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AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)

doi: 10.1097/BOT.0000000000001065
Supplement Article
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Introduction

In adult fractures the injury severity and fracture pattern are important. In pediatric fractures another component is added—the phenomenon of growth. Previous classifications of children’s fractures are very specific, but not universal in application 1–6 and none have been mscientifically validated.7–9 Finally, there is no classification system available for diaphyseal long bone fractures. Any classification for pediatric fractures must be applicable for all fractures and recognize the importance of growth through the epiphyseal plate. To address these needs, the validated AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)1 was introduced to the AO/OTA Compendium of Fractures and Dislocations in 2007.10–12

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The principles and definitions of the pediatric long bone fracture classification

The terminology and coding of the PCCF are based on the principles found in Müller’s Long Bone Comprehensive Classification of Fractures.13 This system only addresses the four long bones.

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Bone

The bones are coded: Humerus (1), Radius (2r), Ulna (2u), Femur (3), Tibia (4t) and Fibula (4f) (Fig 1). Note that the paired bones radius/ ulna or tibia/fibula are classified as individual bones (Fig 2) allowing the detailed documentation of combined fractures of the radius and ulna, or the tibia and fibula.

Fig 1

Fig 1

Fig 2

Fig 2

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Fracture location

The location within the bones is the proximal end segment (1), diaphyseal segment (2), and, distal end segment (3). The end segment consists of the epiphysis and metaphysis. The metaphyseal end segment is determined by a square whose sides are the same length as the widest part of the visible epiphyseal growth plate (Fig 3).11 For the radius/ulna and tibia/fibula, both bones must be included in the square.

Fig 3

Fig 3

Consequently, the three segments can be defined as:

  • • Proximal end segment (1) and distal end segment (3)
  • – Subsegments are the epiphysis (E) and metaphysis (square) (M)
  • • Diaphyseal segment (2)
  • – Subsegment is the section between two end segments (D).

Malleolar fractures are infrequent in children and do not justify a specific coding. They are simply coded as distal end segment tibia and/or fibula fractures.

The subsegments follow the segment and are the diaphysis (D), metaphysis (M) and epiphysis (E) (Fig 3). Epiphyseal fractures are by definition intraarticular fractures. (Fig 3 and Fig 4). The square definition is not applied to the proximal femur where metaphyseal fractures are located between the physis of the head and the intertrochanteric line.

Fig 4

Fig 4

Fracture displacement may distort the fracture fragment’s exact anatomy so the end segment square may not be accurate necessitating reclassification after the fracture reduction.

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Child code

A forward slash “/” (Fig 5) is used to identify the specific child fracture codes:

  • Epiphyseal fracture codes (Fig 6)
  • Specific metaphyseal fracture child codes (Fig 7)
  • Specific diaphyseal fracture child codes (Fig 8)
Fig 5

Fig 5

Fig 6

Fig 6

Fig 7

Fig 7

Fig 8

Fig 8

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Fracture severity code

This code distinguishes between two grades of fracture severity: simple (.1) and multifragmentary (.2) (Fig 9).

Fig 9

Fig 9

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Qualifications

These codes are added as roman numerals between rounded brackets at the end of the fracture code,

eg 13-M/3.1(III). These are described by an additional code for the grade of angulation.

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Humerus 1

Proximal epiphyseal fractures 11-E

CV

CV

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Proximal metaphyseal fractures 11-M

CV

CV

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Diaphyseal fractures 12-D

CV

CV

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Distal metaphyseal fractures 13-M

CV

CV

CV

CV

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Distal epiphyseal fractures 13-E

CV

CV

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Radius/ulna 2

Proximal epiphyseal fractures 21-E

Isolated fractures of the radius

CV

CV

*Qualifications for displaced radial head and neck fractures:

  • Type I No angulation and no displacement
  • Type II Angulation with displacement of up to half of the bone diameter
  • Type III Angulation with displacement of more than half of the bone diameter
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Proximal metaphyseal fractures 21-M

Isolated fractures of the radius

CV

CV

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Diaphyseal fractures 22-D

Fractures of both bones

CV

CV

Isolated fractures of the radius

CV

CV

CV

CV

Isolated fractures of the ulna

CV

CV

Isolated fractures of the radius

CV

CV

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Distal metaphyseal fractures 23-M

