DISEASE CLASSIFICATIONS IN HAND SURGERY

GR CONGENITAL HAND DEFORMITY
(Swanson JHS 1983, 8, 693-702)

I
Failure of formation (Transverse and Longitudinal)

II
Failure of differentiation

III
Duplication

IV
Overgrowth

V
Undergrowth

VI
Constriction ring syndrome

VII
Generalized abnormalities

GR RADIAL CLUB HAND

I
Short distal radius

II
Hypoplastic radius

III
Partial absence of radius

IV
Total absence of radius

GR ULNAR CLUB HAND
(Bayne, L. Ulnar Club Hand. In D. Green (ed.), Operative Hand Surgery)

I
Ulnar hypoplasia, proximal and distal ulnar epiphyses are present, radial bowing minimal

II
Partial ulnar aplasia, distal ulna replaced by anlage, bowed radius, radial head may dislocate, distal radial epiphysis is sloped toward ulnar side

III
Total ulnar aplasia, no anlage, radius almost straight, radial head usually dislocated, elbow unstable, hand and carpal deficiencies

IV
Radio-humeral synostosis, ulnar anlage , ulnar deviation of the hand

GR ULNAR DUPLICATION
(Stelling, 1963 Orthopaedic Surgery in Infancy and Childhood)

I
Soft tissue only

II
Digit articulating with normal or bifid metacarpal or phalanx

III
Duplicated digit with metacarpal (Wassel VI)

GR THUMB DUPLICATION
(Wassel, Clin Orthop 1969, 64, 175-193)

I
Bifid P2 (2%)

II
Duplicated P2 (15%)

III
Bifid P1 (6%)

IV
Duplicated P1 (43%)

V
Bifid MC (10%)

VI
Duplicated MC (4%)

VII
Triphalangia (20%)

VII
Floating thumb (Tada classification, JBJS 1983, 65A, 584-8)

GR THUMB DUPLICATION
(Hung et al. Clin Ortho 1996, 323, 31)

IVA
Hypoplastic

IVB
Ulnar deviated

IVC
Divergant

IVD
Convergant (complex)

GR THUMB DUPLICATION
(Horii et al. JHS 1997, 22A, 671)

A
Wide cartilagenous connection at the bases of proximal phalanges (16%)

B
Separate proximal phalanges (68%)

C
Cartilagenous connection to the metacarpal (6%)

D
Fibrous attachment to the joint capsule (10%)

GR THUMB DUPLICATION
(Kanno et al. Orthop Surg 1978 29, 1561)

I
2 Phalanges

II
Wide space between proximal and distal phalanges

III
3 Segments containing epiphyseal bone

IV
3 Phalanges

GR THUMB HYPOPLASIA
(Blauth, Arch Orthop Unfall-chir 1967, 62, 225)

I
Minor hypoplasia: normal but smaller

II
Adduction contracture, MCPJ ulnar collateral laxity, thenar hypoplasia but normal skeleton

III
Significant hypoplasia: skeletal hypoplasia especially CMCJ, intrinsic aplasia, rudimentary extrinsic tendons

IV
Floating thumb

V
Total absence

GR CLASP THUMB
(Weckesser, JBJS 1955, 37, 977)

I
Deficient extension of thumb

II
Deficient extension of thumb and digits

III
Hypoplasia of thumb

IV
Pre-axial polydactyly with deficient extension

GR RING CONSTRICTION
(Patterson, BJPS 1961, 14, 1)

I
Simple constriction ring

II
Rings accompanied by distal deformity with or without lymphoedema

III
Rings accompanied by distal fusion (acrosyndactyly)

IV
Amputations

GR SYMBRACHYDACTYLY
(Blauth and Gekeler, Handchirurgie 1973, 5, 121)
I (Short Finger) Short or absent middle phalanges, incomplete syndactyly
II (Cleft hand) Absence of the three central digits
+ missing intermediate bone parts in the marginal rays
III (Monodactyly) Hypoplastic thumb or missing intermediate bone parts
+ absence of all digital rays including most parts of the metacarpals
IV (Peromelia) Absence of all digital rays, only carpal bones present

GR CENTRAL HAND DEFICIT
(Nutt &Flatt, JHS 1981, 6, 48)

O
All bones present (some degree of minor failure of differentiation)

I
One ray involved

a
One phalanx present (one or two phalanges missing)

b
All phalanges gone, metacarpal normal

c
Entire ray involved (fragment of metacarpal may be present but at least a portion is missing)

