The 'Tic-Tac-Toe' classification system for mutilating injuries of the hand

Several classifications of mutilating hand injuries exist in the literature. Unfortunately, each of these provides a categorization that is arbitrarily grouped according to the part of the hand predominantly involved. It is imperative that a comprehensive classification system incorporate the degree and precise location of soft-tissue and/or bony destruction and the vascular integrity in addition to the predominantly involved part of the hand. We therefore devised a new classification system for mutilating injuries of the hand which categorizes them into seven types: (I) dorsal mutilation, (II) palmer mutilation, (III) ulnar mutilation, (IV) radial mutilation, (V) transverse amputations, (VI) degloving injuries, and (VII) combination injuries. These types are subcategorized into three subtypes: (A) soft-tissue loss, (B) bony loss, and (C) combined tissue loss. Vascular integrity is recorded with subscript notation: (0) vascularization intact or (1) devascularization. The hand is then systematically divided into nine numerical zones in "tic-tac-toe" fashion with radial, central, and ulnar columns and proximal, central, and distal rows. The "Tic-Tac-Toe" classification system allows the examining surgeon to describe precisely any mutilating injury of the hand. This system permits accurate assessment of each hand injury by assignment of the appropriate classification type, subtype, vascular status, and zone involvement. Clinical examples illustrate the user-friendliness and practicality of this new classification system.