alpha-numeric code for all fractures is necessary and
has always been a part of this system, another relatively
unique feature. Site-specific classifications must be replaced
with a systematic, orderly classification system that encompasses fractures of the entire skeleton. This is absolutely necessary for multi center collaboration, retrospective comparison
of results, international communication and for ease of accomplishing the task of recording information about all fractures in
a trauma database. Although site-specific research is possible
without a comprehensive classification, the more one system
is used consistently for all purposes, the closer we come to a
uniform universal language for fracture care. We believe that
this is a goal that continues to be worth pursuing and is one of
the fundamental advances of the comprehensive classifications of Mller at al2 and the OTA classification.1
ADVANTAGES OF A COMPREHENSIVE
CLASSIFICATION OF FRACTURES
The publication of the English edition of The Comprehensive Classification of Fractures of Long Bones by Mller at
al in 1990 and the subsequent publication of the OTA classification in the 1996 JOT compendium were landmark advances
in fracture classification compared to the state of the art that
was current at that time.1,2 Before these publications, a systematic classification of fractures throughout the skeleton was not
available. Eponyms were rampantColles fracture is an example used to designate diverse patterns of distal radius fractures
variably including intra-articular and extra-articular patterns,
partial and total articular comminution, and variable amounts
of angulation and displacement. Trauma databases were essentially not possible. Classifications were developed by individ 2007 Lippincott Williams & Wilkins
Introduction
S3
Introduction
Through these methods, problems that are now known to increase observer error and disagreement can be readily identified
and minimized as much as possible. Categories within a classification should be as discrete as possible because less discrete
categories lead to wide gray zones and thus increase observer
disagreement. For example, if a category is defined by asking if
a fracture line enters the articular surface, a clear judgment can
be made. However, if the category is defined by the presence or
absence of fracture comminution, this less clear assessment
(how is comminuted defined?) increases the chances for disagreement.24 Similarly, subjective assessments perform poorly,
such as a category defined by a high energy mechanism especially without definition of what this phrase means.24 To the extent possible, categories should be uniquely defined. As an
example, assessing whether the physis is either involved with a
fracture or is not is a more uniquely defined assessment than
whether the fracture is angulated or not. The latter leaves room
for various interpretations of angulation. If measurements are
used to define categories the degree of error in measuring must
be considered and minimized. For example, the degree of displacement of the articular surface in millimeters has been shown
to have high observer error, which means that this commonly
used assessment is a poor way to define categories.24,30 Some
measurements are impossible to make. A category defined as
greater or less than 1 centimeter of displacement between fragments (eg, the greater tuberosity from the rest of the humerus)
requests an observer to measure something on radiographs that
are often exposed in a plane that makes this measurement impossible, relegating the assignment of a fracture category to a
guess unless multiple, carefully exposed radiographs in various
degrees of rotation are evaluated.17 Moreover, categories are
sometimes defined according to a pre-defined cut-off regarding
a continuous diagnostic parameter. For example, the obliquity
of diaphyseal fractures is reduced to a dichotomous variable
(! 30 vs " 30) in the comprehensive long bone classification.
Any such cut-off values ideally should be chosen so that they
are reliably measured and clinically important, but this may not
be the case.
The Comprehensive Classification developed by Mller
at al and modified and adopted by the OTA has not been immune to these problems with observer reliability.1,2 Studies in
the distal radius, distal tibia, proximal tibia, proximal
femur8,1822 and elsewhere have demonstrated that the observer
reliability of the system falls off significantly between the type
and group level and again at the group to subgroup level. It has
generally been conceded that for the purposes of clinical research it has excellent reliability only at the type level.20,21
S4
Introduction
C New
unified classification
Figure
2: Proposal
for a unifiedsystem
numbering AO/OTA system
S5
Introduction
SUMMARY
Since the original publication of the OTA Fracture
Classification in the 1996 JOT Compendium, there has been
important progress in fracture classification. We are farther
along toward the goal of a universally accepted fracture language, but more progress remains to be made. New knowledge has helped us to understand how classifications work, or
sometimes do not work. Much of this new knowledge has
been enlightening; some of it has highlighted areas in which
additional work is necessary. Advances in fracture care are
possible only through an organized grouping of the pathology
presented by the myriad of fracture patterns and associated injuries. Republication of the OTA classification in this compendium combined with advances in fracture classification
software and scientific methodology by the AO/CTF group,
will serve to further this goal. We hope to reinvigorate interest in the language we use to communicate and record information about fractures and dislocations, because it is only
through this language that we can collectively learn from our
experiences to provide better care for future fracture patients.
We encourage those interested in fracture care to utilize this
classification and to participate in further classification improvements that will lead to the publishing of yet another improved version 10 years from now.
Listing of references can be found on page S133.
S6
HUMERUS
Types:
A. Extra-articular, unifocal fracture (11-A)
Groups:
Humerus proximal segment, extra-articular unifocal
(11-A)
1. Avulsion of
3. Non2. Impacted
tuberosity
impacted
metaphysis
(11-A1)
metaphysis
(11-A2)
fracture
(11-A3)
These fractures represent three part fractures, or fracture dislocations by the Neer classification.
