2006/ I

“A classification is useful only if it considers the

severity of the bone lesion and serves as a basis for
treatment and for evaluation of the results.”
Maurice E. Müller, 1988

AO Principles of Fracture Management

T P Rüedi, W M Murphy
C L Colton, A Fernandez Dell’Oca, U Holz, J F Kellam, and P E Ochsner

Thieme and AO Publishing proudly present the AO Principles of

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Long Bones
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Müller AO
Classification of Fractures
The concept
When the long-bone classification was first published [1] the observer was The classification of the fractures is organized in order of increasing
offered a choice from a progressive sequence of 3 options, relative to each severity, according to the morphological complexity, the difficulty of
of three bone segments, to establish the TYPE, GROUP, and SUBGRUOP treatment, and the prognosis. The colors green, orange, and red, as well
of the fracture. Müller et al. have since introduced the binary concept, as the darkening of arrows, indicate the increasing severity. A1 indicates
where each question has two alternative answers. Thus, while retaining the simplest fracture with the best prognosis and C3 the most difficult
the triad-based concept, it is ultimately possible to arrive precisely at one with the worst prognosis. When one has classified the fracture group,
of two conclusions, either the correct diagnosis or the realization that one has established its severity and thus obtained a guide to treatment.
more information is needed [2, 3, 4]. The subgroups represent three characteristic variations within the group.
The Müller concept goes beyond the mere production of an alpha-numeric
coding, valuable though that is in the acquisition, storage, and retrieval
of data; what distinguishes Müller’s system is that one is required to
recognize, identify, and describe the injury to the bone [5].
Coding of the diagnosis
The discipline of the alpha-numeric notation serves to guide the assessor To code the diagnosis of a fracture one must know its location and its
of the fracture to whatever depth the situation requires and afterwards to morphology.
record and store his observations. However, it is the surgeon’s description
of the fracture which is needed to permit good decision making in the
light of the structured observations required by the classification proto- Location: this is designated by two numbers:
col, and as well as to generate the code. which bone? 1 humerus 2 radius/ulna 3 femur 4 tibia/fibula
which segment? 1 proximal 2 diaphyseal 3 distal 4 malleolar

The principle The segments of the long bones:

The fractures of each bone segment (see coding), according to their mor-
phological characteristics, are divided into: types, groups, and subgroups. 11- 21- 31- 41- proximal

Which type?... Which group?... Which subgroup?...

These three questions and the three (two with the binary system) possible
answers to each are the key to the classification [6]. 12- 22- 32- 42- diaphyseal

The scheme of the morphological characterization of the fractures:

13- 23- 33- 43- 44- distal

Type Group Subgroup

The proximal and distal segments of long bones are defined by a square
A1.1
Scale of whose sides are of the same length as the widest part of the epiphysis.
A1 A1.2
A1.3
severity Exceptions: proximal humerus (11), proximal femur (31), and malleolar
A2.1
A A2 A2.2
A2.3
fractures (44)—q. v.
A3.1 Before a fracture can be assigned to a segment, one must first determine its
A3 A3.2
A3.3
center. In a simple fracture, the center of the fracture is obvious. In a wedge
fracture, the center is the broadest part of the wedge. In a complex fracture,
Bone B1.1 the center can only be determined after reduction.
segment B1 B1.2
B1.3 Any fracture associated with a displaced articular component is an articular
B2.1
fracture. If the fracture is associated only with an undisplaced fissure which
B B2 B2.2
B2.3 reaches the joint, it is classified as metaphyseal or diaphyseal depending on
B3.1
B3 B3.2
B3.3
where its center is.
For coding, the alpha-numeric format is used to conform with computing
C1.1 practice. The key which unlocks this fracture classification is accurate
C1 C1.2
C1.3
description. Each bone or bone region is numbered and the long bones
C2.1 are each divided into three segments.
C C2 C2.2
C2.3 The 3 types are labelled A, B, and C. Each type is divided into 3 groups:
C3.1
C3 C3.2 A1, A2, A3 / B1, B2, B3 / C1, C2, C3. Thus, there are 9 groups.
C3.3 Each group is further subdivided into 3 subgroups, denoted by a number
.1, .2, .3. Thus, there are for each segment 27 subgroups.
The morphology The system
All fractures are either simple or multifragmentary. Alpha-numeric code of the classified diagnosis:

simple: A term used to characterize a single circumferential disruption Diagnosis

of a diaphysis, or metaphysis,
or where? what?
a single disruption of an articular surface. Simple fractures of the dia-
physis or metaphysis are spiral, oblique, or transverse.
multifragmentary: A term used to characterize any fracture with one
or more completely separated intermediate fragments. In the diaphyseal
and metaphyseal segments, it includes the wedge and the complex
Bone
1234
Segment
1234 - Type
ABC

Group A1…C3
Group
123 . Subgroup
.1 .2 .3

fractures.
The wordings of the captions under the illustrations on the following pages
The terms wedge and complex are used only for diaphyseal or have to be read in the order of the alpha-numeric code.
metaphyseal fractures.
• wedge: A fracture with one or more intermediate fragments in which, Example 32-B2.1:
after reduction, there is some contact between the main fragments. 3 2 - B 2 .1
The spiral or bending wedge may be intact or fragmented. femur diaphysis wedge bending subtro-
• complex: A fracture with one or more intermediate fragments in fracture wedge chanteric
which, after reduction, there is no contact between the main proximal
and distal fragments. The complex fractures are spiral, segmented, or
irregular. The essence
The term comminuted is imprecise and should not be used. Müller places great emphasis on appreciating the essence of the fracture.
This is the attribute which gives the fracture its particular significance and
impacted: A stable and usually simple fracture of the metaphysis or enables it to be assigned to one particular type rather than another. After
epiphysis in which the fragments are driven into each other. this comes the process of putting into words what the surgeon understands
as prime characteristics of the fracture, the challenges it brings, how it is to
be managed, and what outcome may be anticipated with proper treatment
[7]. The observer should express in words what he sees on the emergency
x-ray and then try to match its features to a basic diagram on the leaflet.
Specific terms for the proximal and distal segments This will provide a starting point on the hierarchical path to accurate
diagnosis, although for complex variations reference will be needed to
Fractures of the proximal and distal segments are either extra-articular the comprehensive texts listed below [8].
or articular.
References:
extra-articular fractures: do not involve the articular surface although 1. Müller ME, Nazarian S, Koch P (1987) Classification AO des fractures: les os longs.
they may be intracapsular. They include apophyseal and metaphyseal Berlin Heidelberg New York: Springer-Verlag.
fractures. Articular fractures involve the articular suface. They are 2. Rüedi TP, Murphy WM, et al. (2000) AO Principles of Fracture Management.
subdivided into partial and complete. Davos: AO Publishing & Stuttgart New York: Georg Thieme Verlag.
3. Müller ME, Nazarian S, Koch P, et al. (1990) The Comprehensive Classification of Fractures of Long Bones.
partial articular fractures: involve only part of the articular surface Berlin Heidelberg New York: Springer-Verlag.
while the rest of that surface remains attached to the diaphysis. 4. Müller ME, Allgöwer M, Schneider R, et al. (1991) Manual of Internal Fixation. 3rd ed.
Berlin Heidelberg New York: Springer-Verlag.
Types of partial articular fractures: 5. Colton CL (1997) Fracture classification. J Bone Joint Surg [Br]; 79(5):706–707; discussion 708–709.
• pure split: A fracture, resulting from a shearing force, in which the 6. Bernstein J, Monaghan BA, Silber JS, et al. (1997) Taxonomy and treatment—a classification of fracture
classifications. J Bone Joint Surg [Br]; 79(5):706–707; discussion 708–709.
direction of the split is usually longitudinal.
7. Orozco R, Sales JM, Videla M (2000) Atlas of Internal Fixation. Fractures of Long Bones.
• pure depression: An articular fracture in which there is depression of Berlin Heidelberg New York: Springer-Verlag.
the articular surface without a split. The depression may be central or 8. Müller ME (1994) CCF Comprehensive Classification of Fractures. Pamphlet I and II.
Bern: M.E. Müller Foundation.
peripheral.
• split-depression: A combination of a split and a depression, in which
the joint fragments are usually separated.
• multifragmentary depression: A fracture in which part of the joint © 2006 by AO Publishing Switzerland
is depressed and the fragments are completely separated. Clavadelerstrasse, CH–7270 Davos Platz
complete articular fractures: The articular surface is disrupted and phone: +41 (0)81 414 26 66
completely separated from the diaphysis. The severity of these fractures publishing @ aofoundation.org
depends on whether their articular and metaphyseal components are www.aopublishing.org ISBN 3-905363-03-8 US$ 5.–
simple or multifragmentary.
 1 Humerus

