DISLOCATIONS. Practical suggestions for the application of the OTA dislocation classification system. General principles.
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1 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 40- A5). 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 Lippincott Williams & Wilkins S103
2 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) S Lippincott Williams & Wilkins
3 J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Dislocations A. Glenohumeral (10-A) Groups by direction: 1. Anterior (10-A1) 2. Posterior (10-A2) 3. Lateral (theoretical) (10-A3) 4. Medial (theoretical) (10-A4) 5. Other (inferior-luxatio erecta) (10-A5) 2007 Lippincott Williams & Wilkins S105
4 Dislocations J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 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) Subgroups of 10-B3 by severity of displacement: 1. Grade 1 sprain (10-B3.1) 2. Grade 2, partial displacement (10-B3.2) 3. Grade 3, 100% displacement (10-B3.3) 4. Grade 4, grade 3 plus deltoid origin detached from clavicle (10-B3.4) S Lippincott Williams & Wilkins
5 J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 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) 2007 Lippincott Williams & Wilkins S107
6 Dislocations J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 DISLOCATION REGION: Elbow (20): Types by joint involved: A. Ulnohumeral with radiohumeral* (20-A) B. Isolated radiohumeral (20-B) C. Distal radioulnar dislocation (20-C) D. Other (20-D) 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 with the 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 the classification system we generally recommend that fractures and dislocations be separately coded. S Lippincott Williams & Wilkins
7 J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 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) 2007 Lippincott Williams & Wilkins S109
8 Dislocations J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 C. Distal radioulnar dislocations (20-C) Groups by direction: 1. Anterior (volar) (20-C1) 2. Posterior (dorsal) (20-C2) 3. Other (20-C3) S Lippincott Williams & Wilkins
9 J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Dislocations 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) 2007 Lippincott Williams & Wilkins S111
10 Dislocations J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 DISLOCATION REGION: Hip (30): Types by joint involved: Hip joint (30-A) 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) 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 fracture of the central acetabulum. Although commonly referred to as a medial or central dislocation of the hip, the 30-A3 injury is a particular pattern of fracture displacement rather than a true dislocation. It is left to the discretion of the coder to decide when, if ever, to utilize 30-A3 in addition to the fracture code (62). There are no current injury patterns appropriate for 30-B designation. S Lippincott Williams & Wilkins
11 J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Dislocations DISLOCATION REGION: Knee (40) Types by joint involved: A. Tibiofemoral (40-A) B. Patellofemoral (40-B) C. Tibiofibular (proximal) (40-C) D. Tibiofibular (distal) (40-D) Notes for classification of knee dislocations: The classification committee recognizes that distal tibiofibular dislocations are NOT knee dislocations but they fit well here and ARE dislocations associated with the leg bone segment 4. Distal tibiofibular dislocations (as well as DRUJ) could reasonably be moved to 80 foot and ankle dislocations (and DRUJ to 70 wrist and hand dislocations). However, those segments already have many codes because there are so many joints in these body parts with small bones. Therefore for practical and consistency reasons 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 Lippincott Williams & Wilkins S113
12 Dislocations J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 A. Tibiofemoral (40-A) Groups by direction: 1. Anterior (40-A1) 2. Posterior (40-A2) 3. Medial (40-A3) 4. Lateral (40-A4) 5. Other (40-A5) S Lippincott Williams & Wilkins
13 J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Dislocations B. Patellofemoral (40-B) Groups by direction of the patella: 1. Distal (quadriceps tendon disruption) (40-B1) 2. Proximal (patellar tendon disruption) (40-B2) 3. Medial patellofemoral dislocation (40-B3) 4. Lateral patellofemoral dislocation (40-B4) 5. Other (40-B5) 2007 Lippincott Williams & Wilkins S115
14 Dislocations J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 C. Proximal tibiofibular dislocation (40-C) 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) 2. Inferior (40-C5.2) S Lippincott Williams & Wilkins
15 J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Dislocations D. Distal tibiofibular dislocation (40-D) Groups by the direction of the fibula: 1. Anterior (40-D1) 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) 2007 Lippincott Williams & Wilkins S117