S7
Humerus
A1
A2
3. Multifragmentary (11-A3.3)
(1) wedge
(2) complex
(3) glenohumeral dislocation
A3
S8
Humerus
B1
B2
B3
S9
Humerus
C1
C2
3. Cephalotubercular fragmentation
(11-C3.3)
(1) head intact
(2) head fragmented
C3
S10
Types:
A. Simple fracture (12-A)
Groups:
Humerus diaphyseal, simple (12-A)
1. Spiral
2. Oblique
(12-A1)
!30) (12-A2)
(!
Humerus
3. Transverse
"30) (12-A3)
("
3. Fragmented
wedge (12-B3)
S11
Humerus
A1
!30) (12-A2)
Humerus diaphyseal, simple, oblique (!
1. Proximal zone (12-A2.1)
2. Middle zone (12-A2.2)
A2
"30) (12-A3)
Humerus diaphyseal, simple, transverse ("
1. Proximal zone (12-A3.1)
2. Middle zone (12-A3.2)
A3
S12
Humerus
B1
B2
B3
S13
Humerus
C1
(12-C2)
2. With 1 intermediate segmental and
additional wedge fragments (12-C2.2)
(1) pure diaphyseal
(2) proximal diaphysio-metaphyseal
(3) distal diaphysio-metaphyseal
(4) distal wedge
(5) 2 wedges, proximal and distal
C2
C3
S14
Types:
A. Extra-articular fracture (13-A)
Groups:
Humerus distal segment, extra-articular (13-A)
1. Apophyseal
3. Meta2. Metaavulsion (13-A1) physeal
physeal multisimple (13-A2) fragmentary
(13-A3)
Humerus
articular (13-C)
3. Articular,
metaphyseal
multifragmentary (13-C3)
S15
Humerus
A1
(3) juxta-epiphyseal
with anterior displacement (Kocher II)
A2
3. Complex (13-A3.3)
A3
S16
Humerus
3. Transtrochlear multifragmentary
(13-B1.3)
(1) epiphysio-metaphyseal
(2) epiphysio-metaphyseal-diaphyseal
B1
3. Transtrochlear multifragmentary
(13-B2.3)
(1) epiphysio-metaphyseal
(2) epiphysio-metaphyseal-diaphyseal
B2
B3
S17
Humerus
C1
3. Complex (13-C2.3)
C2
C3
S18
RADIUS/ULNA
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 and
ulna (21-A3)
3. Multifragmentary of
both (21-C3)
S19
Radius/Ulna
3. Metaphyseal multifragmentary
(21-A1.3)
A1
A2
A3
S20
Radius/Ulna
B1
B2
3. Articular multifragmentary
(21-B3.3)
(1) ulna, radius extra-articular simple
(2) ulna, radius extra-articular multifragmentary
(3) radius, ulna extra-articular simple
(4) radius, ulna extra-articular multifragmentary
B3
S21
Radius/Ulna
C1
Radius/ulna, proximal, articular, both bones, 1 simple the other multifragmentary (21-C2)
1. Olecranon multifragmentary, radial 2. Olecranon simple, radial head multi- 3. Coronoid process simple, radial
head multifragmentary (21-C2.3)
fragmentary (21-C2.2)
head, simple (21-C2.1)
C2
C3
S22
Types:
A. Simple (22-A)
Groups:
Radius/ulna, diaphyseal, simple (22-A)
1. Ulna simple,
3. Simple frac2. Radius simradius intact
ple, ulna intact ture both
(22-A1)
bones (22-A3)
(22-A2)
Radius/Ulna
B. Wedge (22-B)
C. Complex (22-C)
S23
Radius/Ulna
A1
A2
A3
S24
Radius/Ulna
B1
B2
B3
S25
Radius/Ulna
of ulna (22-C1)
2. Bifocal with radial fracture (22-C1.2)
(1) radius simple
(2) radius wedge
C1
of radius (22-C2)
2. Bifocal, ulna fracture (22-C2.2)
(1) simple ulna
(2) wedge ulna
3. Irregular (22-C2.3)
(1) ulna intact
(2) ulna simple
(3) ulna wedge
C2
3. Irregular (22-C3.3)
C3
S26
Types:
A. Extra-articular (23-A)
Groups:
Radius/ulna, distal, extra-articular (23-A)
1. Extra-articular 2. Extra-artic3. Extra-articuulna fracture,
lar, multifragular simple
radius intact
mentary
radius frac(23-A1)
radius fracture
ture, ulna
(23-A3)
intact (23-A2)
Radius/Ulna
S27
Radius/Ulna
3. Metaphyseal multifragmentary
(23-A1.3)
(1) wedge
(2) complex
A1
Radius/ulna, distal, extra-articular fracture of radius, simple metaphyseal and impacted (23-A2)
(1) radioulnar dislocation (fracture of styloid process)
(2) simple fracture of ulnar neck
(3) multifragmentary fracture of ulnar neck
(4) fracture of ulna head
(5) fracture of ulna head and neck
(6) fracture proximal to ulnar neck
1. Transverse, no tilt, but may be
2. With dorsal tilt, oblique fracture up- 3. Volar tilt, oblique upwards and foraxially shortened (23-A2.1)
