integral classification of injuries (ici) to the bones, joints, and ligaments—application to...

Injury, Int. J. Care Injured (2004) 35, S-B3—S-B9

Integral classification of injuries (ICI) to the bones,

joints, and ligaments—application to injuries of the

foot

Hans Zwipp1, Frank Baumgart2, Patrick Cronier3, Eduardo Jorda4, Kaj Klaue5, Andrew K. Sands6, Shing Wai Yung7

1 Trauma Department of the University Hospital of Dresden, 01307 Dresden, Germany2 AOTK Consultant, 8595 Altnau, Switzerland3 Traumatologie, Centre Hospitalier universitaire, 49033 ANGERS Cedex 01, France4 ORTODOC S. L, 07006 Palma de Mallorca, Spain5 Clinica Luganese, 6900 Lugano, Switzerland6 Saint Vincents Medical Center, New York, NY 10003, USA7 Specialist Healthcare, Paragon, Singapore 238859, SG

KEYWORDS:

Foot classification;

fractures; fracture

dislocations; bones;

ligaments; cartilage.

Summary1 The integral classification of injuries (ICI) is a very logical, descrip-

tive classification of fractures and dislocations of the human skeleton. By enu-

merating all 28 foot bones in relation to the three anatomical and functional

regions of the foot, ie, hindfoot (81), midfoot (82), forefoot (83), from proximal

to distal, and by introducing lowercase letters for the joints of the foot skeleton,

the localization of the injury can be described precisely.

The uppercase A defines extra-articular, B describes intra-articular and C is for

fracture dislocations. By introducing the uppercase D, different dislocations can

be described. By using additional lowercase Greek letters, the direction of a

dislocation can be coded. For simple ’everyday‘ use, a fracture of the calcaneus

(81.2) involving three joints can be described as a B3-fracture. For scientific or

database coding purposes, one can describe in square brackets which joints or

segments are involved and how they are injured in relation to three different

subgroups representing first the tissue (bone, cartilage, capsule, and ligaments),

second the kind of injury (three graduations of fracture, cartilage, or ligament

damage), and third (three graduations) the extent of the dislocation or displace-

ment. Following ten conventions, a complex foot trauma can be coded as pre-

cisely as a simple dislocation of the big toe.

Introduction

Classification of injuries has been known since Hippocrates (460—375 b. Chr.), who first wrote about joints ( ). Classification of talar [1, 4, 5,

8, 13, 26], calcaneal [2, 6, 10, 13, 14, 24, 28], Chopart [12, 29], and Lisfranc injuries [7, 12, 23] has been established over the past hundred years by reviewing frequent fracture patterns, typical pathomechanisms, and special groups of fractures or types of dislocations. In 1970, M. Müller et al [15—17] established an ABC Classification for long bone fractures, which is organized into three hierarchical types with 27 subgroups [17, 18]. This classification

1 Abstracts in German, French, Italian, Spanish, Japanese,

and Russian are printed at the end of this supplement.

0020–1383/$ — see front matter � 2004 Published by Elsevier Ltd.doi:10.1016/j.injury.2004.07.008

was later defined as the Comprehensive Classifica-tion of Fractures (CCF) using a binary system [18]. The CCF was recently renamed a Comprehensive Classification System (CCS) [19] or Système de Clas-sification Intégrale (SCI) [20]. The enormous work of Maurice Müller and his co-workers over three decades has been extended to the classification of fractures of the spine, pelvis, and acetabulum [9, 11, 22, 27] as well as other joint fractures, but not, however, for injuries of the foot.

Until now, there has been no established classi-fication system for fractures of all the foot bones, or for their joints including cartilage, capsule, and ligament tears. This new classification system also considers the complex severity of bone, joint, and adjacent soft tissue damage and serves as a guideline for initial treatment, prognosis, and final evaluation of the results.

Material and methods

The classification presented here is an Integral Clas-sification of Injuries (ICI) of the bones and joints, addressing here only the foot area. This ICI includes injuries to the bone, cartilage and joint capsule/ligaments of the foot.

Whenever possible, the ICI follows the principles of the Comprehensive Classification of Fractures (CCF).