II
Two rays involved

a
Only phalanges missing, metacarpals normal (phalanx may be present but some deficit)

b
One metacarpal at least partially missing (other appears normal)

c
Both metacarpals at least partially missing

III
Three rays involved

a
Only phalanges missing, metacarpals normal

b
One metacarpal at least partially missing

c
Two metacarpals at least partially missing

d
Three metacarpals at least partially missing

GR FDP AVULSION
(Smith JHS 1981, 6, 600-1)

I
Tendon retracts into palm with rupture of both vinculae

II
Tendon retracts to the level of the PIPJ with the long vinculum intact

III
Large fragment of bone avulsed and held by A5 pulley

GR MALLET FINGER

I
Closed ±chip fracture of P3

II
Laceration

III
Abrasion with loss of tendon substance (and skin)

IVA
Trans-epiphyseal in children

IVB
Closed + articular surface involving 20-50%

IVC
Closed + articular surface involving >50%

GR RING AVULSION INJURY
(Urbaniak)

I
Circulation adequate

II
Circulation inadequate

IIA
Circulation inadequate, only arterial damage

III
Complete degloving

GR RING AVULSION INJURY
(Kay et al., JHS 1989, 14A, 204-13)

I
Circulation adequate, with or without skeletal injury

II
Circulation inadequate, with or without skeletal injury

IIA
Arterial circulation inadequate only

IIB
Venous circulation inadequate only

III
Circulation inadequate, with fracture or joint injury

IIIA
Arterial circulation inadequate only

IIIB
Venous circulation inadequate only

IV
Complete amputation

GR ROLLING BELT INJURIES
(Ada et al. JHS 1994, 19B, 601–603)

I
Only skin lesions

IIA
Skin, tendon, artery and nerve uninjured, circulation present

IIB
Skin, tendon, artery and nerve uninjured, circulation absent

IIIA
Skin, tendon, artery and nerve injured, circulation present

IIIB
Skin, tendon, artery and nerve injured, circulation absent

IV
Total finger amputation

Roots MYOTOMES

C5
Shoulder abduction

C6,7,8
Shoulder adduction

C5,6
Elbow flexion

C7,8
Elbow extension

C6,7
Wrist movements

C7,8
Finger movements

T1
Intrinsics

GR MOTOR TESTING (MRC)
(Peripheral Nerve Injuries, HMSO, 1954, 354-361)

M0
No contraction

M1
Flicker

M2
Active movement with gravity eliminated

M3
Active movement against gravity

M4
Active movement against gravity and resistance

M5
Normal power

GR SENSORY TESTING (MRC)
(Peripheral Nerve Injuries, HMSO, 1954, 354-361)

S0
No sensation

S1
Pain sensation (deep)

S1+
Pain sensation (superficial)

S2
Pain and some touch

S2+
Pain and some touch, over-response

S3
Pain and touch without over-response

S3+
Imperfect two point (S2PD 7-15mm)

S4
Complete recovery (S2PD 2-6mm)

GR CARPAL TUNNEL SYNDROME
(Chang & Dellon, J Hand Surg 1993, 18B, 467.)

0
No impairment

1
Paraesthesiae - intermittent

2
Threshold - mild (SWM=2.83-3.84)

3
Abduction - weak

4
Threshold - severe (SWM>3.84)

5
Paraesthesiae - persistent

6
S2PD - mild (7-10mm)

7
Atrophy - mild

8
S2PD - severe (>10mm)

9
Anaesthesia

10
Atrophy - severe

GR HAND-ARM VIBRATION SYNDROME
(HAVS, Stockholm Classification, JHS 1994, 19A, 99)

0
No attacks

1
Occasional attacks, affect tip of one or more fingers

2
Occasional attacks, affect distal and middle phalanges of one or more fingers

3
Frequent attacks, affect all phalanges of most fingers

4
Trophic skin changes

GR MARTIN-GRUBER CONNECTIONS
(Leibovic & Hastings, JHS 1992;17A:47-53)

I
Motor branches from the median to ulnar nerve to innervate "median" muscles (60%)

II
Motor branches from median to ulnar nerves to innervate "ulnar" muscles (35%)

III
Motor fibers from the ulnar to the median nerve to innervate "median" muscles (3%)

IV
Motor fibers from the ulnar to the median nerve to innervate "Ulnar" muscles (1%)

GR POSTERIOR INTEROSSEOUS NERVE PALSY
(Hirachi et al., JHS 1998, 23B, 413)