ward and back (Pouteau-Colles)
ward (Goyrand-Smith) (23-A2.3)
(23-A2.2)
A2
3. Complex (23-A3.3)
A3
S28
Radius/Ulna
3. Medial (23-B1.3)
B1
Radius/ulna, distal, partial articular fracture of radius, dorsal rim (Bartons) (23-B2)
(1) radioulnar dislocation (fracture of styloid process)
(2) simple fracture of ulnar neck
(3) multifragmentary fracture of ulnar neck
(4) fracture of ulna head
(5) fracture of ulna head and neck
(6) fracture proximal to ulnar neck
1. Simple (23-B2.1)
2. With lateral sagittal fracture
(23-B2.2)
B2
Radius/ulna, distal, partial articular fracture of radius, volar rim (reverse Bartons, Goyrand-Smith II) (23-B3)
(1) radioulnar dislocation (fracture of styloid process)
(2) simple fracture of ulnar neck
(3) multifragmentary fracture of ulnar neck
(4) fracture of ulna head
(5) fracture of ulna head and neck
(6) fracture proximal to ulnar neck
1. Simple with small fragment
3. Multifragmentary (23-B3.3)
2. Simple with larger fragment
(23-B3.1)
(23-B3.2)
B3
S29
Radius/Ulna
Radius/ulna, distal, complete articular fracture of radius, articular simple, metaphyseal simple (23-C1)
(1) radioulnar dislocation (fracture of styloid process)
(2) simple fracture of ulnar neck
(3) multifragmentary fracture of ulnar neck
(4) fracture of ulna head
(5) fracture of ulna head and neck
(6) fracture proximal to ulnar neck
1. Posteromedial articular fragment
2. Sagittal articular fracture line
3. Frontal articular fracture line
(23-C1.1)
(23-C1.2)
(23-C1.3)
C1
Radius/ulna, distal, complete articular fracture of radius, articular simple, metaphyseal multifragmentary (23-C2)
(1) radioulnar dislocation (fracture of styloid process)
(2) simple fracture of ulnar neck
(3) multifragmentary fracture of ulnar neck
(4) fracture of ulna head
(5) fracture of ulna head and neck
(6) fracture proximal to ulnar neck
1. Sagittal articular fracture line
2. Frontal articular fracture line
3. Extending into diaphysis (23-C2.3)
(23-C2.1)
(23-C2.2)
C2
C3
S30
FEMUR
Types:
A. Trochanteric area (31-A)
Groups:
Femur, proximal trochanteric (31-A)
1. Pertro3. Intertro2. Pertrochanteric simple chanteric
chanteric
(31-A1)
(31-A3)
multifragmentary
(31-A2)
S31
Femur
A1
Femur proximal, trochanteric fracture, pertrochanteric multifragmentary (always have posteromedial fragment with lesser
trochanter and adjacent medial cortex) (31-A2)
1. With 1 intermediate fragment
3. Extending more than 1 cm below
2. With several intermediate frag(31-A2.1)
lesser trochanter (31-A2.3)
ments (31-A2.2)
A2
3. Multifragmentary (31-A3.3)
(1) extending to greater trochanter
(2) extending to neck
A3
S32
Femur
B1
B2
B3
S33
Femur
C1
C2
C3
S34
Types:
A. Simple (32-A)
Groups:
Femur, diaphyseal, simple fracture (32-A)
1. Spiral (32-A1) 2. Oblique
3. Transverse
30) (32-A3)
30) (32-A2) (
(
Femur
B. Wedge (32-B)
C. Complex (32-C)
3. Irregular
(32-C3)
S35
Femur
30) (32-A2)
Femur, diaphyseal, simple oblique (
1. Subtrochanteric zone (32-A2.1)
2. Middle zone (32-A2.2)
A1
A2
30) (32-A3)
Femur, diaphyseal, transverse (
2. Middle zone (32-A3.2)
1. Subtrochanteric zone (32-A3.1)
A3
S36
Femur
B1
B2
B3
S37
Femur
C1
C2
5cm)
3. With extensive shattering (
(32-C3.3)
(1) pure diaphyseal
(2) proximal diaphysio-metaphyseal
(3) distal diaphysio-metaphyseal
C3
S38
Types:
A. Extra-articular (33-A)
Groups:
Femur, distal, extra-articular (33-A)
1. Simple
2. Meta(33-A1)
physeal
wedge
(33-A2)
Femur
3. Metaphyseal
complex
(33-A3)
S39
Femur
A1
A2
A3
S40
Femur
3. Multifragmentary (33-B1.3)
B1
3. Multifragmentary (33-B2.3)
B2
B3
S41
Femur
C1
C2
C3
S42
TIBIA/FIBULA
Types:
A. Extra-articular (41-A)
Groups:
Tibia/fibula, proximal, extra-articular
1. Avulsion
2. Metaphy(41-A1)
seal simple
(41-A2)
(41-A)
3. Metaphyseal
multifragmentary (41-A3)
S43
Tibia/Fibula
A1
3. Transverse (41-A2.3)