Since the foot represents a large group of 28 bonesand 35 joints, and because fracture dislocations andpure dislocations occur frequently in foot injuries, amore complex enumeration was required. It was nec-essary to name each individual bone as well as eachsingle joint. Furthermore, a new type, D, represent-ing pure dislocations, and a definition for extendedfractures have been added to types A, B, and C of

the CCF. In contradistinction to the CCF, the typesA, B, C, or D (with their subgroups) can be combinedfor coding different lesions in a single bone in onecoding string. The type of the more severe injury ismentioned first. In complex foot trauma, the injurieshave been grouped for coding simplicity.

The ten established conventions are as follows:

Convention 1: DiagnosisThe diagnosis is made by first describing the locali-zation as foot, region of the foot, bone, segment or joint.Secondly by the morphology: Type of injury, tissue involved, severity of lesion, and the extent of dis-placement or dislocation.

Convention 2: Nomenclature of bonesThe nomenclature uses ascending numbers from proximal to distal. Bones at the same anatomical level (eg, the metatarsals) are numbered from me-dial to lateral.

The foot is considered as a whole or as a group of bones. It has 3 anatomical and functional regions.

Fig 1: Bones of the foot.

Fig 2: Joints of the foot.

Fig 3: Bone segments (example talus).

S-B4 H. Zwipp et al.

Integral classification of injury to bones, joints and ligaments S-B5

The three regions of the foot are defined as hind-foot, midfoot, and forefoot (Fig. 1, 2).

The segments of a bone are defined as: proximal, middle, and distal (Fig. 3) and specifically defined for the different bones (Table 1).

Convention 3: Nomenclature of jointsThe joints are named using lowercase Latin lettersin alphabetical order from proximal to distal, and from medial to lateral.

The joints are labeled from “a” to “p” (Fig. 2). The ankle joint is considered as one joint including the three facets a, b, c as well as the coxa pedis includes e, f, g.

Convention 4: Definition of types and groupsThe four different types A, B, C, and D have a very clear definition like the three groups as follows:

Type A = Extra-articular fracturesIe, a fracture through the non articular cartilage bearing bone surfaces.Groups: 1 One segment involved.

2 Two segments involved.3 Three segments involved.

Type B = Intra-articular fracturesIe, a fracture through the articular cartilage bear-ing surface in which the main part (more than half)

Talar Segments Cuboidal Segments

1 Proximal: Corpus: the whole body including the posterior and lateral process.

1 Proximal: The calcaneal facet and adjacent bone.

2 Middle: Neck: The whole part between the cartilage of the corpus and the cartilage of the head.

2 Middle: The body including the tubercle, the navicular facet and the lateral cuneiform facet.

3 Distal: Head: The whole part covered with cartilage of the head.

3 Distal: The metatarsal facets and the adjacent bone including the sulcus peronealis.

Calcaneal Segments Cuneiform Segments

1 Proximal: The body including the tuberosity and the posterior facet.

1 Proximal: The navicular, proximal intercuneiform and cuboidal facets including adjacent bone.

2 Middle: The sustentaculum tali including the middle facet and the sulcus calcanei.

2 Middle: The bodies and distal intercuneiform facets.

3 Distal: The anterior process including the anterior facet and the cuboidal facet.

3 Distal: The metatarsal facets including adjacent bone.

Navicular Segments Metatarsal and Phalangeal Segments

1 Proximal: The talar facet and adjacent bone. 1 Proximal: The cuneiform / cuboidal facets with the adjacent bone in the metatarsals, the proximal part of the MTP / PIP / DIP-joint in the phalangeals.

2 Middle: The corpus including the navicular tubercle, any accessory bone and the cuboidal facet.

2 Middle: The metatarsal or phalangeal diaphysis.

3 Distal: The innominate facets and the adjacent bone.

3 Distal: The distal part of the MTP / PIP / DIP joint and the adjacent bone.

Table 1: Definition of specific bone segments.

of the articular surface is still within the regular confines of the joint.Groups: 1 One joint surface fractured. 2 Two joint surfaces fractured. 3 Three (or more) joint surfaces frac-

tured.

Type C = Articluar fracture dislocationsIe, a fracture through the articular cartilage where the main part (more than half) of the articular surface is no longer within the regular confines of the joint.Groups: 1 One joint dislocated. 2 Two joints dislocated. 3 Three (or more) joints dislocated.

Type D = Pure dislocationsIe, pure soft tissue injury with a partial or complete loss of articulation, temporary or permanent.Groups: 1 One joint dislocated. 2 Two joints dislocated. 3 Three (or more) joints dislocated.