11 proximal; 3 types according to topography and extent of bony lesion

11-A1 11-A2 11-A3 11-B1 11-B2 11-B3 11-C1 11-C2 11-C3

11-A extra-articular unifocal fracture 11-B extra-articular bifocal fracture 11-C articular fracture
11-A1 tuberosity 11-B1 with metaphyseal impaction 11-C1 with slight displacement
11-A2 impacted metaphyseal 11-B2 without metaphyseal impaction 11-C2 impacted with marked displacement
11-A3 nonimpacted metaphyseal 11-B3 with glenohumeral dislocation 11-C3 dislocated

12 diaphysis
12-A1 12-A2 12-A3 12-B1 12-B2 12-B3 12-C1 12-C2 12-C3

12-A simple fracture 12-B wedge fracture 12-C complex fracture

12-A1 spiral 12-B1 spiral wedge 12-C1 spiral
12-A2 oblique (≥ 30°) 12-B2 bending wedge 12-C2 segmental
12-A3 transverse (< 30°) 12-B3 fragmented wedge 12-C3 irregular

13 distal
13-A1 13-A2 13-A3 13-B1 13-B2 13-B3 13-C1 13-C2 13-C3

13-A extra-articular fracture 13-B partial articular fracture 13-C complete articular fracture
13-A1 apophyseal avulsion 13-B1 sagittal lateral condyle 13-C1 articular simple, metaphyseal simple
13-A2 metaphyseal simple 13-B2 sagittal medial condyle 13-C2 articular simple, metaphyseal multifragmentary
13-A3 metaphyseal multifragmentary 13-B3 frontal 13-C3 articular multifragmentary
 2 Radius / Ulna

21 proximal
21-A1 21-A2 21-A3 21-B1 21-B2 21-B3 21-C1 21-C2 21-C3

21-A extra-articular fracture 21-B articular fracture 21-C articular fracture of both bones
21-A1 ulna, radius intact 21-B1 ulna, radius intact 21-C1 simple
21-A2 radius, ulna intact 21-B2 radius, ulna intact 21-C2 one artic. simple, other artic. multifragmentary
21-A3 both bones 21-B3 one bone, other extra-atricular 21-C3 multifragmentary

22 diaphysis
22-A1 22-A2 22-A3 22-B1 22-B2 22-B3 22-C1 22-C2 22-C3

22-A simple fracture 22-B wedge fracture 22-C complex fracture

22-A1 ulna, radius intact 22-B1 ulna, radius intact 22-C1 ulna complex, radius simple
22-A2 radius, ulna intact 22-B2 radius, ulna intact 22-C2 radius complex, ulna simple
22-A3 both bones 22-B3 one bone wedge, other simple or wedge 22-C3 both bones complex

23 distal
23-A1 23-A2 23-A3 23-B1 23-B2 23-B3 23-C1 23-C2 23-C3

23-A extra-articular fracture 23-B partial articular fracture 23-C complete articular fracture of radius
23-A1 ulna, radius intact 23-B1 radius, sagittal 23-C1 articular simple, metaphyseal simple
23-A2 radius, simple and impacted 23-B2 radius, frontal, dorsal rim 23-C2 articular simple, metaphyseal multifragmentary
23-A3 radius, multifragmentary 23-B3 radius, frontal, volar rim 23-C3 articular multifragmentary
 3 Femur