A2
3. Complex (41-A3.3)
(1) slightly displaced
(2) significantly displaced
A3
S44
Tibia/Fibula
B1
3. Medial (41-B2.3)
(1) central
(2) anterior
(3) posterior
(4) total
B2
B3
S45
Tibia/Fibula
C1
C2
C3
S46
Tibia/Fibula
Types:
A. Simple (42-A)
B. Wedge (42-B)
Groups:
Tibia/fibula, diaphyseal, simple (42-A)
1. Spiral (42-A1) 2. Oblique
3. Transverse
30) (42-A2) (
(
30)
(42-A3)
C. Complex (42-C)
S47
Tibia/Fibula
A1
A2
A3
S48
Tibia/Fibula
B1
B2
B3
S49
Tibia/Fibula
C1
C2
4cm)
3. Extensive shattering (
(42-C3.3)
(1) pure diaphyseal
(2) proximal diaphysio-metaphyseal
(3) distal diaphysio-metaphyseal
C3
S50
Types:
A. Extra-articular (43-A)
Groups:
Tibia/fibula, distal, extra-articular (43-A)
1. Metaphyseal 2. Metaphy3. Metaphysimple (43-A1)
seal complex
seal wedge
(43-A3)
(43-A2)
Tibia/Fibula
S51
Tibia/Fibula
3. Transverse (43-A1.3)
A1
A2
A3
S52
Tibia/Fibula
3. Metaphyseal multifragmentary
(43-B1.3)
B1
B2
3. Metaphyseal, multifragmentary
(43-B3.3)
B3
S53
Tibia/Fibula
C1
C2
3. Epiphysio-metaphysio-diaphyseal
(43-C3.3)
C3
S54
Types:
A. Infrasyndesmotic lesion (44-A)
Groups:
Tibia/fibula, malleolar, infrasyndesmotic lesions
(44-A)
3. With
2. With me1. Isolated
postero-medial
dial malleolar
(44-A1)
fracture
fracture
(44-A3)
(44-A2)
Tibia/Fibula
3. Proximal
fibula (44-C3)
S55
Tibia/Fibula
A1
A2
A3
S56
Tibia/Fibula
3. Multifragmentary (44-B1.3)
B1
3. Multifragmentary (44-B2.3)
(1) rupture of medial collateral ligament
(2) fracture of medial malleolus
B2
Tibia/fibula, malleolar, transsyndesmotic with medial lesion and a Volkmann (fracture of posterolateral rim) (44-B3)
(1) extra-articular avulsion
(2) peripheral articular fragment
(3) significant articular fracture
1. Fibula simple with medial collateral 2. Simple fibula fracture with fracture
3. Multifragmentary with fracture of
ligament rupture (44-B3.1)
of medial malleolus (44-B3.2)
medial malleolus (44-B3.3)
B3
S57
Tibia/Fibula
C1
C2
C3
S58
PELVIS
Types:
A. Lesion sparing (or with no displacement of)
posterior arch (61-A)
ACKNOWLEDGEMENTS
The O.T.A. Coding and Classification Committee gratefully
acknowledges the following individuals for their significant
contributions to the development of systematic universal
pelvic and acetabular classifications:
Emile Letournel, MD; Marvin Tile, MD; Balz Isler, MD; David
Helfet, MD; Serge Nazarian, MD
S59
Pelvis
Groups:
Pelvis, ring, stable (61-A)
1. Fracture of innominate bone,
avulsion (61-A1)
S60
Pelvis
A1
A2
A3
S61
Pelvis
Pelvis, ring, partially stable, unilateral, external rotation (open book, APC-II) (61-B1)
(1) ipsilateral
(2) contralateral
(3) anterior lesion
1. Sacroiliac joint anterior disruption
2. Sacral fracture (61-B1.2, c*)
(61-B1.1)
B1
Pelvis, ring, partially stable, unilateral, internal rotation (lateral compression) (61-B2)
1. Anterior compression fracture of
2. Partial sacroiliac joint fracture/subsacrum (LC-I) (61-B2.1)
luxation (LC-II) (61-B2.2)
(1) anterior lesion ipsilateral
(1) anterior lesion ipsilateral
(2) anterior lesion contralateral
(2) anterior lesion contralateral (bucket
(bucket handle)
handle)
B2
B3
S62
Pelvis
C1
Pelvis, ring, unstable, bilateral, ipsilateral complete, contralateral incomplete (LC-III) (61-C2)
2. Complete through sacroiliac joint
1. Complete through ilium
3. Complete through the sacrum
(61-C2.2, b*, c*)
(61-C2.1, b*, c*)
(61-C2.3, b*, c*)
(a1) transiliac fracture dislocation
(a1) lateral (ala)
(a2) pure dislocation
(a2) foraminal
(a3) transsacral fracture dislocation
(a3) medial to foramen
C2
C3
Footnotes:
*a: Ipsilateral posterior pelvic lesion:
a1) sacroiliac joint anterior disruption; a2) sacral
fracture; a3) anterior compression fracture
sacrum; a4) partial sacroiliac joint fracture/subluxation; a5) incomplete posterior iliac fracture.