16 Dislocations J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 DISLOCATION REGION: Pelvic dislocation (60) Types by joint involved: A. Sacroiliac right (60-A) B. Sacroiliac left (60-B) C. Symphysis pubis (60-C) Groups by direction: A. Sacroiliac right (60-A) 1. Anterior (60-A1) 2. Posterior (60-A2) 3. Lateral (60-A3) 4. Other (eg proximal) (60-A4) Notes for classification of pelvic dislocations: Because pubic diastasis and sacroiliac (SI) joint dislocations and fracture dislocations are such an integral component of pelvic ring disruption, pelvic fracture codes (61), the 60 codes are restricted to pure dislocations without fracture. 61 codes are to be used for fracture dislocations or pelvic ring injuries that include fractures AND SI or symphysis disruptions. Therefore the following: 60 codes are for pure dislocations. Pelvic ring disruptions with fractures (with or without SI and symphysis joint injuries) should be 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 the pubic symphysis would be coded 60-B2 (left SI posterior dislocation), 60-A1 (right SI dislocation with ilium anteriorly displaced) and 60-C3 (pubic symphysis dislocation with the right side displaced proximal to the left). S Lippincott Williams & Wilkins
17 J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Dislocations 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) 2007 Lippincott Williams & Wilkins S119
18 Dislocations J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 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, then individual 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. S Lippincott Williams & Wilkins
19 J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Dislocations A. Radiocarpal (wrist joint) (70-A) Groups by direction of the distal fragment: 1. Anterior (volar) (70-A1) 2. Posterior (dorsal) (70-A2) 3. Radial (70-A3) 4. Ulnar (70-A4) 5. Other (70-A5) B. Intercarpal dislocations (70-B) 2007 Lippincott Williams & Wilkins S121
20 Dislocations J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 C. Carpal-metacarpal joints (70-C) Groups by joint involved radial to ulnar: 1. 1 st metacarpal-trapezial dislocation (70-C1) 2. 2 nd metacarpal-trapezium dislocation (70-C2) 3. 3 rd metacarpal capitate dislocation (70-C3) 4. 4 th metacarpal hamate dislocation (70-C4) 5. 5 th metacarpal triquetrum dislocation (70-C5) 6. Multiple carpal-metacarpal dislocations (70-C9) S Lippincott Williams & Wilkins
21 J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Dislocations 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) 2007 Lippincott Williams & Wilkins S123
22 Dislocations J Orthop Trauma Volume 21, Number 10 Supplement, November/December Metacarpal phalangeal joint (70-D1) Subgroups by joint involved radial to ulnar: 1. 1 st metacarpal 2. 2 nd metacarpal 3. 3 rd metacarpal 4. 4 th metacarpal 5. 5 th 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) 2. Proximal interphalangeal joint (70-D2) Subgroups by joint involved radial to ulnar: 1. Thumb (1 st ) 2. Index (2 nd ) 3. Long (3 rd ) 4. Ring (4 th ) 5. Small (5 th ) (70-D2.1) (70-D2.2) (70-D2.3) (70-D2.4) (70-D2.5) 3. Distal interphalangeal joint (70-D3) Subgroups by joint involved radial to ulnar: 1. None 2. Index (2 nd ) 3. Long (3 rd ) 4. Ring (4 th ) 5. Small (5 th ) (70-D3.2) (70-D3.3) (70-D3.4) (70-D3.5) S Lippincott Williams & Wilkins
23 J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Dislocations 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) Groups by direction: 1. Anterior (80-A1) 2. Posterior (80-A2) 3. Medial (80-A3) 4. Lateral (80-A4) 5. Other (80-A5) 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) Lippincott Williams & Wilkins S125
24 Dislocations J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 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) 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) S Lippincott Williams & Wilkins
25 J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 Dislocations Tarsal-metatarsal dislocation (80-C5) Subgroups by joint involved medial to lateral: 1 st metatarsal medial cuneiform dislocation (80-C5.1) 2 nd metatarsal second cuneiform dislocation (80-C5.2) 3 rd metatarsal lateral cuneiform dislocation (80-C5.3) 4 th metatarsal cuboid dislocation (80-C5.4) 5 th 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) 2007 Lippincott Williams & Wilkins S127
26 Dislocations J Orthop Trauma Volume 21, Number 10 Supplement, November/December 2007 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. 1 st metatarsal phalangeal joint (80-D1.1) 2. 2 nd metatarsal phalangeal joint (80-D1.2) 3. 3 rd metatarsal phalangeal joint (80-D1.3) 4. 4 th metatarsal phalangeal joint (80-D1.4) 5. 5 th metatarsal phalangeal joint (80-D1.5) 2. Proximal interpahalangeal joint (80-D2) Subgroups by joint medial to lateral: 1. 1 st toe (IP joint as there is no PIP in big toe) (80-D2.1) 2. 2 nd toe (80-D2.2) 3. 3 rd toe (80-D2.3) 4. 4 th toe (80-D2.4) 5. 5 th toe (80-D2.5) 3. Distal interphalangeal joint (80-D3) Subgroups by joint medial to lateral: 1. No code as there is no DIP in big toe 2. 2 nd toe (80-D3.2) 3. 3 rd toe (80-D3.3) 4. 4 th toe (80-D3.4) 5. 5 th toe (80-D3.5) S Lippincott Williams & Wilkins
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