I
Complete palsy

II
Loss of little, ring and middle finger extension (recurrent branch)

III
Loss of extension and abduction of thumb and extension of index (descending branch)

GR DUPUYTREN’S CONTRACTURE
(Mikkleson Hand 8:265, 176)

I
Nodule or band; no contracture of fingers

II
Overall contracture 1 to 45 degrees (total contracture of all joints)

III
Overall contracture 46 to 90 degrees

IV
Overall contracture 91 to 135 degrees

V
Overall contracture more than 135 degrees

GR OSTEOARTHRITIS
(Swanson et al. JHS 1985, 10A, 1013-24)

I
Joint narrowing

II
+ Subchondral sclerosis, hypertrophic nodes

III
+ Erosions

IV
+ Cyst formation, deviation

V
+ Dislocation or subluxation

GR CMCJ ARTHRITIS
(Eaton and Littler JBJS 1973, 55A, 1655)

I
Widening of joint space, <1/3 subluxation

II
1/3 subluxation, fragments <2mm diameter

III
>1/3 subluxation, fragments>2mm diameter, minor joint narrowing

IV
Advanced. Major subluxation, joint narrowing, sclerosis, osteophytes

GR SCAPHO-LUNATE INSTABILITY - ARTHROSCOPIC
(Geisler)

I
Cannot insert probe (=tear not true instability)

II
Insert probe (1mm)

III
Twist probe (2mm)

IV
Scope into gap (2.7mm)

GR SLAC WRIST (Scapho-lunate advanced collapse)
(Krakauer et al. JHS 1994, 19A, 751)

I
Radial styloid degeneration only

II
Scaphoid fossa involvement

III
Capito-lunate joint involvement

GR KIENBOCKS DISEASE
(Stahl 1947, Acta Chir Scand, Suppl 126)

I
A dense line through the lunate, caused by a recent compression fracture

II
The fracture changes into a line of rarefaction, by resorption at the fracture site

III
The bone closest to the fracture becomes sclerotic

IV
Fragmentation of the bone by secondary, mostly vertical fracturing.

V
Stationary cases with sequelae at first examination.

GR KIENBOCKS DISEASE

I
No radiological changes or possible compression fracture. Hot bone-scan

II
Increased density but no change in shape other than minor radial height-loss

III
Collapse and sclerosis with carpal disruption

IV
Generalized inter-carpal arthritis

GR KIENBOCKS DISEASE
(Swanson et al. JHS 1989, 14A, 417)

I
Sclerosis of lunate with minimal symptoms and normal carpal bone relationships

II
Sclerosis of lunate with cystic changes and clinical symtoms but normal carpal bone relationships

III
+Fragmentation lunate with ScR angle of 40-60º, carpal collapse 0-5% and minimal carpal translation

IV
+ ScR angle of <70º, carpal collapse 5-10% and moderate carpal translation

V
+ ScR angle of >70º, carpal collapse >10%, severe carpal translation and cystic change in contiguous bones

VI
+ Carpal collapse >15%, significant intercarpal and radiocarpal degenerative changes

GR TFCC LESIONS
(Palmer AK, JHS 1989, 594)

1A
Central perforation

1B
Ulnar avulsion with or without distal ulnar fracture

1C
Distal avulsion

1D
Radial avulsion with or without sigmoid notch fracture

2A
TFCC wear

2B
TFCC wear + lunate or ulnar chondromalacia

2C
TFCC perforation + lunate or ulnar chondromalacia

2D
C+ L-T ligament perforation

2E
D+ ulnocarpal arthritis

GR RHEUMATOID ARTHRITIS
(Larsen, Acta Radiol Diagn1977, 18, 481-91)

0
Normal

1
Osteoporosis, soft tissue swelling ± minimal joint space narrowing

2
Erosions with normal architecture

3
Erosions with abnormal architecture

4
Severe joint destruction, joint visible

5
Mutilans. Joint line not visible

GR RHEUMATOID ARTHRITIS (Wrightington wrist classification)
(Hodgson et al. JHS 1989, 14B, 451)

1
Architecture preserved±
Mild scaphoid rotatory instability
Periarticular osteoporosis
Erosions or early cyst formation

2
Radio-scaphoid and intercarpal joints well preserved±
Ulnar translocation
VISI
Flexed scaphoid
Radio-lunate joint degenerate

3
Radius well preserved apart from pseudocyst formation ±
Intercarpal joints degenerate
Radio-scaphoid joint eroded
Volar subluxation of the carpus on the radius

