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The “Tic-Tac-Toe” Classification System for Mutilating Injuries of the Hand

Weinzweig, Jeffrey M.D.; Weinzweig, Norman M.D.

Plastic and Reconstructive Surgery: October 1997 - Volume 100 - Issue 5 - p 1200–1211
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Several classifications of mutilating hand injuries exist in the literature. Unfortunately, each of these provides a categorization that is arbitrarily grouped according to the part of the hand predominantly involved. It is imperative that a comprehensive classification system incorporate the degree and precise location of soft-tissue and/or bony destruction and the vascular integrity in addition to the predominantly involved part of the hand. We therefore devised a new classification system for mutilating injuries of the hand which categorizes them into seven types: (I) dorsal mutilation, (II) palmer mutilation, (III) ulnar mutilation, (IV) radial mutilation, (V) transverse amputations, (VI) degloving injuries, and (VII) combination injuries. These types are subcategorized into three subtypes: (A) soft-tissue loss, (B) bony loss, and (C) combined tissue loss. Vascular integrity is recorded with subscript notation: (0) vascularization intact or (1) devascularization. The hand is then systematically divided into nine numerical zones in “tic-tac-toe” fashion with radial, central, and ulnar columns and proximal, central, and distal rows. The “TicTac-Toe” classification system allows the examining surgeon to describe precisely any mutilating injury of the hand. This system permits accurate assessment of each hand injury by assignment of the appropriate classification type, subtype, vascular status, and zone involvement. Clinical examples illustrate the user-friendliness and practicality of this new classification system. (Plast. Reconstr. Surg. 100: 1200, 1997.)

The mutilated hand “has suffered a severe injury involving loss of substance, and…has been left…lacking in prehension.”

D. A. Campbell Reid1 (1984)

Providence, R.I., and Chicago, Ill.

From the Department of Plastic Surgery, Brown University School of Medicine, Rhode Island Hospital, and Divisions of Plastic Surgery and Departments of Orthopaedic Surgery, University of Illinois at Chicago and Cook County Hospital. Received September 10, 1996; revised November 20, 1996.

Presented at the New England Hand Society, in Sturbridge, Massachusetts, in December of 1994 and at the New England Society of Plastic and Reconstructive Surgeons, in Boston, Massachusetts, in June of 1995. Also presented, in part, as a Scientific Exhibit at the American College of Surgeons, in Chicago, Illinois, in October of 1994, and at the American Association for Hand Surgery, in Marco Island, Florida, in January of 1995.

Jeffrey Weinzweig, M.D.

Department of Plastic Surgery

Brown University School of Medicine

Rhode Island Hospital

2 Dudley Street, Suite 450

Providence, R.I. 02905

©1997American Society of Plastic Surgeons