Fractures of both bones

CV

CV

Isolated fractures of the radius

CV

CV

Isolated fractures of the ulna

CV

CV

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Distal epiphyseal fractures 23-E

Fractures of both bones

CV

CV

CV

CV

Isolated fractures of the radius 23-E

CV

CV

Isolated fractures of the ulna 23-E

CV

CV

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3 Femur

Proximal epiphyseal fractures 31-E

CV

CV

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Proximal metaphyseal fractures 31-M

CV

CV

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Diaphyseal fractures 32-D

CV

CV

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Distal metaphyseal fractures 33-M

CV

CV

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Distal epiphyseal fractures 33-E

CV

CV

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Tibia/fibula 4

Proximal epiphyseal fractures 41-E

Isolated fractures of the tibia

CV

CV

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Proximal metaphyseal fractures 41-M

Fractures of both bones

CV

CV

Isolated fractures of the tibia

CV

CV

Isolated fractures of the fibula

CV

CV

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Diaphyseal fractures 42-D

Fractures of both bones

CV

CV

Isolated fractures of the tibia

CV

CV

Isolated fractures of the fibula

CV

CV

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Distal metaphyseal fractures 43-M

Fractures of both bones

CV

CV

Isolated fractures of the tibia

CV

CV

Isolated fractures of the fibula

CV

CV

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Distal epiphyseal fractures 43-E

Fractures of both bones

CV

CV

Isolated fracture of the tibia

CV

CV

CV

CV

Isolated fractures of the fibula

CV

CV

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Frequent fracture combinations

Radius/ulna

CV

CV

Tibia/fibula

CV

CV

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References

1. Salter RB, Harris WR. Injuries Involving the Epiphyseal Plate. JBJS. 1963;45(3):587–622.
2. Ellbogen Baumann E.. In Nigst H, ed. Spezielle Frakturen- und Luxationslehre: ein kurzes Handbuch in fünf Bänden. Band. II/1 ed. Stuttgart: Thieme; 1965.
3. Gartland JJ. Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet. 1959 Aug;109(2):145–54.
4. von Laer L. Frakturen und Luxationen im Wachstumsalter. 4. überarbeitete und aktualisierte Auflage ed. 2001.
5. Judet J, Judet R, Lefranc J. Fractures du col radial chez l’enfant. Ann Chir. 1962 Sep;16:1377–1385.
6. von Laer L, Gruber R, Dallek M, et al. Classification and documentation of children's fractures. European Journal of Trauma. 2000;26(1):2–14.
7. Audige L, Bhandari M, Kellam J. How reliable are reliability studies of fracture classifications? A systematic review of their methodologies. Acta Orthop Scand. 2004 Apr;75(2):184–194.
8. Audigé L, Hunter J, Weinberg AM, et al. Development and evaluation process of a pediatric long-bone fracture classification proposal. European Journal of Trauma. 2004;30(4):248–254.
9. Audige L, Bhandari M, Hanson B, et al. A concept for the validation of fracture classifications. J Orthop Trauma. 2005 Jul;19(6):401–406.
10. Slongo T, Audigé L, Schlickewei W, et al. Development and validation of the AO pediatric comprehensive classification of long bone fractures by the Pediatric Expert Group of the AO Foundation in collaboration with AO Clinical Investigation and Documentation and the International Association for Pediatric Traumatology. J Pediatr Orthop. 2006 Jan–Feb;26(1):43–49.
11. Slongo T, Audigé L, Clavert JM, et al. The AO comprehensive classification of pediatric long-bone fractures: a web-based multicenter agreement study. J Pediatr Orthop. 2007 Mar;27(2):171–180.
12. Slongo T, Audigé L, Lutz N, et al. Documentation of fracture severity with the AO classification of pediatric long-bone fractures. Acta Orthop. 2007 Apr;78(2):247–253.
13. Müller ME, Nazarian S, Koch P, et al. The Comprehensive Classification of Fractures of Long Bones. Berlin, Heidelberg, New York:Springer-Verlag; 1990.
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