4
Bone stock loss of the radius and erosion of its medial side

GR TRIGGER FINGER
(Quinnell, Practitioner 1980, 224, 187)

I
Pain and nodularity

II
Triggering, self correctable

III
Triggering, manually correctable

IV
Irreducible

GR BOUTONNIERE

I
Mild, lag 10 - 15º

II
Moderate, lag 30 - 40º

III
Severe, extension deficit

GR BOUTONNIERE

I
Dynamic imbalance, passively supple

II
Established extensor tendon contracture. Deformity cannot be passively corrected but joint not involved

III
Secondary joint changes such as volar plate or collateral ligamant scarring

GR SWAN NECK
(Nalebuff, Hand Clinics 1989, 5, 203)

I
PIPJ flexible in all positions

II
PIPJ flexion limited in some positions

III
PIPJ flexion limited in all positions

IV
Stiff PIPJ with poor radiographic appearance

GR Z DEFORMITY OF THUMB
(Nalebuff, Bull Hosp Joint Dis 1968, 29, 119)

I
Boutonniere, CMCJ unaffected, passively correctable

II
Boutonniere, CMCJ affected, adduction deformity

III
Swan neck + adduction deformity

IV
Gamekeeper

V
Swan neck alone

VI
Skeletal collapse with bone loss

GR EPIPHYSEAL FRACTURES
(Salter)

I
Trans-epiphysial plate

II
Metaphysis-plate

III
Epiphysis-plate

IV
Metaphysis-plate-epiphysis

V
Crush

GR SCAPHOID NON-UNION
(Alnot Rev Chir Ortho 1988, 74, 714)

I
Linear pseudarthrosis

IIA
Slight bone resorption, no displacement

IIB
Unstable pseudarthrosis, anterior flexion, adaptive DISI, anterior bone loss

IIIA
Radioscaphoid arthritis

IIIB
Radiocarpal arthritis

GR POST-BURN CONTRACTURES - PIPJ
(Stern et al. JHS 1987, 12A, 450.)

I
Correctable with MCPJ flexion

II
Not fully correctable with MCPJ correction

III
Unaffected by MCPJ position

GR POST-BURN CONTRACTURES - MCPJ
(Graham et al. JHS 1990, 15A, 450.)

I
Correctable with wrist extension

II
MCPJ flexion <30º with wrist extension

III
Unaffected by wrist position

GR SAGITTAL BAND INJURIES
(Rayan GM et al. JHS 1994; 19A:590–594)

I
Injury without extensor tendon instability

II
Injury with tendon subluxation

III
Injury with tendon dislocation

GR TETRAPLEGIA
(McDowell, JHS 1986, 604-8)
 

O
Ocular input  

Cu
Cutaneous (S2PD<10mm)  

0
No muscle below elbow suitable for transfer (flexion of elbow and supination)  

1
BR  

2
ECRL (Extension of the wrist)  

3
ECRB  

4
PT (Pronation)  

5
FCR (Flexion of wrist)  

6
Finger extensors (Extrinsic extension of fingers)  

7
Thumb extensor (Extrinsic extension of thumb)  

8
Partial digital flexors (Weak extrinsic flexion of fingers)

9
Lacks only intrinsics (extrinsic flexion of fingers)  

X
Exceptions  

GR CEREBRAL PALSY
(Zancolli, JHS 1983, 8, 766-772)

I
Finger extension with wrist in neutral or less than 20º of flexion

IIA
Active wrist extensors present. Finger extension only with wrist in more than 20º of flexion

IIB
No active wrist extensors present. Finger extension only with wrist in more than 20º of flexion

III
Finger extension not possible even with maximal wrist flexion

GR PRONATION DEFORMITY IN CEREBRAL PALSY
(Gschwind & Tonkin, JHS 1992 17B: 391-395)

I
Active supination beyond neutral position

II
Active supination to less than, or to, neutral position

III
No active supination, free passive supination

IV
No active supination, tight passive supination

GR DIABETIC STIFF HAND
(Rosenbloom, J Diabet Comp 1989, 3, 77)

0
No limitation. Equivocal or unilateral findings

I
Mild limitation. Involvement or one or two IPJ or only MCPJ bilaterally

II
Moderate limitation. Involvement of three or more IPJ or one finger and one large joint bilaterally

III
Severe limitation. Obvious hand deformity at rest

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If you are aware of other classifications that I have not listed, I would be grateful if you could email me

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