In contrast to the CCF classification the types A, B, C, or D with the assessed groups can be combined for coding different lesions of a single bone in one coding string. In this case, the most severe type is mentioned first.

Convention 5: Direction of dislocationThe direction of a dislocation is described by lower-case Greek letters (Fig. 4):α = anterior λ = lateralπ = plantar β = posteriorµ = medial δ = dorsal The letters can be combined eg, β λ = postero-lateral.

Convention 6: Definition of subgroupsThe subgroups relate first to the tissue involved, second to the kind of injury, and third to the extent of displacement or dislocation (Table 2).

Convention 7: CodingThe alphanumeric code of the injury is structured principally for fractures and dislocations as follows, shown by an example of a fracture of the calcaneus extending into two articular cartilage bearing sur-faces.

1. Subgroup = Tissue 2. Subgroup = Kind of injury3. Subgroup = Amount of displacement /

dislocation

1 = Bone

1 = fissure / simple fracture 1 = nondisplaced fracture

2 = wedge / avulsion 2 = mild displaced fracture

3 = impacted / multifragmentary 3 = severely displaced fracture

2 = Cartilage

1 = contusion or simple chondral frac-ture.

1 = undisplaced

2 = osteochondral fracture. 2 = displaced

3 = degloving of cartilage 3 = “dislocated”

3 = Capsule and ligaments

1 = rupture of capsule / 1 ligament 1 = no or mild (+) instability

2 = rupture of capsule + 2 ligaments 2 = relevant (++) instability

3 = rupture of capsule + 3 (more) ligaments

3 = severe (+++) instability (dislocated or dislocatable)

Table 2: Subgroups of three different tissues with three different tissue-related kinds of injury and three different possibilities for the extent of displacement or dislocation.

Fig 4: Direction of dislocation.


Where? What?

Localization Morphology

81.2 B2 [d(1.1.2), h(1.2.3)]

General Example calcaneal fracture General Example Calcaneal fracture

group of bones 8 foottype B intra-articular

group B2 2 joints involved

region 81 hindfootsegment / joint B2 [d, h]

[posterior facet, cuboidal facet]

* tissue B2 [d (1), h (1)] (bone), (bone)

bone 81.2 calcaneus

* kind of injuryB2 [d (1.1),

h (1.2)](.simple fracture), (.wedge fracture)

* displacement / dislocation

B2 [d (1.1.2), h (1.2.3)]

(..mild displaced), (severely displaced)

Table 3: Example for Convention 7: Coding—Localization and morphology (including three different subgroups) describ-ing a calcaneus fracture extending into two joints (* = subgroups).

Fig 5: Coding example: Luxatio pedis sub talo medialis.Fig 6: Coding example: Multifragmentary talar head fracture with talonavicular joint dislocation.

Where? What?Localization Morphology81.2 = calcaneus B2 [d(1.1.2), h(1.2.3)]

The morphology of the abbreviated code describes a fracture (B2) involving two joints. In the square brackets, the joints (d = posterior facet, h = cuboi-dal facet) are listed. The first number in the round brackets describes the subgroup “tissue” involved. The second number describes the subgroup “kind of injury” related to the tissue and the third number of the subgroup is the “extent of displacement or dislocation” (see Tables 2 and 3, and Fig. 6).

In cases of a dislocation (Type D) where the whole foot (8), regions of the foot (81, 82, 83), or rays are dislocated, only the joints involved are described.

Example: Luxatio pedis sub talo = 8 D3 [defg (3.3.3)], see Figure 5.

In cases where a single bone, such as the talus or the navicular bone, is enucleated, the joints and bones involved are described. Example: Luxatio tali totalis (enucleatio tali) = 81.1 D3 [a-g (3.3.3)].

Convention 8: Extended fracturesWhen a single bone, especially the talus or cal-caneus, is broken in all three segments or joints, and the proximal or distal adjacent bone is fractured or dislocated as well, but within one region eg, in the hindfoot, the underlying fracture is considered an extended fracture.

The key bone lesion is listed first, and the subse-quent lesion is added by the sign “+”, eg, a 3-joint


fracture of the calcaneus and an additional talar neck fracture is coded as 81.2 B3 [...] + 81.1 A1 [...].

Convention 9: Linked lesions Linked lesions are more severe than extended frac-tures because they may involve extended fractures not only in one region, but in two or three regions of the foot, leading for example to floating joints or a complex foot trauma.

