The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)

Abstract

Background and purpose - To achieve a common understanding when dealing with long bone fractures in children, the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO PCCF) was introduced in 2007. As part of its final validation, we present the most relevant fracture patterns in the upper extremities of a representative population of children classified according to the PCCF. Patients and methods - We included children and adolescents (0-17 years old) diagnosed with 1 or more long bone fractures between January 2009 and December 2011 at the university hospitals in Bern and Lausanne (Switzerland). Patient charts were retrospectively reviewed and fractures were classified from standard radiographs. Results - Of 2,292 upper extremity fractures in 2,203 children and adolescents, 26% involved the humerus and 74% involved the forearm. In the humerus, 61%, and in the forearm, 80% of single distal fractures involved the metaphysis. In adolescents, single humerus fractures were more often epiphyseal and diaphyseal fractures, and among adolescents radius fractures were more often epiphyseal fractures than in other age groups. 47% of combined forearm fractures were distal metaphyseal fractures. Only 0.7% of fractures could not be classified within 1 of the child-specific fracture patterns. Of the single epiphyseal fractures, 49% were Salter-Harris type-II (SH II) fractures; of these, 94% occurred in schoolchildren and adolescents. Of the metaphyseal fractures, 58% showed an incomplete fracture pattern. 89% of incomplete fractures affected the distal radius. Of the diaphyseal fractures, 32% were greenstick fractures. 24 Monteggia fractures occurred in pre-school children and schoolchildren, and 2 occurred in adolescents. Interpretation - The pattern of pediatric fractures in the upper extremity can be comprehensively described according to the PCCF. Prospective clinical studies are needed to determine its clinical relevance for treatment decisions and prognostication of outcome.

Figure 1.

Overall structure of the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO PCCF). Fracture location is identified by the fractured long bone (1 = humerus, 2 = radius/ulna, 3 = femur, and 4 = tibia/fibula) and its injured segments (1 = proximal, 2 = shaft, 3 = distal). If only a single bone of the forearm or the lower leg is fractured, a small letter, describing the bone ("r", "u", "t", or "f") is added after the segment code. The capital letter that follows identifies the fracture type as epiphyseal (E) or metaphyseal (M) for proximal or distal fractures, or diaphyseal (D) for shaft fractures. Fracture morphology is identified by a code for specific child patterns related to the fracture type, a severity code (occurrence of multifragmentation, distinguishing between simple and wedge or complex fractures), and—if required—an additional displacement code for supracondylar or radial head fractures.

Figure 2.

Screen shot of the AOCOIAC interface with documentation of a distal radius fracture caused by a fall.