*b: Contralateral pelvic lesion:
b1) external rotation, open book partial disruption: .1) sacroiliac joint anterior disruption; .2)
sacral fracture
2
b ) internal rotation, lateral compression partial
disruption: .1) anterior compression fracture of
S63
Pelvis
Types:
A. Partial articular, 1 column (62-A)
Groups:
Pelvis, acetabulum, partial articular, one column
(62-A)
1. Posterior wall 2. Posterior
3. Anterior
(62-A1)
(62-A3)
column
(62-A2)
S64
Pelvis
A1
A2
A3
S65
Pelvis
B1
B2
Pelvis, acetabulum, partial articular, transverse posterior hemitransverse, anterior column (62-B3)
3. Anterior column low (62-B3.3, a**)
2. Anterior column high (62-B3.2, a**)
1. Anterior wall (62-B3.1)
B3
S66
Pelvis
C1
C2
Pelvis, acetabulum, complete articular, both columns involving sacroiliac joint (62-C3)
3. Posterior column multifragmen1. Anterior wall (62-C3.1)
2. Posterior column multifragmentary, anterior column low (62-C3.3,
(a1) anterior column simple, high
tary, anterior column high
a***, b**)
(a2) anterior column simple, low
(62-C3.2, a***, b**)
(a3) anterior column multifragmentary,
high
(a4) anterior column multifragmentary,
low
C3
S67
SCAPULA
Types:
A. Extra-articular (not glenoid) (14-A)
Groups:
Scapula, extra-articular (not glenoid) (14-A)
3. Body
2. Coracoid
1. Acromion
(14-A3)
(14-A2)
(14-A1)
S68
Scapula
Subgroups:
Scapula extra-articular (not glenoid) (14-A)
Acromion (14-A1)
2. Acromion, comminuted (14-A1.2)
1. Acromion, noncomminuted
(14-A1.1)
A1
Coracoid (14-A2)
1. Coracoid, noncomminuted (14-A2.1) 2. Coracoid, comminuted (14-A2.2)
A2
Body (14-A3)
1. Body, noncomminuted (14-A3.1)
A3
S69
Scapula
Subgoups:
Scapula extra-articular (glenoid) (14-B)
Anterior rim (14-B1)
1. Anterior rim, noncomminuted
(14-B1.1)
B1
B2
B3
S70
Subgoups:
Scapula extra-articular (glenoid) (14-C)
Extra-articular glenoid neck (14-C1)
1. Extra-articular glenoid neck,
noncomminuted (14-C1.1)
Scapula
C1
C2
C3
S71
CLAVICLE
Type:
A. Clavicle, medial end (15-A)
Type:
B. Clavicle, diaphysis (15-B)
Group:
Clavicle, medial end (15-A)
1. Extra-articular (15-A1)
2. Intra-articular (15-A2)
2. Wedge (15-B2)
2. Intra-articular (15-C2)
3. Comminuted (15-A3)
3. Complex (15-B3)
S72
BONE: CLAVICLE
Clavicle
Groups:
Clavicle, diaphysis, noncomminuted (15-B1)
Subgroups:
1. Spiral (15-B1.1)
2. Oblique (15-B1.2)
2. 2 transverse (15-B3.2)
3. Transverse (15-B1.3)
3. Comminuted (15-B2.3)
S73
Clavicle
BONE: CLAVICLE
S74
Groups:
Clavicle, lateral end, extra-articular
(15-C1)
Subgroups:
1. Impacted (C-C ligament intact)
(15-C1.1)
Bones:
Lunate (71)
Scaphoid (72)
Capitate (73)
Hamate (74)
Metacarpals (77)
Phalanges (78)
S75
B. Comminuted (71-B)
A. Noncomminuted (72-A)
1. Proximal Pole (72-A1)
B. Comminuted (72-B)
1. Proximal Pole (72-B1)
2. Waist (72-A2)
2. Waist (72-B2)
A. Noncomminuted (73-A)
B. Comminuted (73-B)
Scaphoid (72)
Capitate (73)
S76
Hamate (74)
A. Noncomminuted (74-A)
B. Comminuted (74-B)
A. Noncomminuted (75-A)
1. Pisiform (75-A1)
2. Triquetrum (75-A2)
B. Comminuted (75-B)
1. Pisiform (75-B1)
2. Triquetrum (75-B2)
A. Noncomminuted (76-A)
1. Trapezium (76-A1)
2. Trapezoid (76-A2)
B. Comminuted (76-B)
1. Trapezium (76-B1)
2. Trapezoid (76-B2)
S77
METACARPALS
Types:
A. Metacarpal proximal and distal
nonarticular and diaphysis noncomminuted (77-A)
Groups:
1. Metacarpal,
2. Metaproximal extra- carpal, diapharticular (77-A1) ysis noncomminuted
(77-A2)
S78
3. Metacarpal,
distal extraarticular
(77-A3)
2. Metacarpal,
1. Metacarpal,
proximal partial diaphysis
articular (77-B1) wedge
(77-B2)
3. Metacarpal, distal
partial articular (77-B3)
C. Metacarpal proximal
and distal complete articular diaphysis comminuted
(77-C)
1. Metacarpal,
proximal
complete
articular
(77-C1)
3. Metacarpal, distal
complete
articular
(77-C3)
Metacarpals
A1
3. Transverse (77-A2.3)
A2
A3
S79
Metacarpals
3. Split/depression (77-B1.3)
(1) unicondyle medial
(2) unicondyle lateral
(3) coronal split volar fragment
(4) coronal split dorsal fragment
B1
2. Bending (77-B2.2)
3. Comminuted (77-B2.3)
B2
3. Split/depression (77-B3.3)
(1) unicondyle medial
(2) unicondyle lateral
(3) coronal split volar fragment
(4) coronal split dorsal fragment