31 proximal; defined by a line passing transversely through the lower end of the lesser trochanter

31-A1 31-A2 31-A3 31-B1 31-B2 31-B3 31-C1 31-C2 31-C3

31-A extra-articular fracture, trochanteric area 31-B extra-articular fracture, neck 31-C articular fracture, head
31-A1 pertrochanteric simple 31-B1 subcapital, with slight displacement 31-C1 split (Pipkin)
31-A2 pertrochanteric multifragmentary 31-B2 transcervical 31-C2 with depression
31-A3 intertrochanteric 31-B3 subcapital, displaced, nonimpacted 31-C3 with neck fracture

32 diaphysis
32-A1 32-A2 32-A3 32-B1 32-B2 32-B3 32-C1 32-C2 32-C3

32-A simple fracture 32-B wedge fracture 32-C complex fracture

32-A1 spiral 32-B1 spiral wedge 32-C1 spiral
32-A2 oblique (≥ 30°) 32-B2 bending wedge 32-C2 segmental
32-A3 transverse (< 30°) 32-B3 fragmented wedge 32-C3 irregular
32-A(1–3).1 = subtrochanteric zone 32-B(1–3).1 = subtrochanteric zone

33 distal
33-A1 33-A2 33-A3 33-B1 33-B2 33-B3 33-C1 33-C2 33-C3

33-A extra-articular fracture 33-B partial articular fracture 33-C complete articular fracture
33-A1 simple 33-B1 lateral condyle, sagittal 33-C1 articular simple, metaphyseal simple
33-A2 metaphyseal wedge and/or fragmented wedge 33-B2 medial condyle, sagittal 33-C2 artic. simple, metaphyseal multifragmentary
33-A3 metaphyseal complex 33-B3 frontal 33-C3 articular multifragmentary
 4 Tibia / Fibula

41 proximal
41-A1 41-A2 41-A3 41-B1 41-B2 41-B3 41-C1 41-C2 41-C3

41-A extra-articular fracture 41-B partial articular fracture 41-C complete articular fracture
41-A1 avulsion 41-B1 pure split 41-C1 articular simple, metaphyseal simple
41-A2 metaphyseal simple 41-B2 pure depression 41-C2 artic. simple, metaphyseal multifragmentary
41-A3 metaphyseal multifragmentary 41-B3 split-depression 41-C3 articular multifragmentary

42 diaphysis
42-A1 42-A2 42-A3 42-B1 42-B2 42-B3 42-C1 42-C2 42-C3

42-A simple fracture 42-B wedge fracture 42-C complex fracture

42-A1 spiral 42-B1 spiral wedge 42-C1 spiral
42-A2 oblique (≥ 30°) 42-B2 bending wedge 42-C2 segmental
42-A3 transverse (< 30°) 42-B3 fragmented wedge 42-C3 irregular

43 distal
43-A1 43-A2 43-A3 43-B1 43-B2 43-B3 43-C1 43-C2 43-C3

43-A extra-articular fracture 43-B partial articular fracture 43-C complete articular fracture
43-A1 simple 43-B1 pure split 43-C1 articular simple, metaphyseal simple
43-A2 wedge 43-B2 split-depression 43-C2 artic. simple, metaphyseal multifragmentary
43-A3 complex 43-B3 multifragmentary depression 43-C3 articular multifragmentary

44 malleolar segment ; based on the relationship of the lateral malleolar lesion to the syndesmotic ligament
44-A1 44-A2 44-A3 44-B1 44-B2 44-B3 44-C1 44-C2 44-C3

44-A infrasyndesmotic lesion 44-B transsyndesmotic fibular fracture 44-C suprasyndesmotic lesion
44-A1 isolated 44-B1 isolated 44-C1 fibular diaphyseal fracture, simple
44-A2 with fractured medial malleolus 44-B2 with medial lesion 44-C2 fibular diaphyseal fracture, multifragmentary
44-A3 with posteromedial fracture 44-B3 with medial lesion and a Volkmann 44-C3 proximal fibular lesion