scapula fracture classification system - Kreiskrankenhaus Mechernich

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Classification of glenoid fractures 513 Conclusion: This new system for scapular glenoid fractures has proved to be sufficiently reliable and accurate when applied by experienced shoulder surgeons. Further validation of the most detailed system, as well as involvement of surgeons with different levels of training in the framework of clinical routine and research, however, should be considered. Level of evidence: Level II, Development of Diagnostic Criteria, Diagnostic Study. Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Scapula fracture; glenoid fossa; fracture classification; diagnostic; reliability; accuracy Scapular fractures are rare and account for 1% of all fractures and 3% to 5% of all shoulder girdle fractures. 7 In the Swedish population, the annual incidence was estimated at 10 per 10,000 inhabitants. 18 AccordingtoGoss, 13 the scapular body is involved in up to 45% of all scapula fractures, with the remainder involving the glenoid (approximately 10%), the scapular neck (25%), the processes (approximately 15%), and the spine (5%). Treatment modalities depend on the fracture location, pattern, and displacement on the one hand and the patient’s age, demands, and comorbidity on the other. In contrast to fractures of the scapular body, which are mostly treated conservatively, surgery is more often indicated for 80% of fractures involving the glenoid. 24 This is explained by the specific shape and function of the glenoid. Glenoid rim fractures can result in joint instability, where surface incongruity may increase the risk of post-traumatic arthrosis accompanied by pain and limited function. The surgical approach is influenced by the main pathology. Not all glenoid fractures can be sufficiently reduced and stabilized by an anterior approach. Posterior fracture patterns have to be managed through a posterior approach that is more complex and less frequently practiced. In the clinical environment, diagnosis of scapular fractures is based mainly on radiographic examination of the shoulder. Three plains comprising an anteroposterior view, outlet view, and axillary view are very helpful in gathering essential information. If the glenoid is involved, it is strongly recommended to obtain an additional computed tomography (CT) scan to precisely evaluate the glenoid surface. It is also crucial to analyze the fracture systematically with the help of a clinically relevant, reliable, and valid fracture classification system. 5,9,11,19 Until now, a number of glenoid fracture classifications have been in use 1,10,14-16,20 ; however, none of these are comprehensive and validated. A comprehensive scapula classification system has been developed as a collaborative effort between the AO Foundation and the Orthopaedic Trauma Association. 17 The purpose of this study was to create and validate a focused classification of the glenoid as an extension of this system. Materials and methods Scapula classification group and phase I consensus development The international Scapula Classification Group (SCCG) comprising 7 experienced shoulder specialist surgeons was established to propose a focused system for fractures of the glenoid fossa, along with definitions and illustrations. This system was to be descriptive, clinically relevant, sufficiently comprehensive, and intuitive for both inexperienced and experienced surgeons. Under coordination by a methodologist statistician, a phase 1 consensus development process was implemented in an iterative manner with a series of 3 agreement studies (classification sessions), followed by face-to-face review meetings to discuss disagreements and improve the system. Consensus was reached when the SCCG agreed that the system was well defined, clinically relevant, and reliable for its purpose. 4 This development process was the first of 3 research phases that is required to be completed before the classification could be considered as validated. Fracture classification system The classification system for bony lesions of the scapula consists of separate codes, that is, one each for the involvement of the articular segment (glenoid fossa), the body, and any of the processes. In addition, each code comprises 2 levels, where level 1 represents a basic system for rapid simplified documentation 17 and level 2 provides a focused system for detailed documentation. Classification of the scapula is divided into 3 regions: the articular segment, the processes, and the body. The articular segment includes the area involving the glenoid fossa and the articular rim, which is limited by a line joining the superior articular rim to the lateral border of the suprascapular notch and a line positioned medially and parallel to the plane of the glenoid fossa that starts cranially at the lateral border of the suprascapular notch. In the basic system, fractures of the articular segment (denoted F) are classified in 1 of 3 groups (Fig. 1): F0, fracture of the articular segment, not through the glenoid fossa, but resulting in the fossa being detached from any part of the scapula body; F1, fracture involving the glenoid fossa with a simple rim, transverse, or oblique fracture pattern; and F2, multifragmentary joint fracture involving the glenoid fossa with 3 or more articular fragments. The focused system is an extended classification of F1 or F2 fractures according to their location in 4 quadrants within the glenoid fossa (Fig. 2). These quadrants are defined by the equatorial line and the intertubercular line running from the supraglenoid tubercle to the infraglenoid tubercle. There are 5 subgroups, consisting of 3 for F1 fractures and 2 for F2 fractures: F1(1), simple anterior articular rim or oblique fracture; F1(2), simple posterior articular rim or oblique fracture; F1(3), simple transverse or short oblique fracture; F2(4), multifragmentary fracture with more than 1 fracture line exit point; and F2(5), central fracture-dislocation, with no exit line through the rim. Simple anterior (1) and posterior (2) articular rim or oblique fractures are further divided into 3 categories (Fig. 3): 1a/2a,
514 M. Jaeger et al. Figure 1 Fractures of the articular segment. Ó 2012, Jaeger et al. Figure 2 Four areas defined within the glenoid fossa. Ó 2012, Jaeger et al. infra-equatorial fracture located in 1 quadrant (same side as the maximum glenoid meridian); 1b/2b, rim fracture anterior/posterior to the maximum glenoid meridian with exits superior/inferior to the equatorial line; and 1c/2c, fracture oblique line exiting on the opposite side (posterior/anterior) to the maximum glenoid meridian. (Initial definitions used for the last evaluation session are presented in Appendix I, available on the journal’s website at www. jshoulderelbow.org. A revision and final proposal are presented in Fig. 3). Simple transverse or short oblique fractures (3) are also further divided into 3 categories (Fig. 4): 3a, infra-equatorial; 3b, equatorial; and 3c, supra-equatorial. For multifragmentary fractures with a combination of 2 ‘‘simple’’ fracture lines, the focused codes describing this combination may be added as an optional specification (Fig. 5); for example, in the case of a transverse and rim fracture, the classification would be F2(4/1c3c). Consecutive series and classification sessions The classification system was evaluated for reliability and accuracy using a consecutive series of scapula fractures documented with CT scans and conventional radiographs obtained from 2 centers in Europe and North America. Cases were included
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scapula fracture classification system - Kreiskrankenhaus Mechernich

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