B3
S80
Metacarpals
C1
C2
C3
S81
PHALANX - HAND
Types:
A. Phalanx proximal and distal extra-articular and diaphysis noncomminuted
(78-A)
Groups:
1. Phalanx,
2. Phalanx diproximal extra- aphysis, nonarticular (78-A1) comminuted
(78-A2)
S82
2. Phalanx,
1. Phalanx,
proximal partial diaphysis
articular (78-B1) wedge
(78-B2)
3. Phalanx,
distal partial
articular
(78-B3)
1. Phalanx,
proximal
complete
articular (78-C1)
2. Phalanx,
diaphysis
comminuted
(78-C2)
3. Phalanx,
distal complete articular (78-C3)
Phalanx - Hand
2. Comminuted (78-A1.2)
A1
3. Transverse (78-A2.3)
A2
2. Comminuted (78-A3.2)
A3
S83
Phalanx - Hand
3. Split/depression (78-B1.3)
(1) unicondyle medial
(2) unicondyle lateral
(3) coronal split volar fragment
(4) coronal split dorsal fragment
B1
2. Bending (78-B2.2)
3. Fragmented (78-B2.3)
2. Depression (78-B3.2)
3. Split/depression (78-B3.3)
(1) unicondyle medial
(2) unicondyle lateral
(3) coronal split volar fragment
(4) coronal split dorsal fragment
B2
B3
S84
Phalanx - Hand
C1
C2
C3
S85
PATELLA
Types:
A. Patella extra-articular (34-A)
Groups:
Patella, extra-articular (34-A)
1. Patella, extra- 2. Patella,
extra-articuarticular,
avulsion (34-A1) lar isolated
body (34-A2)
Patella, complete
1. Patella,
articular,
transverse
(34-C1)
S86
Patella
B1
B2
S87
Patella
3. Distal (34-C1.3)
C1
3. Distal (34-C2.3)
C2
C3
S88
FOOT
Bones:
Talus (81)
Calcaneus (82)
Navicular (83)
Cuboid (84)
Cuneiforms (85)
Metatarsals (87)
Phalanges (88)
S89
Foot
Location: Foot (81-85)
Types:
A. Avulsion or process or head fractures
(81-A)
Groups:
Talus avulsions process, or head fractures (81-A)
3. Head frac2. Process
1. Avulsions
tures (without
(81-A2)
(81-A1)
neck fracture)
(81-A3)
S90
3. Displaced
with subluxation of subtalar and ankle
joints (81-B3)
3. Ankle and
subtalar joint
involvement
(81-C3)
2. Process (81-A2)
1. Lateral (81-A2.1)
Foot
A
2. Other (81-A1.2)
Groups:
Neck fractures (81-B)
1. Nondisplaced (81-B1)
2. Posterior (81-A2.2)
2. Comminuted (81-A3.2)
2. Comminuted (81-B2.2)
2. Comminuted (81-B3.2)
Groups:
Body fractures (81-C)
1. Ankle joint involvement, dome fractures (81-C1) 2. Subtalar joint involvement (81-C2)
1. Noncomminuted (81-C2.1)
1. Noncomminuted (81-C1.1)
2. Comminuted (81-C1.2)
2. Comminuted (81-C2.2)
2. Comminuted (81-C3.2)
S91
Foot
Types:
A. Avulsion or process or tuberosity (82-A)
S92
Foot
Groups:
Avulsion or process or tuberosity (82-A)
1. Anterior process (82-A1)
1. Noncomminuted (82-A1.1)
3. Tuberosity (82-A3)
1. Noncomminuted (82-A3.1)
2. Comminuted (82-A1.2)
2. Comminuted (82-A2.2)
2. Comminuted (82-A3.2)
Groups:
Nonarticular body fractures (82-B)
1. Noncomminuted (82-B1)
2. Comminuted (82-B2)
Groups:
Articular fractures involving posterior
facet (82-C)
1. Nondisplaced (82-C1)
S93
Foot
B. Comminuted (83-B)
Types:
A. Noncomminuted (84-A)
B. Comminuted (84-B)
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)
Types:
A. Hind Foot (89-A)
B. Midfoot (89-B)
S94
C. Forefoot (89-C)
METATARSALS
Types:
1. Metatarsal proximal and distal
nonarticular and diaphysis noncomminuted (87-A)
Groups:
1. Metatarsal,
2. Metatarsal,
proximal extra- diaphysis
articular (87-A1) noncomminuted (87-A2)
3. Metatarsal,
distal extraarticular
(87-A3)
2. Metatarsal,
1. Metatarsal,
proximal partial diaphysis
articular (87-B1) wedge
(87-B2)
3. Metatarsal,
distal partial
articular
(87-B3)
1. Metatarsal,
proximal
complete
articular (87-C1)
2. Metatarsal,
diaphysis
comminuted
(87-C2)
3. Metatarsal,
distal complete articular (87-C3)
S95
Metatarsals
A1
3. Transverse (87-A2.3)
A2
2. Comminuted (87-A3.2)
A3
S96
Metatarsals
3. Split/depression (87-B1.3)
(1) unicondyle medial
(2) unicondyle lateral
(3) coronal split volar fragment
(4) coronal split dorsal fragment
B1
2. Bending (87-B2.2)
B2
3. Split/depression (87-B3.3)
(1) unicondyle medial
(2) unicondyle lateral
(3) coronal split volar fragment
(4) coronal split dorsal fragment
B3
S97
Metatarsals
C1
C2
C3
S98
PHALANX - FOOT
BONE: PHALANX (88)
Modifiers for phalanx:
T1 and T2, thumb toe
1/2; N1, N2 and N3,
index toe 1/2/3; M1,
M2 and M3, middle toe
1/2/3; R1, R2 and R3,
ring toe 1/2/3; L1, L2
and L3, little toe 1/2/3.