When two or more adjacent bones are injured in an extended fracture, or two or three regions of the foot are involved due to the same trauma, the coding of these separate lesions can be linked by the sign “+”.

eg, 81.... + 82... + 83.....

Convention 10: Complex Foot Trauma (CFT)If the rating of the overall injuries in one foot ex-ceeds a certain critical value, it is considered to be a complex foot trauma. This critical value has not yet been determined. It will be assessed after col-lection of sufficient clinical experiences in applying the ICI. The CFT rating is a result of the rated values of many simple lesions, severe single lesions and ad-ditional soft tissue injuries, all caused by the same trauma. The CFT expresses a resultant of all lesions, and not the sum.

Discussion

The major advantage of the CCF [17] has been its ease of use for describing the increasing severity of fractures for types A, B, and C and groups 1—3. Severity increases from A through C and from group 1 through 3. By using this classification, some indi-rect hints for treatment and some prediction of the final outcome became possible, which made the CCF superior to all previous classifications.

Later [18], the introduction of subgroups (pam-phlet II—now with 27 main fracture groups) forced the trauma surgeon to describe an individual frac-ture using one of only 27 codes. This limitation of 27 codes is sufficient when describing fractures of the long bones of the upper and lower extremity and some intra-articular fractures [3, 21, 25]. However, the bones of the foot, because of the high number and large proportion of articular cartilage (when compared with the extra-articular long bones), dif-fer completely from all other regions of the skeleton, except the hand. For example, the talus is covered by cartilage over more then two thirds of its sur-face and the calcaneus has 3-4 different articular surfaces. It became evident that the principles of

the CCF had to be modified and extended to be a classification.

It should be addressed here that the CCF is based on bone injuries with numbers for each bone or the functional unit (eg, 4 = tibia-fibula). But the joints always belong to two bones! So it was a logical must to use a new identifier (lowercase Latin letter) for each joint and at the same time to coordinate this with the bone-oriented numbering of CCF. The coordinating definition that the irregular relative displacement of a part of the joint surface is an injury of the involved more distal bone, is in agree-ment with common understanding. Therefore, it was necessary to:

1. Introduce a capital D for the pure dislocations. 2. Precisely describe the anatomy by enumerating

each foot bone and labeling each joint of the foot area.

3. Describe more precisely which segments in A-Fractures or which joints in B- and C-Fractures or D-Dislocations are involved, and how they are involved, ie, by fracture, cartilage damage or ligament tear.

4. Introduce three different subgroups:– Tissue (bone, cartilage, capsule, and liga-

ment). – Kind of injury related to the tissue involved

(three graduations of fracture, cartilage or ligament damage).

– Extent of displacement or dislocation (three degrees) This explanation uses round brackets with three numbers behind the listed segment or joint.

5. Introduce a description of the displacement di-rection of a dislocated bone.

It should be addressed here that the CCF is based on bone injuries with numbers for each bone or the functional unit (eg, 4 = tibia-fibula). But the joints belong always to two bones. So, it was a logical must to use for each joint a new identifier (small Latin letter) and the same time to coordinate this with the bone oriented numbering of CCF. The coordinating definition that the irregular relative displacement of a part of the joint surface is an injury of the involved more distal bone is in agreement with the common understanding.

The 27 subgroups of the CCF [18], which describe special fracture types and which are very different from joint to joint, are difficult for an individual to remember. They are replaced in the ICI by three tissue groups, three kinds of injury and three gradu-ations of displacement or dislocation. The 27 pos-sible permutations are precisely described for each segment or joint.


The ICI is not limited to only 27 codes because it is a descriptive classification that is able to describe each individual fracture and dislocation. In addition, other subgroups can be added (eg, physeal injuries). It is an extendable system for the “kind of injury” or the “extent of displacement or dislocation”-sub-groups can be added without limitation.

The definition of extended fractures helps with the description of complex foot trauma and linked lesions such as a “floating” joint.

Acknowledgement

The introduced new Integral Classification of Inju-ries (ICI) was initiated in1993 by the new founded Foot and Ankle Study Group of the AO promoted by Stephan Perren and financially supported for 25 meetings by the AOTK of AO Davos, Switzerland.

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Correspondence address:

Hans Zwipp, MDProfessor of TraumatologyTrauma Department of the University Hospital of DresdenFetscherstraße 4701307 Dresden, Germanyemail: [email protected]


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