Types:
A. Phalanx proximal and distal extraarticular and diaphysis noncomminuted
(88-A)
Groups:
1. Phalanx,
2. Phalanx diproximal extra- aphysis, nonarticular (88-A1) comminuted
(88-A2)
2. Phalanx,
1. Phalanx,
proximal partial diaphysis
articular (88-B1) wedge
(88-B2)
3. Phalanx,
distal partial
articular
(88-B3)
1. Phalanx,
proximal
complete
articular (88-C1)
2. Phalanx,
diaphysis
comminuted
(88-C2)
3. Phalanx,
distal complete articular (88-C3)
S99
Phalanx - Foot
2. Comminuted (88-A1.2)
A1
3. Transverse (88-A2.3)
A2
2. Comminuted (88-A3.2)
A3
S100
Phalanx - Foot
3. Split/depression (88-B1.3)
(1) unicondyle medial
(2) unicondyle lateral
(3) coronal split volar fragment
(4) coronal split dorsal fragment
B1
2. Bending (88-B2.2)
3. Fragmented (88-B2.3)
2. Depression (88-B3.2)
3. Split/depression (88-B3.3)
(1) unicondyle medial
(2) unicondyle lateral
(3) coronal split volar fragment
(4) coronal split dorsal fragment
B2
B3
S101
Phalanx - Foot
C1
C2
C3
S102
DISLOCATIONS
Practical suggestions for the application of the OTA dislocation classification system.
General principles.
Although there are many different ways in which dislocations can be classified, the OTA dislocation classification system is based primarily upon the basic tenets of identification of the exact joint involved and the direction of the distal bone relative to the proximal bone. These two basic principles of classification are applicable throughout the
skeletal system. The ligaments that are disrupted in each dislocation can be inferred from the classification but is not
a specific component of the classification process. Fracture-dislocations are generally assigned 2 separate codes, 1
for the fracture (bone) and 1 for the dislocation (joint). In general, the first digit of the numerical code represents the
body part and the second digit of the numerical code is 0 for dislocation. For example, 30 represents a hip dislocation with 3 indicating thigh and 0 dislocation of the hip (femoral-acetabular) joint. The third place (A,B,C,D and E)
is utilized when there are more than 2 bones in the anatomic region and hence more than 1 joint. Each specific 2
bone joint is assigned a third place designation (eg, knee joint 40-A is tibiofemoral and 40-B is patellofemoral). In
general, the dislocations are subclassified by the direction the distal bone is positioned relative to the proximal bone
at the time of dislocation. In most instances, the subtypes are 1, 2, 3, 4 and 5: 1 = anterior, 2 = posterior, 3 = lateral,
4 = medial, and 5 = other. For example, 40 refers to dislocations about the knee with 40-A1 being an anterior dislocation of the knee joint (with the tibia anterior to the femur). The designation of other is used for various situations including spontaneous reduction of a presumed dislocation where the direction is not known (eg, a knee injury
with disruption of the ACL and PCL but with the presentation radiographs demonstrating a reduced knee joint is 40A5). This other or 5 category is also used when direction of the dislocation does not meet the standard 4
anatomic directions (eg, 10-A5 for inferior dislocation of the shoulder or luxatio erecta). Some dislocations were
included in the long bone fracture classification (eg, forearm), and there is the potential for more than 1 code to be
appropriate for a given injury.
S103
Dislocations
A. Glenohumeral (10-A)
S104
B. Acromioclavicular (10-B)
C. Sternoclavicular (10-C)
D. Scapulothoracic (10-D)
Dislocations
A. Glenohumeral (10-A)
Groups by direction:
2. Posterior (10-A2)
1. Anterior (10-A1)
3. Lateral (theoretical)
(10-A3)
4. Medial (theoretical)
(10-A4)
S105
Dislocations
B. Acromioclavicular (10-B)
Groups by direction:
1. Anterior (theoretical) (10-B1)
2. Posterior (10-B2)
3. Superior (10-B3)
4. Inferior (10-B4)
5. Other (10-B5)
S106
Dislocations
C. Sternoclavicular (10-C)
Groups by direction:
1. Anterior (10-C1)
2. Posterior (10-C2)
3. Lateral (theoretical)
(10-C3)
4. Medial (theoretical)
(10-C4)
5. Other (10-C5)
D. Scapulothoracic (10-D)
S107
Dislocations
D. Other (20-D)
S108
Dislocations
A. Ulnohumeral (20-A)
Groups by direction:
1. Anterior (20-A1)
2. Posterior (20-A2)
3. Medial (20-A3)
4. Lateral (20-A4)
5. Divergent (20-A5)
B. Radiohumeral (20-B)
Groups by direction:
1. Anterior (20-B1)
2. Posterior (20-B2)
3. Medial (20-B3)
4. Lateral (20-B4)
S109
Dislocations
Groups by direction:
1. Anterior (volar) (20-C1)
S110
3. Other (20-C3)
Dislocations
B. Thoracic (50-B)
C. Lumbar (50-C)
S111
Dislocations
Groups by direction:
1. Anterior (30-A1)
2. Posterior (30-A2)
3. Medial or central
(30-A3)
4. Obturator (30-A4)
5. Other (30-A5)
S112
Dislocations
B. Patellofemoral (40-B)
C. Tibiofibular (proximal)
(40-C)
D. Tibiofibular (distal)
(40-D)
S113
Dislocations
A. Tibiofemoral (40-A)
Groups by direction:
1. Anterior (40-A1)
S114
2. Posterior (40-A2)
3. Medial (40-A3)
4. Lateral (40-A4)
5. Other (40-A5)
Dislocations
B. Patellofemoral (40-B)
5. Other (40-B5)
S115
Dislocations
Groups by direction:
1. Anterior (40-C1)
2. Posterior (40-C2)
3. Lateral (40-C3)
4. Medial (40-C4)
5. Other (40-C5)
Subgroups of 40-C5:
1. Superior (40-C5.1)
S116
2. Inferior (40-C5.2)
Dislocations
2. Posterior (40-D2)
3. Lateral (40-D3)
4. Other (40-D5)
Subgroups of 40-D5:
1. Superior (40-D5.1)
2. Inferior (40-D5.2)
S117
Dislocations
Groups by direction:
A. Sacroiliac right (60-A)
1. Anterior (60-A1)
2. Posterior (60-A2)
3. Lateral (60-A3)
S118
Dislocations
2. Posterior (60-B2)
3. Lateral (60-B3)
S119
Dislocations
B. Intercarpal
(70-B)
C. Carpal-metacarpal
(70-C)
D. Phalanx (70-D)
Carpal bones
S120
Dislocations
2. Posterior (dorsal)
(70-A2)
3. Radial (70-A3)
4. Ulnar (70-A4)
5. Other (70-A5)
S121
Dislocations
S122
Dislocations
2. Proximal interphalangeal
(70-D2)
3. Distal interphalangeal
(70-D3)
S123
Dislocations
2. 2nd metacarpal
phalangeal joint
(70-D1.2)
3. 3rd metacarpal
phalangeal joint
(70-D1.3)
4. 4th metacarpal
phalangeal joint
(70-D1.4)
5. 5th metacarpal
phalangeal joint
(70-D1.5)
4. Ring (4th)
(70-D2.4)
5. Small (5th)
(70-D2.5)
4. Ring (4th)
(70-D3.4)
5. Small (5th)
(70-D3.5)
2. Index (2nd)
(70-D2.2)
3. Long (3rd)
(70-D2.3)
S124
2. Index (2nd)
(70-D3.2)
3. Long (3rd)
(70-D3.3)
Dislocations
C. Midfoot (80-C)
D. Forefoot (80-D)
A. Ankle (80-A)
Groups by direction:
1. Anterior (80-A1)
2. Posterior (80-A2)
3. Medial (80-A3)
4. Lateral (80-A4)
5. Other (80-A5)
S125
Dislocations
B. Subtalar (80-B)
Groups by direction:
1. Anterior (80-B1)
2. Posterior (80-B2)
3. Medial (80-B3)
4. Lateral (80-B4)
5. Other (80-B5)
C. Midfoot (80-C)
2. Calcaneocuboid (80-C2)
3. Navicular-cuneiform dislocation
(80-C3)
S126
Dislocations
D. Forefoot (80-D)
S127
Dislocations
S128
SPINE
Types:
A. Compression injuries of the body
(compressive forces) (5_-A)
C. Multidirectional injuries
with translation affecting the
anterior and posterior elements (axial torque causing
rotation injuries) (5_-C)
S129
Spine
Groups:
Vertebral body compression type (5_-A)
1. Impaction fractures (5_-A1)
S130
Types:
A. Compression injuries of the body
(compressive forces) (5_-A)
1. Sagittal (5_-A2.1)
2. Coronal (5_-A2.2)
3. Pincer (5_-A2.3)
Groups:
Anterior or posterior element injury with distraction (5_-B)
1. Posterior disruption
predominantly
ligamentous (flexiondistraction injury) (5_-Bl)
Spine
3. Anterior disruption
through the disc (hyperextension-shear injury) (5_-B3)
S131
Spine
C. Multidirectional injuries
with translation affecting the
anterior and posterior elements (axial torque causing
rotation injuries) (5_-C)
Groups:
Anterior or posterior element injury with rotation (5_-C)
1. Rotational wedge, split,
and burst fractures (5_-C1)
S132
REFERENCES
1. Fracture and dislocation compendium. Orthopaedic Trauma Association
Committee for Coding and Classification. J Orthop Trauma. 1996:10
(Suppl 1):v-ix, 1154.
2. Mller ME, Nazarian S, Koch P, et al. The Comprehensive Classification
of Fractures of Long Bones. Berlin, Germany: Springer-Verlag;1990.
3. Websters New Riverside University Dictionary. Boston, MA: Riverside
Publishing; 1984:268.
4. Martin JS, Marsh JL. Current classification of fractures. Rationale and
utility. Radiol Clin North Am. 1997;35:491506.
5. Brumback RJ, Jones AL. Interobserver agreement in the classification
of open fractures of the tibia. The results of a survey of two hundred and
forty-five orthopaedic surgeons. J Bone Joint Surg Am. 1994;76:
11621166.
6. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The
Toronto experience 19681975. Clin Orthop Relat Res. 1979;138:
94104.
7. Siebenrock KA. Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus. J Bone Joint Surg Am.
1993;75:17511755.
8. Martin JS, Marsh JL, Bonar SK, et al. Assessment of the AO/ASIF
fracture classification for the distal tibia. J Orthop Trauma. 1997;11:
477483.
9. Sidor ML, Zuckerman JD, Lyon T, et al. The Neer classification system
for proximal humeral fractures. An assessment of interobserver reliability and intraobserver reproducibility. J Bone Joint Surg Am. 1993;75:
17451750.
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